Use of lotus petal flap in the treatment of perineal hidradenitis suppurativa

Perineal hidradenitis suppurativa is a complex problem to treat. Various methods of treatment have been tried in the past, but recurrence was common. In this paper, we describe the use of the lotus petal flap in hidradenitis suppurativa of the perineum in three patients. Many local flaps have been used for covering the defect after excision of hidradenitis suppurativa; in our cases, we have used the lotus petal flap. Until now, this flap has been used for vaginal reconstruction after cancer surgery [Yii NW, Niranjan NS (1996) Lotus petal flaps in vulvo vaginal reconstruction. Br J Plast Surg 49(8):547–554, Hashimoto I et al (1999) Vulvo vaginal reconstruction with gluteal fold flaps. J Jpn P R S 19:92–98]. Three patients had five lotus petal flaps after the excision of perineal hidradenitis suppurativa, and there were no recurrences of the lesion in the excised area after follow-up at 2 years.     

The reverse posterior interosseous flap: A solution for flap necrosis based on a review of 87 cases.

PURPOSE: The relationship of the flap necrosis to the placement of the flaps on the forearm was outlined and a solution in avoiding flap necrosis is discussed. METHODS: The relationship of the flap necrosis to the placement of the flaps on the forearm was investigated in 87 consecutive posterior interosseous island flaps used for the reconstruction of the hand and wrist. Fifty-eight flaps were taken from the middle and proximal thirds of the forearm, the distal edges being within the middle third of the forearm in 24 and the distal edges being within the distal third of the forearm in 34. Twenty-nine flaps were harvested within the boundaries of the distal two-thirds of the forearm, the distal edge being proximal to the distal third of the forearm in 23 and the distal edge being distal to the third of the forearm in six. The Length of the flaps varied from 6.5 cm to 12 cm. The pedicle length measure 4-13 cm. The number of perforators for each flap was recorded also. RESULTS: Flaps survived complete in 78 (89.6%) patients. Six patients had superficial necrosis of the distal part of the flap (6.8%). Three flaps were totally lost and alternative coverage was used (3.8%). The flaps that ended up with partial necrosis appeared to be in related to the site it was taken from. One flap with total necrosis and one with partial ncrosis were taken within the boundaries of the proximal third of the forearm while the distal edge was proximal to the level of distal third. One flap with total necrosis and one with partial necrosis were taken from the proximal third of the forearm while their distal edge were at the limits of the distal third of the forearm. The remaining flap ending up with total necrosis was taken from the distal third of the forearm with a short pedicle. CONCLUSIONS: For the reverse posterior interosseous flap to be reliable the flap should include the septocutaneous perforators in the distal third of the forearm. To cover distant defects reliably by a flap with a long pedicle, the flap should extend up to the distal third of the forearm to include a piece of skin with numerous perforators.     

Venous flow-through flap as an external monitor for buried radial forearm free flap in head and neck reconstruction.

Postoperative monitoring of buried free flaps in head and neck reconstruction can be extremely difficult or impossible. The authors describe a series of 11 cases over a 21-month period, of buried radial forearm free flaps used in head and neck reconstruction. To monitor the main buried flap a small venous flow-through flap is supplied by and attached to the cephalic vein of a radial forearm free flap. This small venous skin flap is inset separately from the main paddle, so that it is visible at the external surface of the neck, furnishing information about the perfusion of the entire flap.     

Upper extremity salvage with a flow-through free flap

In complex extremity injuries, which include composite tissue lost with devascularization caused by segmental vascular damage, simultaneous coverage of the defects with revascularizations should be required. One-stage reconstruction of both soft tissue coverage and vascular damage can be performed by a flow-through-type free flap. In this series, 5 patients between 13 and 36 years of age with wide composite tissue defects in the cubital region and segmental defects in brachial arteries were operated at our clinic between 1996 and 2003. With the aim of reconstructing the wide tissue defects in the cubital region as well as that of the brachial artery, a radial arterial flow-through flap was applied. The radial artery of the flow-through flap was anastomosed to the proximal ends of the brachial and ulnar arteries in an end-to-end fashion. In 4 of the patients, the radial arterial flow-through flap was prepared from the distal aspect of the wounded forearm and in 1 patient from the contralateral forearm. In the postoperative period, no complications related to the anastomosis were encountered in the flap with all anastomoses found to be patent, and distal circulation was restored. The radial arterial flow-through flap is very useful in the clinical field of major trauma of the cubital region with brachial artery damage with numerous advantages that include the opportunity to work in one single surgical area, shorter dissection times resulting from simple and fixed anatomy, perfect color and tissue adaptation, and the suitability of the vessel caliber and length.     

