Arterial anatomy of the oral cavity: an analysis of vascular territories

Knowledge of the specific cutaneous or surface regions supplied by constant named arterial sources has allowed for increasing clinical application of flap transfers of tissue. Despite the routine use of intraoral flaps for reconstruction of congenital or acquired defects of the oral cavity and pharynx, no previous investigation has centered on understanding the surface or mucosal arterial territories of the oral cavity. In a cadaver study, six mucosal territories of the intraoral cavity were defined using selective ink and lead oxide injections through named arteries. The anatomical boundaries of these territories are predictable and constant in location for different cadavers. The six contiguous territories are based on the buccal, labial, inferior alveolar, ascending palatine, ascending pharyngeal, and lingual arteries. This study supports the safe vascular basis of existing clinical procedures of the intraoral cavity and may have implications for the design of new intraoral reconstructive procedures.     

The anatomic basis and clinical applications of flaps based on the posterior tibial vessels

The vascular anatomy of the posterior tibial vessels has been studied in 20 legs of 10 cadavers. The number, size and distribution of the direct cutaneous and direct muscle branches of the posterior tibial vessels were recorded. For analysis, the leg was divided into four equal segments, Zone I being the most distal and Zone IV the most proximal. The direct cutaneous branches were found to cluster mainly around Zone II. The direct muscle branches to the soleus and flexor digitorum longus muscles arose chiefly in Zones II and III. Based on this knowledge, we performed fasciocutaneous, island soleus muscle, musculo-fasciocutaneous and flexor digitorum longus muscle flaps based on the posterior tibial vessels in 12 patients. Four were free fasciocutaneous flaps and eight were pedicled flaps. All flaps survived and there were no major complications. Delayed wound healing was encountered in three patients.     

Comparison of two different delay procedures in a rat skin flap model

The overall objective of this study was to investigate how a strategic delay procedure could generate large flaps survival. On the basis of the vascular anatomy in 10 rats, a long three-territory skin flap spanning the length of the rat dorsum was designed. This flap was distally based on the deep circumflex iliac artery. The adjacent territories consisted of a large perforator of the posterior intercostal artery and the lateral thoracic artery in sequence. Two different vascular delay procedures were used and compared in nine animals. One dorsal midline incision was used to perform the two different delay procedures. The limited delay technique was performed by ligating a large cutaneous perforator of the posterior intercostal artery on one side of the rat. The extensive delay procedure was completed by ligating the cutaneous perforators of the posterior intercostal artery and the lateral thoracic artery on the other side of the rat. After a delay period of 10 days, the paired flaps were elevated, respectively, and sutured back in place. Seven days later, the area of viable skin flap was measured by the paper template technique. The animals were then killed, and the dorsal skin arteriograms were obtained by injecting a lead oxide mixture. Vascular changes of the paired flaps were assessed. In the extensive delay group, 100-percent survival was seen in four animals and distal partial necrosis was observed in five animals. The average survival area in the extensive delay group was 85.5 +/- 14.2 percent (mean +/- SD), whereas the flaps in limited delay group showed 100-percent survival in all animals (p < 0.05). In flaps that survived completely, the choke vessels among three vascular territories anastomosed throughout the flap. In the partially necrotic flaps, some choke and true anastomoses existed between the deep circumflex iliac and the posterior intercostal artery territories and the flap necrosis occurred in the third territory. This study suggests that the limited delay technique (ligation of one artery in the territory adjacent to the base of the flap) was the more effective delay procedure in the rat dorsal skin flap model.     

MRI of the intracerebral lesions at 0.5 Tesla: comparison of fast spin-echo and conventional spin-echo sequences

The purpose of this study was to identify the angiosome of the medial saphenous artery and vein and to evaluate the use of this cutaneous angiosome as a free skin flap in the dog. In phase 1 of this study, selective angiography of the medial saphenous artery performed in six canine cadavers showed that the skin covering the entire medial femorotibial area, the distal half of the caudal head of the sartorius muscle, and the gracilis muscle were perfused by the medial saphenous artery. In phase 2, a medial saphenous fasciocutaneous island flap was raised and sutured back to the skin edges of the donor wound in three dogs. One hundred percent survival of all of the flaps occurred. In phase 3, a medial saphenous fasciocutaneous microvascular free flap was transferred to a wound that was created over the dorsal metacarpal (n = 3) or metatarsal region (n = 3). The mean length +/- SD of the medial saphenous vascular pedicle was 80 +/- 13 mm (n = 5); the mean diameter +/- SD of the medial saphenous artery was 2.8 +/- 0.2 mm (n = 5) and the mean diameter +/- SD of the medial saphenous vein was 4.2 +/- 0.2 mm (n = 5). One hundred percent of all flaps survived (n = 6). Selective angiography or the distal cranial tibial artery (metatarsal wounds, n = 3) and the median artery (metacarpal wound, n = 3) was performed 3 weeks after surgery. All of the vascular anastomoses were patent and neovascularization of the wound beds was present. This free flap was found to be acceptable for cosmetic reconstruction of wounds located on the distal extremity.     

