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.     

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.     

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.     

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.     

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.     

Microsurgical reconstructions of the lower face, after projectile injuries. Value of fibular flaps. Apropos of 20 cases

Projectile trauma of the lower face causes major functional damage and disfigurement. Reconstruction with tissue flaps, after microsurgical revascularization to guarantee tissue vitality, can restore satisfactory mental function. We report 26 mental reconstructions, including 20 using free fibular flaps which, due to its vascular pedicle and length of the available bone, appears to be the best adapted for reconstruction of the lower face. When used with cutaneo-aponevrotic flaps, only one operation is needed.     

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.     

Magnetic resonance tomography in diagnosis of cardiac space-occupying lesions]

The ability to assess viability of tissues by monitoring changes in oxygenation and perfusion during harvesting and following transfer of free and pedicled flaps is potentially important in reconstructive surgery. Rapid detection of a critical change in tissue oxygenation could enable earlier and more successful surgical intervention when such problems arise. In this study near infra-red spectroscopy (NIRS) was used to assess changes in tissue oxygenation, haemoglobin oxygenation and blood volume in a porcine prefabricated myocutaneous flap model in response to pedicle manipulations. As far as we are aware this is the first usage of a NIRS instrument to assess changes in oxygenation in a flap model which closely simulates the clinical situation. A myocutaneous flap was raised (n = 9 pigs), tubed and the flap circulation allowed to readjust for periods between 7 and 9 days. The pedicle vessels were then subjected to arterial (n = 9), venous (n = 12) and total occlusion (n = 6). Repeatable and reproducible patterns of change were measured in each case. Comparison of mean values indicated that the differences between arterial and venous, and venous and total occlusions were significant for all NIRS parameters. The monitor was easily able to detect two additional features: (i) the presence of venous congestion indicated by raised levels of deoxygenated haemoglobin and an increase in blood volume; and (ii) the presence and magnitude of reactive hyperaemia. In two flaps release of arterial or total occlusion did not result in the expected reactive hyperaemia associated with an increase in blood volume (oxygenated haemoglobin) suggestive of possible damage to the vascular bed. NIRS proved able to detect and distinguish between microcirculatory changes occurring as a result of arterial, venous or total vascular occlusion. We believe that NIRS provides a sensitive and reliable postoperative monitor of tissue viability following transfer of free and pedicled flaps. It can accurately identify different types of problems with the pedicle vessels. In addition its predictive capabilities would allow assessment of flaps buried deep to the skin. This monitor is excellent for surgical and intensive care unit monitoring since it is unaffected by light, portable and is extremely easy to use.     

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.     

Tissue radiation dosages using the RVG-S with and without niobium filtration

Twenty-five free tissue transfers for reconstruction after lower limb trauma or release of scar contractures were performed in 23 children over an 8-year period. The ages ranged from 2 to 14 years (mean 7.1 years). Fourteen (61%) patients had major associated injuries. The reconstruction sites were all in the distal leg. The overall vascular success rate was 96%. Three patients underwent re-explorations because of vascular insufficiency. One flap failed and two were salvaged. The causes of vascular complications were considered to be inadequate debridement of an avulsed vessel, venous kinking and inadequate protection of the vascular pedicle. The three cases with vascular insufficiency were children with associated injuries on the ipsilateral leg proximally. Postoperative complications were not uncommon (28%). Six of the seven complications occurred in patients with major associated injuries. The mean follow-up was 57 months. Long-term problems such as a limping gait, frequent flap ulcers, toe contracture or a bulky flap were common. Our results suggest that free tissue transfer is reliable and safe for the reconstruction of major leg injuries in children. Associated injuries proximal to the reconstructed defects on the ipsilateral leg predispose to more vascular complications. Since postoperative complications and long-term morbidity are common in children, special precautions should be taken with the preoperative assessment, planning, execution of surgery and postoperative care to achieve better results.     

Birth after electroejaculation coupled to intracytoplasmic sperm injection in a gun-shot spinal cord-injured man

Cervical reconstruction after postburn scarring remains a challenge for the plastic surgeon. Several well-known procedures are possible: split or full-thickness skin grafts, local flaps, free skin flaps, expanded skin,... In order to evaluate each technique, three procedures are compared with a long-term follow-up (> or = 1 year): skin expansion, free flap surgery and full-thickness skin grafting. Fifteen patients are reviewed, with five patients operated according to each method. In this study, each burn patient was suffering from a severe neck burn contracture, restricting the neck motility to a few degrees. These patients were operated on by different surgeons, according to their personal indications. The full-thickness skin graft is usually harvested from the abdomen (by means of a miniabdominoplasty) and is applied under a tie-over dressing. This simple procedure has few complications and gives satisfactory results. Skin expansion provides a good texture and color matching but has a higher morbidity and necessitates several procedures. Free flap surgery is time-consuming, gives a good functional result but poor cosmetic aspect (different colour, excessive bulk). Comparing the functional and aesthetic result of the three types of reconstruction in terms of morbidity, neck mobility, skin elasticity, skin sensitivity, matching and scar recurrence, full-thickness skin grafting seems to be the most adequate technique.     