Thermography of hands after a radial forearm flap has been harvested

To determine the change of blood flow in the hand after radial forearm flap harvest, several studies using thermography or color Doppler ultrasonography have been reported (Iida et al., Ann Plast Surg 49:156, 2002; Suominen and Asko-Seljavaara, Scand J Plast Reconstr Hand Surg 30:307, 1996). One study using Doppler ultrasonography (Iida et al., Ann Plast Surg 49:156, 2002) found reduced blood flow, while another study using thermography (Suominen and Asko-Seljavaara, Scand J Plast Reconstr Hand Surg 30:307, 1996) reported warm digits. However, the thermographic study did not examine the postoperative period. We evaluated temperature changes by thermography during three different postoperative periods: 3, 6, and 12 months. Differences in temperature were measured between the donor hand and the other hand in the resting state and after cold stress at the thenar eminence. The differences in temperature were divided into three grades. The donor hand was classified as being warmer, similar, or cooler than the other hand. There was a tendency for cold stress to accentuate differences in temperature. After cold stress, the percentage for warmer was 75.0% at 3 months, while similar increased to 87.5% at 6 and 12 months. The temperature of the donor hand increased for a limited period after surgery for up to 3 months, and the temperature of the donor hand became similar to that of the nondonor hand. Therefore, circulatory changes in the hand undergoing flap harvest are thought to be minimal. Considering other reports, we think the high temperature at the thenar eminence of the donor hand shortly after surgery is partially explained by sympathetic nerve damage.     

Creating two independent fasciocutaneous free flaps from a single radial forearm donor site

The authors describe the creation of two independent fasciocutaneous free flap units from a single radial forearm donor site. After the radial forearm flap is elevated in the standard manner, based on the entire length of the radial artery, the individual flap units are developed as island flaps based on the proximal and the distal radial artery respectively by transecting the radial artery, its accompanying veins, and the cephalic vein. Thus, two independent radial forearm free flaps are created from a single donor site: The proximal one has antegrade flow and the distal one has retrograde flow. The individual free flap units were transferred, and microvascular anastomoses were performed simultaneously by two surgical teams. This technique was used in 2 patients presenting with bilateral foot defects that required reconstruction with a thin, reliable flap such as the radial forearm flap.     

The radial (Chinese) flap in hand surgery

The radial (Chinese) flap is an fascio-cutaneous flap raised on the volar aspect of the forearm based on the radial pedicle axis which can be used either pedicled or by microsurgical free transfer. In hand and thumb reconstruction, it is used as an island flap vascularized by a reverse flow from the ulnar artery via the palmar arch, keeping the pivot point at the snuff box level. The possibility to raise a composite flap with vascularized bone or tendons make the chinese flap very useful in hand reconstruction. Of the 35 cases presented, there were 30 pedicled and 5 free flaps from the opposite forearm. The island flaps were reverse flow in 30 cases and with proximal pedicle in 5. In 4 cases the flap contained flexor carpi radialis longus tendon, and in 2 cases a bone graft from the radius. The five free radial flaps transferred from the contralateral side were used as flow-through flap. There were no vascular complications. The advantages and disadvantages of the methods are discussed.     