Anatomical study of the cutaneous perforator arteries and vascularisation of the biceps femoris muscle

We present an anatomical study that describes the distribution of the cutaneous perforators (CP) of both heads of the biceps femoris muscle.

Material and methods

In this study, we dissected 18 legs from nine cadavers. The study was centered on the biceps femoris muscle and musculocutaneous perforator arteries from both muscular heads. Only perforator arteries with comitant vein diameters of over 0.5 mm were selected. The vascular origin and length were also studied. In all cases, measurements were taken from the bicondyle line.

Results

The measurements taken from the muscle bellies of the biceps gave the following results; for the long head 33.91 cm as medium length (SD=2.70) and for the short head 23.85 cm as medium length (SD=2.96).The total number of perforator arteries obtained from the two muscle bellies was 139, with the greatest percentage located in the lower half of the thigh. The majority follow an intramuscular route (80.48%) and less frequently they are septals (19.52%).The lengths of perforator arteries from its origin in the axial vessel of the muscle to the subcutaneous fat were, for the short head 5.01±1.33 (3.0–10.0), whereas the same measurement, in the long head was 4.54±1.36 (2.5–9.0).The principal vascular origin of the perforator arteries was the popliteal artery in both muscle bellies, whilst the second arterial vessel in importance was the first and second profunda perforator artery.

Conclusion

From the results obtained in our work, we can deduce that it is always possible to locate perforator arteries in both muscle bellies; most frequently they have intramuscular distribution and are located in the proximity of the vascular septum. Their most common origins are the popliteal artery and first and second profunda perforator artery. Finally, it is possible to design pedicle and free flaps, with less morbidity and more versatility than musculocutaneous flaps.     

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.     

Clinical application of rhombotrapezious island musculocutaneous flap for skull base and/or craniomaxillary operation with malignant tumor

Regional pedicled musculocutaneous flaps are the mainstay of the head and neck reconstruction. They provide a rapid, highly reliable and single-staged technique that is applicable in most cases. The rhombotrapezious island musculocutaneous flap is valuable in the base and craniomaxilloface reconstruction. In this study we updated our experience with the rhombotrapezious island musculocutaneous flap (RTIMF) in 6 cases from 1989 to 1993. Dissections were performed on 9 cadavers, 4 preserved and 5 fresh, yielding 18 pairs or dorsal scapular and transverse cervical artery for evaluation. In the five fresh cadavers, the arteries were selectively cannulated and injected with colored latex. 67% with dorsal scapular and transverse cervical artery commonly arose from the thyro-cervical trunk. 33% with the dorsal scapular artery directly arose from the second part of the subclavian artery. In the period of 1989-1993, 6 rhombotrapezious island musculocutaneous flaps with vascularized pedicle were used for immediate repair in the skull base or craniomaxillary cancer operations. There was no complication of the flaps. Donor site complications were relatively minor. The disturbance in shoulder function was well tolerated. We advocated the incorporation of both the greater and lesser rhomboid muscle to form the compound rhombotrapezious flaps to enhance the vascular supply to the overlying skin. The major advantage of the RTIMF are that it provides a long paddle of thin pliant, hairless skin and muscle that can be rotated as far as the craniomaxilloface and scalp in a single stage. It offers the longest arc of rotation and thus the greatest versatility for the skull base or craniomaxillary reconstruction.     

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

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

Flap prefabrication: effectiveness of different vascular carriers

A new experimental model of a vascular carrier to prefabricate a "secondary" island flap, the popliteal musculovascular pedicle, was developed in the rat. Using quantitative skin-surface fluorometry 30 minutes after sodium fluorescein injection and a flap survival area in the prefabricated 8 x 2.5-cm abdominal composite island flap, we compared the revascularization ability of our muscular carrier to nonrevascularized controls: the skeletonized arteriovenous pedicle and the fasciovascular pedicle. The free composite graft with no vascular carrier exhibited near-total necrosis. The skeletonized vascular pedicle demonstrated 15.2% +/- 7.8% perfusion of normal skin on dye fluorescence index measurements and 50% flap survival. The fasciovascular pedicle exhibited better revascularization, with a dye fluorescence index of 36.2 +/- 15.5 (p < 0.01) and 90% +/- 10% flap survival (p < 0.001). India ink injection study and histological examination of our model provided visual evidence of revascularization from the musculovascular pedicle, along with preservation of the carrier's muscular architecture. The musculovascular pedicle is a reliable carrier for making new, vascularized composite flaps.     

Early detection of colonic cancer by colonoscopy

Experimental arterial occlusion was performed on eight dogs by means of inflatable and releasable balloons, in five of which a reliable and long lasting arterial occlusion was obtained. Three accidents occurred. One dog died when the liquid latex was emptied spontaneously from the balloon and the territory was embolized causing a severe general reaction. In two other dogs the emptying of the balloon, inflated with iodine, was followed by distal embolization of the empty latex balloon. The possibility of such accidents would be too great a risk for human application, but it now seems possible with the new glue, isobutyl-2-cyanoacrylate, to embolize vascular territories more accurately and more safely by means of inflatable and releasable balloons.     

