The thin circumflex scapular artery perforator flap.

The development of microsurgery has most recently been focused upon the evolution of perforator flaps, with the aim of minimising donor site morbidity, and avoiding the transfer of functionally unnecessary tissues. The vascular basis of perforator flaps also facilitates radical primary thinning prior to flap transfer, when appropriate. Based upon initial clinical observations, cadaveric, and radiological studies, we describe a new, thin, perforator flap based upon the circumflex scapular artery (CSA). A perforator vessel was found to arise within 1.5cm of the CSA bifurcation (arising from the main trunk, or the descending branch). The perforator arborises into the sub-dermal vascular plexus of the dorsal scapular skin, permitting the elevation and primary thinning of a skin flap. This thin flap has been employed in a series of five clinical cases to reconstruct defects of the axilla (two cases of hidradenitis suppurativa; pedicled transfers), and upper limb (one sarcoma, one brachial to radial artery flowthrough revascularisation plus antecubital fossa reconstruction, and one hand reconstruction with a chimeric flap incorporating vascularised bone, fascia, and thin skin flaps; free tissue transfers). No intramuscular perforator dissection is required; pedicle length is 8-10cm and vessel diameter 2-4mm. There was no significant peri-operative complication or flap failure, all donor sites were closed primarily, patient satisfaction was high, and initial reconstructive aims were achieved in all cases. Surgical technique, and the vascular basis of the flap are described. The thin circumflex scapular artery perforator flap requires no intramuscular dissection yet provides high quality skin (whose characteristics can be varied by orientation of the skin paddle), and multiple chimeric options. The donor site is relatively hair-free, has favourable cosmesis and no known functional morbidity. This flap represents a promising addition to the existing range of perforator flaps.     

Serratus anterior free fascial flap for dorsal hand coverage.

Reconstruction of the dorsal surface of hand defects requires thin, pliable, well-vascularized tissue with a gliding surface for the extensor tendon course. Fasciocutaneous or fascial flaps are the two surgical options. Fascial flaps present the advantages of thinness and low donor site morbidity. The authors present 4 cases of serratus anterior free fascial flap (SAFFF) used to cover the dorsum of the hand. The SAFFF with skin graft has many advantages for a fascial flap: long, constant vascular pedicle; very thin, well-vascularized tissue; low donor site morbidity; and the possibility of simultaneous donor and recipient site dissection. Furthermore, it can be associated with other flaps of the subscapular system for complex reconstructions. Of the 4 observations described, 2 used associated flaps, 1 used the SAFFF with a latissimus dorsi flap, and 1 used a scapular bone flap with the SAFFF. One flap was lost due to an electrical lesion to the forearm vessels.     

Reconstruction of through-and-through osteocutaneous defects of the mouth and face with subscapular system flaps

BACKGROUND: Major ablative surgery in the head and neck region may create composite defects involving the oral mucosa, bone and the overlying facial skin. The large surface area and the three-dimensional nature of these defects pose a difficult reconstructive challenge requiring adequate bone and large, positionally versatile skin flaps. PATIENTS AND METHODS: From September 1993 to May 2000, 19 patients with through-and-through osteocutaneous defects of the mouth and face were reconstructed with composite subscapular artery system flaps. The evaluated parameters included: (i) site and dimensions of the tissue defect; (ii) specific flap properties; and (iii) review of the recipient and donor site morbidity. RESULTS: 10 variants of scapular osteocutaneous flaps, eight latissimus dorsi with serratus anterior and rib osteo-myocutaneous flaps, and one combination of an osteocutaneous scapular and myocutaneous latissimus dorsi flap were used to reconstruct composite facial defects with mean dimensions of: skin 54.4 cm(2), mucosa 56.2 cm(2) and bone of 8.2 cm. Ischaemic complications occurred in three patients including one total flap failure and one failure of the bony component in previously irradiated patients. The third flap was successfully salvaged. No significant long-term donor site morbidity was noted. CONCLUSION: Composite flaps based on the subscapular artery system are a versatile reconstructive modality for large through-and-through defects of the mouth and face.     

Free flaps in the reconstruction of hand and distal forearm injuries.