改良桡动脉穿支皮瓣在修复额面部组织缺损中的应用

目的 探讨改良桡动脉穿支皮瓣在修复额面部中小面积缺损中的临床应用.方法 以桡动脉腕上皮支动脉和桡动脉伴行静脉为蒂.通过筋膜蒂营养的前臂近端桡侧皮瓣(最大面积10 cm×5 cm),游离移植修复额面部肿瘤切除后的组织缺损10例.结果 修复额部缺损6例,面颊都缺损4例,术后皮瓣全部存活,经随访6～12个月后行皮瓣修薄整形术.10例病例经8～18个月随访,平均随访11.3个月,其中7例于术后6～9个月进行二次整形.所有病例皮瓣柔软,瘢痕不明显,皮色与面颊部基本接近,皮瓣两点分辨率在20～40mm.结论 改良的前臂桡动脉穿支皮瓣是修复额面部中小面积缺损的主要方法之一.     

The radial forearm flap

Described in 1981 by the Chinese authors Yang Kuofan et al. [1] as a free flap, then in 1982 by Lu et al. [2] as a retrograde flow pedicle flap, this fasciocutaneous flap is designed at the level of the anterior and external faces of the forearm, and vascularized by the radial artery via a network of septal arteries. Prior to utilization it must be reversed on its distal pedicle. This flap allows repairing cutaneous substance loss of the whole hand and fingers. The emergence of the Chinese flap in the 1980’s resulted in a regression of the Mac Gregor groin flap that was widely used at this time [3,4]. Nevertheless, other forearm flaps, less “expensive” in terms of vascular involvement [5–9] have reduced its indications. The Chinese flap however keeps two essential indications: the multi-finger important defect that no other forearmflapmay cover; and composite substance loss of the thumb (despite the fact that the Chinese flap shares these indications with interosseous artery composite flaps).     

The truly distal lateral arm flap: rationale and risk factors of a microsurgical workhorse in 30 patients

The forearm part of the extended lateral arm flap may be separately raised on the most distal septocutaneous perforator of the posterior collateral radial artery. This truly distal lateral arm flap shares most of the advantages of the radial forearm flap and is associated with less donor site morbidity. From April 2000 to March 2004, we used 30 such flaps as the fasciocutaneous free flap of choice, mostly for reconstructions in the head and neck region. The eventful postoperative course observed in 5 of these flaps motivated us to evaluate the rationale and risk factors of this procedure.We prospectively analyzed the influence on the incidence of partial or complete flap loss of 19 patient-related or procedure-related characteristics that may have acted as risk factors. None were found to be of statistical significance. We found the distal lateral arm flap to have a less robust vascular anatomy than the radial forearm flap, resulting in the need for advanced surgical expertise to raise and handle it. As we recognized the difficulty of this flap to be associated predominantly with this anatomy of its vascular pedicle, we now take a more liberal stand toward the possibility of intraoperative conversion to the use of a radial forearm flap.     

Reconstruction of the middle and lower face with three simultaneous free flaps: combined use of bilateral fibular flaps for maxillomandibular reconstruction

A 23-year-old man sustained massive maxillofacial destruction from a close-range, high-velocity gunshot injury. The devastating nature of the injury led to extensive soft-tissue and bone loss involving nearly the total middle and lower portions of his face, including the deeper anatomic structures. Reconstruction of this extraordinarily extensive and three-dimensional defect was accomplished by simultaneous transfer of three free flaps during one session. A specially designed radial forearm flap replaced the internal lining and external cover of the nose, a large fibular osteocutaneous flap restored the lower face, and a second fibular osteocutaneous flap harvested from the other leg restored the midface. The second fibular flap was revascularized by combining it with the first one in a flow-through manner, and its pedicle vessels were anastomosed to the distal ends of the vessels of the first flap. Dorsal nasal reconstruction with an expanded paramedian forehead flap, commissurotomy, and intraoral flap debulking were additional procedures performed to improve cosmetic and functional outcome during the following 1-year period. Along with a radial forearm flap, combined use of bilateral osteocutaneous fibular flaps provided simultaneous, single-stage reconstruction of a huge facial defect involving both the lower and middle face with an acceptable result.     