Comparative pathogenesis of human WA1 and Babesia microti isolates in a Syrian hamster model

The medial thigh flap is a perforator-based flap nourished with septocutaneous or muscle perforators originating from the femoral vessels. To date, 8 patients have been repaired with this flap and extended or connected flaps including this flap: 4 patients with lower leg defects and 4 patients with intraoral and neck defects. The advantages of this flap are (1) several pedicle perforators exist for this flap, which makes possible duplicated vascular anastomoses to establish reliable circulation of the transferred flap; (2) the flap can be extended or connected to other neighboring flaps in the anterior thigh, so that extensively wide defects can be closed in one stage; (3) the great saphenous vein can be simultaneously used as a vein graft or for venous drainage for the flap; (4) the anterior branch of the femoral nerve can be used for sensory potential; and (5) there is minimum morbidity of the donor defect and a large dominant vessel for the leg can be preserved. The suitable indications for this flap are defects after removal of skin cancer in the foot or lower leg and wide defects after resection of head and neck cancer, which can be reconstructed with the flap connected to neighboring skin flaps. The disadvantages of this flap are that it has a small, short vascular pedicle and the bulkiness of the flap's fatty tissue often requires thinning.     

Inhibitory effects of inhaled flunisolide on inflammatory functions of alveolar macrophages

Reconstruction after total laryngectomy ideally includes restoration of voice with protected swallowing. Local flaps and tracheo-esophageal puncture with a prosthesis are widely used to accomplish this. Persistent problems, perhaps inherent to this solution, have led to the recent use of a tubed, folded radial forearm free flap for postlaryngectomy reconstruction. This flap has produced a good voice with low phonation pressures and minimal aspiration in 7 patients. A new configuration for this flap is described and 3 patients reported. Our flap's advantages include a simplified pedicle path, ease of construction, remote microanastomosis, and safer revision. Both patients with surviving flaps rapidly developed a good voice after reconstruction. Mild aspiration in 1 delayed oral intake and forced a successful revision. Our reconfigured flap may have some technical advantages, survives to length, and restores a good voice without significant aspiration. This and its simple care make it popular with patients. Development of this flap holds promise of more complete reconstruction after total laryngectomy.     

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.     

Apprehension about communication and human resilience

PURPOSE: The purpose of the study was to investigate how in vivo expanded urothelium can be transplanted onto a prefabricated capsule-pouch for urinary reconstruction. MATERIALS AND METHODS: Urothelial cells from 40 rats were harvested for culture. A tissue expander was used to induce a capsule-pouch on which the cell culture were reimplanted ten days later. As delivery vehicle we compared standard culture media and fibrin glue. RESULTS: The histology demonstrated viable, multilayered clusters of urothelium cells only in the group using the fibrin glue delivery vehicle. CONCLUSION: We conclude that cultured urothelial cells can be successfully reimplanted onto a prefabricated capsule-pouch via fibrin glue, showing potential for urinary reconstructions.     

Paraumbilical perforator flap without deep inferior epigastric vessels

With the introduction of supramicrosurgery, a new paraumbilical perforator flap without a deep inferior epigastric vessel and with very small perforator anastomoses was used for nine patients. The abdominal defects of two patients, the lower leg or foot defects of five patients, and the scalp defects of two patients were repaired with an island perforator flap. The advantages of the paraumbilical perforator flap are as follows: (1) there is a very short operating time for flap elevation; (2) there is no invasion or sacrifice of any rectus abdominis muscle; (3) for middle-aged, obese patients, the donor site may be the best from the cosmetic point of view; (4) many small recipient vessels to anastomose the perforator exist throughout the body; (5) a thin skin flap with adequate thickness can be created easily with simultaneous removal of fatty tissue; (6) secondary defatting around the perforator can be done by minor surgery under local anesthesia; and (7) a vascularized adiposal flap with adequate thickness can be created easily. This flap seems to be indicated for female patients with defects in the abdominal wall and the lower leg. The island flap can easily resurface abdominal skin defects, such as intestinal fistula or radiation ulcers. The free flap is suitable for covering defects in the lower leg, foot, and scalp temporarily before administration of a tissue expander.     

Prefabrication of bilaminar-epithelialized composite flap with tissue expander and cultured keratinocytes

This study investigated the feasibility of prefabrication of a bilaminar-epithelialized flap by using a tissue expander and cultured keratinocytes, for reconstruction of perforate defects in the oral cavity and upper aerodigestive tract. In each of six rats, a 10-ml volume expander was implanted under the inferior epigastric flap and a thin silicon catheter was introduced into periexpander space. Seven days after implantation, 10 x 10(6) cultured keratinocytes, isolated from inbred donor rats, were suspended in fibrin glue and injected into the periexpander space through the catheter (n = 4 of 6). The expansion was started immediately after cell inoculation and lasted at least 3 weeks at the speed of 2 to 3 ml every 5 to 7 days. At the end of expansion, the periexpander space was opened and the capsule around the tissue expander was found to be covered completely with a neoepithelium. Thus, a bilaminar-epithelialized flap based on femoral vessels was elevated and successfully transferred to cover the excisional perforate defect in the oral cavity with the neoepithelial side as inner lining. All flaps treated with 10 x 10(6) cultured keratinocytes survived with complete wound healing during a 1-week follow-up (n = 4 of 6). Both macroscopic and histologic findings demonstrated that a bilaminar-epithelialized composite flap can be fabricated by using a tissue expander and keratinocyte-fibrin glue suspension.     

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.     

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.     

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.