We report a series of 32 free flap reconstructions following acute hand and forearm trauma. The series consists of two dorsalis pedis flaps, four scapular flaps and 26 lateral arm flaps. One flap became infected and failed completely, and a partial necrosis occurred in another flap. The transfers covered large skin defects, exposed tendons, tendon grafts, bone, bone grafts, joints, nerves and nerve grafts. The donor site morbidity was negligible. Our study shows that free microvascular flaps are a safe and convenient alternative to conventional flaps in hand surgery. The lateral arm flap seems very suitable for small and medium size defects.     

前锯肌肌肉筋膜瓣桥式移植修复小腿软组织缺损

目的 总结游离前锯肌肌肉筋膜瓣桥式移植修复小腿软组织缺损的临床应用经验.方法 2006年9月至2009年1月应用游离前锯肌肌肉筋膜瓣桥式移植修复7例小腿软组织缺损.肌肉筋膜瓣切取连带肩胛下与旋肩胛血管,血管蒂呈T形,与健侧小腿胫后动脉两断端行端端吻合,肌肉筋膜瓣及其血管蒂用中厚皮片网状移植覆盖.结果 7例肌肉筋膜瓣全部成活.术后经过顺利,取得了较满意的效果.随访9～42个月,供区无明显功能障碍,且供、受区外形均较好.健侧小腿经临床观察与多普勒超声血流探测仪检查,胫后动脉通畅.结论 该术式适宜修复小腿软组织缺损仅有1条主要动脉者,不损伤健侧小腿胫后动脉,且对供区的损伤也较轻.

Abstract：

Objective To investigate the application of free anterior serratus musculo-fascial flap in bridge style for the soft tissue defect at leg.Methods From Sept.2006 to Jan.2009,the free anterior serratus musculo-fascial flaps were used in bridge style in 7 cases with soft tissue defects at legs.The anterior serratus musculo-fascial flaps were elevated with subscapular and circumflex scapular vessels forming a T-shaped vascular pedicles.The T-shaped pedicle was end-to-end anastomosed with the two ends of the posterior tibial artery at the healthy leg.The musculo-fascial flap and its pedicle were covered with skin graft.Results All the 7 flaps survived completely with satisfactory result.The patients were followed up for 9-42 months with good functional and esthetic result both in donor site and recipient site.The patency of posterior tibial artery was demonstrated by clinical and Doppler examination.Conclusions This technique is particularly useful in leg reconstructive surgery when only one vessel remains.The patency of the posterior tibial artery at the healthy leg is preserved and the morbidity in donor site is minimal.     

Consecutive flap transfer for repairing massive soft tissue defects in the opisthenar with improved donor site closure

Objective：To explore a surgical model of utilizing consecutive free scapular flap and adjacent pedicled flap transfer for repairing massive soft tissue defects on the dorsum of the hand while minimizing the donor site morbidity.Methods：Six patients with massive soft tissue injuries on the opisthenar and forearm were treated with free scapular flaps.Afterwards,a pedicled flap adjacent to the donor site was transferred to cover the donor site defect by direct closure.Results：All six free scapular flaps survived without signs of infection.Three adjacent pedicled flaps presented minor signs of insufficient blood flow on the distal apex,which resolved after six weeks with only conservative therapy.All the incisions healed without other complications.At six-month follow-up,the patients regained full shoulder function.Conclusion：With the assistance of an adjacent pedicled flap,the scapular flap is a highly applicable approach in repairing massive soft tissue defects in the opisthenar.It can achieve positive outcomes in both reconstructive and aesthetic aspects.     

Medial sural artery perforator flap for intraoral reconstruction following cancer ablation