An effective pharyngoesophageal reconstruction with free radial forearm flaps

Summary Treatment of cancer of the cervical aerodigestive tract is challenging due in part to the difficulty in reestablishment of pharyngoesophageal continuity after resection of the involved tract. From May 1989 to August 1990, six patients underwent immediate reconstruction utilizing microvascular transfer of free radial forearm flaps following resection of pharyngoesophageal neoplasms. A small island flap connected to the radial vascular pedicle by fasciocutaneous branch was used to monitor the vascular condition of the hidden fabricated free forearm flap. Stricture is the most troublesome complication of esophageal reconstruction using a conventional free forearm flap. Two small triangular flaps were designed and inserted bilaterally in the distal anastomosis of both lateral esophageal walls to prevent circular contracture. The outer layer sutures were anchored to surrounding rigid structures to withstand shrinkage and circular contraction. The problem of stricture was solved by these procedures. This one-stage, easily monitored operation for pharyngoesophageal reconstruction is considered to be as useful as a free jejunal transfer.     

Free anterolateral thigh flap for reconstruction of head and neck defects: preliminary results and a comparison with the radial forearm flap

BACKGROUND: The authors present their personal preliminary experience with the free anterolateral thigh flap in the reconstruction of head and neck defects and compare these first cases with the radial forearm flaps. METHODS: Seventeen patients undergoing free flap reconstruction between December 1998 and September 2001 have been selected for this retrospective study and evaluated. In fourteeen patients reconstruction was performed with a radial forearm flap. In three patients an anterolateral thigh flap was used. Six dissections on cadavers have also been performed in order to study the anatomical variations of the perforators of the lateral circumflex femoral system. RESULTS: All flaps survived, without any major vascular impairment. CONCLUSIONS: Despite a laborious dissection of the pedicle the anterolateral thigh is a versatile flap, with a minimal morbidity of the donor area. Even if the radial forearm is overall accepted as the gold standard for head and neck reconstruction, the anterolateral thigh flap is suggested as a good and safe surgical option, especially when a large flap is requested or in female patients concerned with the cosmetic result in the forearm donor area.     

Fascial flaps based on perforators for reconstruction of defects in the distal forearm.

Twenty fascial flaps were used in the reconstruction of defects in the distal forearm, wrist and hand in 18 patients over a 2-year period. In 16 patients the fascial flaps were based on a single fascial feeding vessel or 'perforator' arising from the anterior interosseous artery and/or ulnar artery when the radial artery had been used as the donor vessel in free flap reconstruction elsewhere in the body. There was no loss of any fascial flap in the study. The use of fascial flaps based on fascial feeders of the anterior interosseous and ulnar arteries extends the range of fascial flaps that can be raised in the forearm for reconstruction of defects in the distal forearm, wrist and hand.     

The use of innervated radial artery superficial palmar branch perforator free flap for complex digital injuries reconstruction

Loco-regional flaps have been widely used for the reconstruction of digital injuries without requiring microvascular anastomosis, however, they result in scarring and compromised functional outcomes. This study demonstrates our experience utilizing the innervated radial artery superficial palmar branch (RASPB) perforator free flap for complex digital injury reconstruction. From May 2007 to March 2014, the innervated RASPB perforator free flap was used to reconstruct 79 distal complex hand and digital soft tissue defects of which 14 were used to re-vascularise the distal digit in a flow-through fashion. All free flaps were innervated by the palmar cutaneous branch of the median nerve. All 79 free flaps survived and all 14 digits re-vascularized successfully. One flow-through free flap developed distal skin necrosis which healed uneventfully without further procedure. The average follow-up was 21.5 months. Measurement of two-point discrimination ranged from 7 to 13?mm. All patients were satisfied with the aesthetic results. The innervated RASPB perforator free flap is a feasible and effective option for the reconstruction of complex digital defects and the flow-through concept, when utilized in cases with compromised vascularity, provides reliable re-vascularization. Level III, therapeutic study.     

A new flap design for monitoring the circulation of a buried free radial forearm flap in pharyngoesophageal reconstruction

The viability of a free radial forearm flap which is used in pharyngoesophageal reconstruction is difficult to monitor because it is hidden by skin. As the most reliable method for monitoring, exteriorization of a small island flap has been reported. The authors used a skin paddle which is placed ulnar to the radial forearm reconstruction flap at the ulnar side of the distal part of the forearm as a monitor flap in one patient. Flap viability was assessed by observing tissue color, turgor, capillary refill, and bleeding of the monitor flap. This monitor flap is easy to elevate. The perfusion of the flap is good because it has a wide pedicle. It permits a long vascular pedicle for the radial forearm reconstruction flap and does not reduce available forearm skin for pharyngoesophageal reconstruction.     

