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.     

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.     

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.     

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.     

Paracoccidioidoma: case record and review

The ulcer resulting from snake-bite injury was characterized by deep and wide tissue necrosis and secondary infection. The patient was at high risk of loss of function of his extremity. From 1989 to 1996, 16 cases with deep ulcer of the upper extremity resulting from snake-bite injury were treated with different types of axial thoraco-abdominal skin flaps, depending on the location of the ulcer. Thoraco-umbilical skin flap was used in 2 cases, lateral thoracoabdominal skin flap in 1 case, iliolumbar skin flaps in 5 cases, lower abdominal skin flaps in 6 cases, lower abdominal divided foliated skin flap in 1 case and Y-shaped hypogastric skin flap in 1 case. Reparative operation was carried out within 3 weeks after injury and primary repair were undertaken in 6 of them. The pedicles were divided in 17 to 24 days after operation. Twelve flaps survived. Three of the 6 flaps had mild signs of inflammation which disappeared after administration of antibiotics. One had necrosis of the distal part of the flap, and was healed with split skin graft. This type of skin flap was an ideal method for the treatment of snake-bite injury of the upper extremity.     

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.     

Delayed healing of rhytidectomy flap resurfaced with CO2 laser

Combining facial rhytidectomy with laser resurfacing, theoretically, provides the best opportunity for achieving an optimal facial rejuvenation result. Previous studies have demonstrated the pernicious effect of a deep peel on a skin flap, but the safety of treating the rhytidectomy flap with laser has not been investigated. This study was conducted to investigate the safety of using these techniques concomitantly. Sixty sites were selected on three Yucatan minipigs, a species of swine chosen because of its hairless nature and opportunity to raise a true skin flap (without the panniculus carnosus). The healing time of 20 laser-treated sites without flap elevation was compared with that of 20 areas treated with laser following flap elevation, shortening (to emulate a more realistic rhytidectomy process), and repair. Twenty flaps were elevated and shortened without laser treatment to serve as a control. The CO2 laser parameters were set at 500 mJ, 50 watts, and a density of 5. Two passes were made to penetrate the upper dermis. The mean healing time for areas treated with laser alone was 12.05 days, ranging from 11 to 14 days. In comparison, the healing time for the laser-treated areas subsequent to flap elevation averaged 17.95 days, with a range of 14 to 24 days (p < 0.05). Two flaps treated with laser (10 percent) failed to heal completely in 24 days. At the time that all 20 of the areas treated solely with laser had re-epithelialized completely, only one of the flaps treated with laser had re-epithelialized completely (p < 0.001). A delay in healing, as well as return of pigment, was demonstrated in the distal portions of all flaps receiving laser treatment. The control flaps all healed normally except for a 5-percent superficial loss on a single flap. It was concluded from this study, and from clinical observation of delayed healing on six of seven patients who underwent concomitant rhytidectomy and laser resurfacing at a conservative laser setting, that laser resurfacing of the rhytidectomy flap is unsafe and results in delayed re-epithelialization. This combination should be avoided altogether or performed with extreme prudence on patients undergoing a deeper plane facial rhytidectomy or by using very low laser settings.     

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.     

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.     

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.     

Transposition of a skin flap from the nasal dorsum for repair of skin loss on the nasal wing. Apropos of 9 clinical cases

The authors use a transposition island skin flap from the nasal dorsum for repair of the ala nasi. It is a modification of the stalk-flap advocated by Edgerton in 1967 to augment the columella. The flap is vascularized by branches of the anterior ethmoidal artery. The main modifications are;-the size of the flap which is 50 mm long and 15 mm wide;-the vascular pedicle is not dissected; this makes the flap very reliable;-the outstanding vascularization of this flap is corroborated by the fact that, in the same stage, it may be lined with a partially composite chondrocutaneous graft. The composite graft is taken from the concha and repaired with the Masson procedure. This flap is a very easy procedure for alar cutaneous repair for partial alar reconstruction, it is possible to fold the flap onto itself after resecting a 2 mm transverse skin strip, making the distal extremity a secondary skin island flap which ensures the lining of the proximal part. For total alar reconstruction and hemi-rhinoplasty; the flap is lined with a composite graft, which allows a one-stage thin reconstruction. The flap was used in 9 patients. In one case, there was a total skin necrosis, while half of the fasciomuscle layer survived.     

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.     

The dartos flap as an adjunct in preventing urethrocutaneous fistulas in repeat hypospadias surgery

PURPOSE: Vascularized flaps for repeat hypospadias repair are often limited. We report our experience with the dartos flap in children undergoing secondary hypospadias and complex urethral repair. MATERIALS AND METHODS: The dartos flap is fibroadipose tissue between the scrotal skin and tunica vaginalis layers with its vascular pedicle based at the penoscrotal angle. The flap reaches the distal penile shaft without tension. Eight patients 1 to 17 years old (mean age 6) underwent urethral surgery and an interposed dartos flap procedure in 1994 to 1995. RESULTS: Of 6 patients cosmesis was excellent in 84%, erections were straight in 100%, and urinary streams were of good quality and without fistula in 100% after repeat hypospadias surgery. Following staged repair for anterior urethral valves a urethrocutaneous fistula developed in 1 patient and following urethral duplication repair results were excellent in 1. Mean followup was 1 year. CONCLUSIONS: The dartos flap is easy to mobilize and it provides excellent coverage for repeat proximal hypospadias surgery, since the dartos remains undisturbed. We endorse its use for complex urethral surgery and believe that the extra layer of closure helps to prevent urethrocutaneous fistulas.     

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.     

Overview of quality measurement and improvement

BACKGROUND: Oro-mandibular reconstruction using vascularized bone-containing free-flaps can be accomplished with flap survival rates in the range of 95%. Primary reconstruction offers the best opportunity to achieve the optimal aesthetic and functional results. Patients presenting for secondary oro-mandibular reconstruction have a unique set of problems; these include the presence of soft tissue contracture displacing the mandibular segments in malposition and soft tissue deficiencies, that makes surgical correction more difficult and potentially more hazardous. Vascularized bone-containing free-flaps are indicated in secondary oro-mandibular reconstruction where both hard and soft tissues replacement is needed or when the recipient bed is unfavourable due to previous surgery and/or radiation. METHODS: Authors presents personal experience in ten cases of secondary oro-mandibular reconstruction treated at Maxillofacial Department of Parma from September 1995 to September 1996 with secondary oro-mandibular reconstruction using bone containing free flaps. Two different donor sites were used to harvest bone-containing free flaps: iliac crest in 2 cases and fibula in the others. In 4 cases the flap was only osseous while in the other 6 cases it was osteocutaneous. RESULTS: All flaps were transplanted successfully; in 1 case necrosis of the skin component of the flap was observed. CONCLUSIONS: The introduction of vascularized bone containing free flaps transferred from distant sites by microvascular techniques has changed mandibular reconstruction. Vascularized bone transferred into tissue beds compromised by salivary contamination and previous irradiation and the rational use of the soft tissutal components of the flap permit also the restoration of articulation, deglutition and mastication with quality of life better than non-vascularized alternatives.     

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.     

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.     

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.     

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.