In oral cavity reconstruction, the fasciocutaneous flaps of the distal extremities have always been preferred to any other kind of flap because of their thinness and pliability, which makes them adaptable to different areas in the oral cavity. The radial forearm flap is frequently considered the first choice for intraoral reconstruction, but the disadvantages of donor site morbidity include sacrificing a major artery to the hand and leaving a conspicuous donor site scar. The search for another primarily thinned skin flap as an alternative has led to the application of the medial sural artery perforator flap, which is harvested from the medial aspect of the upper calf. Between June 2003 and March 2007, 22 free medial sural artery perforator flaps were transferred for intraoral defects after cancer ablation, including tongue and floor of mouth (15 cases), buccal mucosa (5 cases), retromolar trigone (1 case), and anterior floor of mouth (1 case). We paid attention to the major perforator (vein > or =1 mm), which was confirmed by the endoscope, as the vascular relay for the skin flap. The size of the skin paddle varied from 7.5 x 4 cm to 17 x 8 cm. The main advantage of this flap is that it provides thin and pliable coverage to achieve better accuracy in the oral cavity. Other advantages of minimizing donor site morbidity include maintaining the function of the medial gastrocnemius muscle, avoiding the need to sacrifice major arteries of the leg, and possible primary closure of the donor defect.     

Technical refinements of composite thoracodorsal system free flaps for 1-stage lower extremity reconstruction resulting in reduced donor-site morbidity

A multitude of local flaps has been suggested for lower extremity reconstruction. However, the gold standard for defect coverage remains free tissue transfer. In this regard, the scapular vascular axis is a well-established source of expendable skin, fascia, muscle, and bone for use in free flap reconstruction of defects requiring bone and soft tissue in complex 3-dimensional relationships.Composite bone and soft-tissue flaps derived from the subscapular vascular axis include the osteocutaneous scapular flap, the "latissimus/bone flap," and the thoracodorsal artery perforator-scapular osteocutaneous flap.Patient outcome following reconstruction of lower extremity defects with composite free flaps from the thoracodorsal system were analyzed. Here, we demonstrate the execution of technical refinements on free composite flap transfers based on the thoracodorsal vascular axis, thus resulting in a stepwise reduction of donor-site morbidity.     

Clinical application of a free scapular fascial flap

The free scapular fascial flap based on the circumflex scapular vessels with skin graft on top has been used to cover the soft-tissue defects in 6 cases--5 hands and 1 foot, over the past one year. The size of the fascial flap ranged from 10 x 6 to 13 x 7 cm. Five flaps were survival completely and one with loss of a small portion due to infection. Compared with the cutaneous flap, myocutaneous flap or muscular flap, the fascial flap is thinner, showing no bulkiness on the recipient site, and also no impairment was noted in the donor site. The shortcoming is darker colour of the skin graft overlying it. The authors consider that the free fascial flap is mainly indicated for the soft-tissue defects of the extremities and those sites where no augmentation is required.     

游离腓动脉穿支筋膜瓣修复手部皮肤缺损

目的 探讨应用游离腓动脉穿支筋膜瓣修复手部软组织缺损,减少供区损伤的方法和临床效果.方法 2007年12月至2009年10月,对6例手部皮肤缺损患者,应用游离腓动脉肌皮穿支筋膜瓣进行修复,切取面积为5.0 cm×4.5 cm～10.0 cm×7.0 cm,以肌皮穿支为蒂.动脉血管蒂与受区血管采用端侧吻合,受区筋膜瓣行断层植皮覆盖.供区创面直接缝合.结果 术后6例筋膜瓣全部存活;术后7 d,筋膜表面植皮成活大于90%4例,80%2例.随访时间为3～12个月,1例皮瓣臃肿,术后3个月行皮瓣修整术;5例皮瓣略臃肿,外观满意.小腿供区仅留线条瘢痕.结论 腓动脉穿支筋膜瓣是在腓动脉穿支皮瓣基础上的改良,目的 是减少供区创伤,改善小腿外观.筋膜瓣本身可以填充组织缺损,为功能重建提供条件.     

Reverse digital artery flap from radial and ulnar borders of palm

Reconstructing skin defects of the volar aspect of fingers can be a challenging task due to a lack of local expendable tissue. The reverse digital artery flap is a versatile and reliable technique that can be used to manage such disabling injuries. Various authors have used this flap effectively, but most have used the digit itself as the donor site. This limits the size of the flap and also necessitates skin grafting to cover the donor site. Large reverse digital artery flaps can be raised from the radial and ulnar borders of the palm facilitating coverage of significant digital defects and primary closure of the donor site, resulting in minimal donor-site morbidity. We describe 3 illustrative cases to highlight the flaps versatility.     

Free ascending scapular flap.