Posterior interosseous free flap: various types

The posterior interosseous artery is located in the intermuscular septum between the extensor carpi ulnaris and extensor digiti minimi muscles. The posterior interosseous artery is anatomically united through two main anastomoses: one proximal (at the level of the distal border of the supinator muscle) and one distal (at the most distal part of the interosseous space). In the distal part, the posterior interosseous artery joins the anterior interosseous artery to form the distal anastomosis between them. The posterior interosseous flap can be widely used as a reverse flow island flap because it is perfused by anastomoses between the anterior and the posterior interosseous arteries at the level of the wrist. The flap is not reliable whenever there is injury to the distal forearm or the wrist. To circumvent this limitation and to increase the versatility of this flap, we have refined its use as a direct flow free flap. The three types of free flaps used were (1) fasciocutaneous, (2) fasciocutaneous-fascia, and (3) fascia only. Described are 23 posterior interosseous free flaps: 13 fasciocutaneous flaps, 6 fasciocutaneous-fascial flaps, and 4 fascial flaps. There were 13 sensory flaps using the posterior antebrachial cutaneous nerve. The length and external diameter of the pedicle were measured in 35 cases. The length of the pedicle was on average 3.5 cm (range, 3.0 to 4.0 cm) and the external diameter of the artery averaged 2.2 mm (range, 2.0 to 2.5 mm). The hand was the recipient in 21 patients, and the foot in 2. All 23 flaps covered the defect successfully.     

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.     

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.     

Stepladder V-Y advancement flap for repair of postero-plantar heel ulcers

Random fasciocutaneous flaps with bilateral adipofascial pedicles were elevated from the posterior heel and transferred distally to defects of the postero-plantar heel in 4 patients, using a stepped incision technique, in combination with the V-Y advancement principle. In all cases the flap was successfully transferred without any linear scar or scar contracture in the posterior heel. The absence of recurrence of ulcers during the postoperative follow-up between 1.5 and 4 years indicated the reliability and durability of the flaps. Application of this procedure permits rapid resurfacing and excellent recontouring of small to moderate-sized defects of the heel with minimal donor site morbidity.     

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.     

Importance of arterial blood supply to the femur and tibia for transplantation of vascularized femoral diaphyses and knee joints

The role of the periosteal and intraosseous blood supply to the femur and the proximal tibia was investigated to improve the operating technique for transplantation of allogenic vascularized femoral diaphyses and knee joints in humans. Altogether 48 limbs were injected with gelatin, red latex milk, or Revertex and macroscopically prepared; 41 limbs were studied for the variation and division of the truncus profundo-circumflexus. In 200 femurs and 200 tibias the location of the nutrient foramen was determined. The arteries supplying the periosteum of the distal femur and the proximal tibia have defined nutritive areas. The following technique should be followed: If the femoral artery alone is prepared as the vascular pedicle, the optimal section for resection of the femur in knee joint transplantations is 6 to 12 cm above the level of the femur condyles and 5 to 7 cm below the tibial plateau. For the transplantation of femoral diaphyses, the deep femoral artery can be used if the lateral femoral circumflex artery is protected. The Proximal line of resection is defined between the greater and lesser trochanter. For shorter grafts one must consider the number and location of nutrient foramens. For longer grafts the distal branches of the femoral artery must be respected as the intraosseous blood supply reaches distally down to the level of about 8 cm above the femoral condyles. In all these operations of the variation of the truncus profundo-circumflexus and the trifurcation of the popliteal artery must be considered.     

Position specificity of Ki-ras oncogene mutations during the progression of colorectal carcinoma

Accusations of excessive donor-site morbidity as an unavoidable sequela of fasciocutaneous flaps has negatively prejudiced this option for coverage of adjacent defects such that a muscle flap, if available, would instead be preferable even at the risk of loss of marginally expendable function. Our entire experience with 147 juxtaposed muscle-type and 122 fascia-type flaps was analyzed to confirm instead that actual donor-site morbidity was extremely uncommon for either type. Overall, there were 20 (14 percent) complications of the donor site of muscle flaps and 17 (14 percent) for fascial flaps, with only 4 (3 percent) major complications in each group. This almost minuscule incidence of major morbidity was about five times less than the rate of major complications involving the flaps themselves (14 percent for muscle and 15 percent for fascial flaps). Unless aesthetic considerations are of paramount importance, at least from a functional standpoint, no difference in donor-site complications could be discerned between these two disparate flap types. However, the skin-grafted donor site of the fasciocutaneous flap results in a significant cosmetic disadvantage similar to that of a large musculocutaneous flap.     

The covering of radionecrosis in plastic surgery. Apropos of a series of 20 cases

Twenty radionecroses with various locations were operated on between 1982 and 1993 in the Plastic Surgery Department at Strasbourg. Flap covers were performed. The results and indications as a function of localization and of the size and quality of the structures involved was analyzed for these radio-induced lesions. A wide range of therapeutic option are available to the plastic surgeon who must chose the most reliable reconstruction technique after the most extensive exeresis possible. Muscle and pediculated musculo-cutaneous flaps are preferred due to their safety, their vascular, trophic and anti-infectious quality and their excellent capacity of coverage.     

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.