Single-stage muscle flap reconstruction of major scrotal defects: report of two cases.

Major scrotal defect with exposed testes and/or spermatic cords are a challenge for the reconstructive surgeon. The bacterial flora of the perineum, difficulty of immobilisation and the contour of the testes make testicular cover a difficult task [Br. J. Plast. Surg. 41 (1988) 190].Traditional approaches have used simple skin grafts or if not feasible, multi-staged procedures with initial burying of the testes under delayed medial thigh flaps. Better techniques then evolved to permit early single-staged coverage using flaps rather than skin grafts in these usually contaminated and unsuitable wounds to improve the cosmetic outcome of the reconstruction and reduce patient discomfort and hospital stay.Muscle flaps represent an excellent reconstruction option in the contaminated perineum especially in patients with impaired ability to deal with infection such as diabetic or toxic patients.We present two cases of reconstruction of the scrotum using simple, reliable single-stage muscle flap techniques with good aesthetic results and review the literature.     

Microvascular reconstruction of the columella using a small radial forearm free flap: a case report

Columellar defects can result from various causes, a number of methods have been described for the reconstruction using local, regional, or free flaps. When local tissues are not available due to the presence of scars, free flaps become the treatment of choice. We present the case of a columellar defect resulting from a distal necrosis of a forehead flap in total nasal reconstruction. The columella was reconstructed using a small radial forearm free flap and a conchal cartilage graft. The flap and the graft survived completely with a satisfactory cosmetic result and good respiratory function during the follow-up time of 2 years. The result was achieved in a single-stage operation: the patient did not need any further procedures to improve the nasal appearance. We propose that the radial forearm free flap may be an easy and reliable alternative among the surgical options for columellar defects when local tissues are not available.     

Thumb reconstruction using a neurovascular pedicled island flap

Since June 1983, seven kinds of neurovascular pedicled island flaps have been applied for thumb reconstruction in 14 cases with satisfied results. The donor flaps were from dorsum of index finger in 4 cases, from radial aspect of index in 3 cases, from both the dorsum and the radial aspect of index in 2 cases, from the dorsum and radial aspect of the index finger and the radial aspect of long finger in 2 cases, from the ulnar aspect of the index and the radial aspect of long finger in 2 cases, and from the radial aspect of forearm in 1 case. In other case, the thumb was reconstructed by an osteocutaneous flap arising from radial aspect of forearm. The procedures are faster, simpler and safer than the microsurgical flap transfer: the contour and function are better than those of traditional tube-pedicle graft.     

Pedicled deltoid hatchet flap for treatment of pressure sore at the shoulder

Whereas decubitus ulcer in the back or hip region is a common entity in plegic or elderly patients, the occurrence in the lateral shoulder region is seldom seen. However, resulting from continuous lateral decubitus positioning or limited compliance by the patient, pressure sores may occur in almost any region of the body, but predominately, they arise in acral zones with underlying bone prominences. The deltoid area is such an anatomically critical region, especially if the underlying deltoid muscle is paralyzed. The transposition of a pedicled deltoid flap, slightly modified as a hatchet flap, is described for cover of a decubitus ulcer in the deltoid region in a paraplegic male. Although utilization of the deltoid flap as a free flap is an established procedure for selected indications [Russell et al. (1985) Extremity reconstruction using the free deltoid flap. Plast Reconstr Surg 76:586–595, Serafin D (1996) The deltoid flap. In: Serafin D (ed) Atlas of microsurgical composite tissue transplantation, chapter 19. Saunders, Philadelphia, PA, pp 153–159, Wang et al. (2003) The free deltoid flap: microscopic anatomy studies and clinical application to oral cavity reconstruction. Plast Reconstr Surg 112:404–411], transposition as a pedicled flap, to the best of our knowledge, has not been previously described in the available literature.