Four patients with free tissue transfer using ascending cutaneous branches of circumflex scapular vessels are herein presented. The free ascending scapular flap is located on the superior vertical axis, differentiated with the scapular flap horizontally and the parascapular flap vertically designed. The flap is an excellent choice because of easy dissection, a constant artery and venous system, 2- to 3-mm-diameter vessels, and sufficient length of the vascular pedicle. All flaps survived completely with a fairly thin skin. The shoulder donor site could be closed primarily. No functional deficit of the shoulder was observed.     

Free digital artery flap: an ideal flap for large finger defects in situations where local flaps are precluded

The heterodigital arterialized flap is increasingly accepted as a flap of choice for reconstruction of large finger wounds. However, in situations where the adjacent fingers sustained concomitant injuries, the use of this flap as a local flap is precluded. This paper describes our experience with the free digital artery flap as an evolution of the heterodigital arterialized flap. Four patients with large finger wounds were reconstructed with free digital artery flap. Our indications for digital artery free flap were concomitant injuries to adjacent fingers that precluded their use as donor sites. The arterial supply of the flap was from the digital artery and the venous drainage was from the dominant dorsal vein of the finger. The flap was harvested from the ulnar side of the finger. The digital nerve was left in situ to minimize donor morbidity. The donor site was covered with a full-thickness skin graft and secured with bolster dressings. Early intensive mobilization was implemented for all patients. All flaps survived. No venous congestion was noted and primary healing was achieved in all flaps. In addition to providing well-vascularized tissue for coverage of vital structures, the digital artery was also used as a flow-through flap for finger revascularization in one patient. Donor-site morbidity was minimal, with all fingers retaining protective pulp sensation and the distal and proximal interphalangeal joints retaining full ranges of motion. In conclusion, the free digital artery flap is a versatile flap that is ideal for coverage of large-sized finger defects in situations where local flaps are unavailable. Donor-site morbidity can be minimized by preservation of the digital nerve, firmly securing the skin graft with bolster dressings, and early mobilization of the donor finger.     

Free latissimus dorsi flap transfer for subtotal scalp and cranium defect reconstruction: report of 7 cases

OBJECT: The purpose of the paper is to review the results of free latissimus dorsi transfer for scalp and cranium reconstruction in case of large defects with exposed brain tissue, deperiosted cranial bone, and dura that cannot be reconstructed with local flaps or skin grafts. METHODS: Free latissimus dorsi transfer was carried out in an interdisciplinary approach involving neurosurgery and plastic surgery in seven patients with subtotal and total scalp defects (two reconstruction after tumor removal, two reconstructions after longstanding osteitis, 2x tissue break down after irradiation, 1x defect reconstruction after high voltage injury). There were three male and four female patients. The age ranged from 36 to 72 years. Reconstruction was carried out with a muscle flap (1x) or a myo-cutaneous flap (6x) in combination with a split thickness skin mesh (1:1.5) graft, done in a single-stage procedure. In a retrospective clinical study the following criteria were evaluated: 1) flap healing, 2) esthetic result, and 3) complications. All flaps healed primarily, and all wound remained closed without any signs of infection. Complete wound healing was achieved after 4-8 weeks, depending on the healing of the skin grafts. Secondary skin grafting was necessary in two patients, revision of the donor site in two patients. From an esthetic point of view four patients complained about the appearance of the retroauricular skin island. After removal of the skin island 6 months after the initial operation, all patient judged the result as good or acceptable. CONCLUSION: Besides the free omentum flap, the free latissimus dorsi transfer is the only option for coverage of subtotal or total scalp defects. Compared to the omentum flap, the latissimus dorsi offers more tissue, has less donor site morbidity, and secondary surgery such as cranial bone reconstruction is possible. Contrary to most authors, our preferred donor vessels are maxillary artery and the external jugular vein. To avoid any vascular compression we are using a myo-cutaneous flap. The skin island must be removed secondarily. In patients were no bone reconstruction is possible or planned, the deepithelialized skin paddle can be used for correction of a contour defect.     

桥式交叉"T"形血管吻合游离背阔肌皮瓣移植修复小腿软组织缺损

目的 介绍改进桥式交叉游离皮瓣移植的手术方法并总结分析.方法 2003年9月至2007年5月,应用桥式交叉"T"形血管吻合游离背阔肌皮瓣移植方法修复小腿软组织缺损患者6例.男5例,女1例;年龄21～48岁(平均32岁).软组织缺损范围20 cm×9 cm～32 cm×11 cm.皮瓣血管蒂切取时携带肩胛下与旋肩胛血管,使蒂呈"T"形,将其与健侧小腿胫后动脉两断端行端端吻合,血管蒂行中厚网状游离植皮包裹,未用皮管,小腿供区切口直接缝合.结果 1例术后皮瓣远端发生小的表浅感染,换药2周后愈合,皮瓣全部成活,术后经过顺利,获得较满意的效果.随访6个月～4年(平均2.7年),未发现明显的供区功能障碍.供区与皮瓣外形较好,供区小腿经临床观察与多普勒检查证实胫后动脉通畅.结论 利用"T"形血管与胫后血管吻合,降低对侧小腿供区的损伤,只要血管吻合质量好,对皮瓣血供无影响.这种技术特别适用于小腿软组织缺损须行血管吻合的皮瓣修复、但肢体仅有一根主要血管的病例.     

游离肩胛区骨皮瓣在舌和口底及下颌骨联合缺损修复中的应用

目的：介绍游离肩胛区骨皮瓣在舌、口底和下颌骨缺损修复中的临床实践。方法：应用肩胛区骨皮瓣游离移植修复因舌癌行扩大根治切除术后的舌、口底、下颌骨联合缺损病人2例,术中根据下颌骨、牙槽、口底和舌缺损的大小设计肩胛区骨皮瓣;术中顺向或逆向寻找血管蒂,掀起肩胛区骨皮瓣,游离移植于口内,吻合血管,固定肩胛骨瓣于颌骨缺损内,将皮瓣与口内缺损创缘缝合,覆盖牙槽、口底、再造舌。结果：骨皮瓣全部成活。患侧颌面形态和舌外形恢复满意。其中1例患者术后5天死亡,死因疑为消化道大出血。结论：肩胛区骨皮瓣具有血管恒定、切口隐蔽、对供区功能影响小、可供组织种类和组织量多、修复范围广等特点,是修复头颈部复合缺损的一种比较满意的方法。     

Reconstruction of large palatal defects using the free anterolateral thigh flap

The ideal reconstructive method for the palatal defect should provide durable, stable coverage, and a natural contour, while simultaneously minimizing morbidity of both the defect and donor sites. Although small and usual palatal defects can be repaired easily using local adjacent tissues, successful closure of large, complex defects is still a challenging problem. Numerous free tissue options have to date been described for large palatal defects. Although the radial forearm flap constitutes a good option for ideal reconstructive goals, the sacrifice of a major artery to the hand and the skin graft to the forearm with its high potential risk of complications are evident problems attendant upon this donor site. Since the first report of the anterolateral thigh flap, this has become one of the most commonly used flaps for the reconstruction of various soft-tissue defects. Between April 2005 and May 2009, 8 free anterolateral thigh flaps were used to reconstruct defects of the palate. The study involved 6 male and 2 female patients, their ages ranging from 3 to 45. Five patients had palatal defects due to congenital cleft palate deformity, 2 patients had defects due to tumor resection, and the remaining patient had a palatal defect due to a gunshot wound. The size of the flaps ranged from 8 to 14 cm in length and from 4 to 7 cm in width. Facial vessels were used as recipient vascular sources in all patients. Primary thinning of the flap was performed in all cases. Donor sites were closed directly and healed uneventfully in all patients. There were no postoperative complications and all flaps survived totally. No debulking was needed. All patients, and their families in the case of child patients, were satisfied with the results of their surgical treatment. In conclusion, although it has some irregularity in derivation from the main vessels, with its evident structural and cosmetic advantages the anterolateral thigh flap can be considered an excellent and ideal free flap option for most large palatal defects that cannot be closed by regional tissue in selected patients. It can reconstruct defects in single stage with well-vascularized tissue, resulting in minimal donor site morbidity.     

Free latissimus dorsi flap transfer for subtotal scalp and cranium defect reconstruction: report of seven cases

The purpose of this paper is to review the results of free latissimus dorsi transfer for scalp and cranial reconstruction in the case of large defects with exposed brain tissue, cranial bone without periosteal cover, and dura, which cannot be reconstructed with local flaps or skin grafts. Free latissimus dorsi transfer was carried out in seven patients with subtotal and total scalp defects (two reconstruction after tumor removal, two reconstructions after long-standing osteitis, two tissue breakdown after irradiation, one defect reconstruction after high voltage injury). There were three male and four female patients. The age ranged from 36 to 72 years. Reconstruction was performed with a muscle flap (1) or a myocutaneous flap (6) in combination with a split-thickness skin mesh (1:1.5) graft in a single-stage procedure. In a retrospective clinical study, the following criteria were evaluated: (1) flap healing, (2) aesthetic result, and (3) complications. All flaps healed primarily, and all wounds remained closed without any signs of infection. Complete wound healing was achieved after 4 to 8 weeks, depending on the “take” of the skin grafts. Secondary skin grafting was necessary in two patients, while revision of the donor site was necessary in two patients. From an aesthetic point of view, four patients complained about the appearance of the retroauricular skin island. After removal of the skin island 6 months after the initial operation, all patients judged the result as good or acceptable. Besides the free omentum flap, the free latissimus dorsi transfer is the only option for cover of subtotal or total scalp defects. Compared to the omentum flap, the latissimus dorsi offers more tissue, has less donor site morbidity, and secondary surgery such as cranial bone reconstruction is possible. Contrary to most authors, our preferred donor vessels are maxillary artery and the external jugular vein. To avoid any vascular compression, we use a myocutaneous flap. The skin island must be removed secondarily. In patients where no bone reconstruction is possible or planned, the de-epithelialized skin paddle can be used for correction of a contour defect.This work was presented at the Spring Meeting of the Belgian Society for Plastic, Reconstructive and Aesthetic Surgery, May 8, 2004 in Ghent, Belgium.     

游离胸背动脉穿支皮瓣桥式移植修复小腿软组织缺损

目的总结游离胸背动脉穿支皮瓣或肌瓣桥式移植修复小腿软组织缺损的临床应用效果。方法自2006年9月至2009年1月,应用游离胸背动脉穿支皮瓣或肌瓣桥式移植修复小腿软组织缺损11例,缺损范围4cm×8cm至8cm×22cm。皮瓣切取连带肩胛下与旋肩胛血管,血管蒂呈T形,与健侧小腿胫后动脉行端端吻合,血管蒂用中厚网状游离植皮覆盖。结果除1例术后皮瓣远端发生小的表浅感染,经换药后愈合外,本组皮瓣全部成活。术后随访9个月至3.6年(平均2.9年),没有发现明显的供区功能障碍,供区与受区外形较好,健侧小腿经临床观察与Doppler检查,胫后动脉通畅。结论本方法适用于修复四肢软组织缺损后,患者仅存1条主要动脉者;行桥式游离胸背动脉穿支皮瓣或肌瓣移植不损伤健侧小腿胫后动脉,降低了对供区的损伤。     

跖内侧皮瓣联合肋骨移植修复多手指末节骨与软组织缺损

目的 总结跖内侧皮瓣联合肋骨移植修复多手指末节掌侧骨与软组织缺损的临床应用结果. 方法 2004年2月至2006年7月,应用吻合血管的跖内侧皮瓣联合肋骨移植修复5例(男4例,女1例)手指末节掌侧骨与软组织缺损,年龄19～43岁(平均31岁).其中,双指损伤3例,3指损伤2例.皮瓣血管蒂与受区的血管行端端吻合,供区创面行中厚网状游离植皮修复. 结果 1例术后供区发生表浅感染,经更换敷料逐渐自行愈合.皮瓣全部成活,随访10～28个月(平均19个月),供区与受区外形较好,手指感觉恢复.两点分辨觉5～14 mm(平均8 mm).结论 跖内侧皮瓣以跖内侧动脉为血供,血运丰富、血管解剖恒定、血管蒂长以及切取容易,联合肋骨移植很适宜修复多手指末节掌侧骨与软组织缺损.