Soft tissue coverage of the elbow: a reconstructive algorithm

Soft tissue defects can occur for various reasons, but they are primarily due to trauma, tumor, and infection. Coverage choices may include primary closure, skin grafting, local cutaneous flaps, fasciocutaneous transposition flaps, island fascial or fasciocutaneous flaps, muscle or myocutaneous pedicled flaps, and microvascular free-tissue transfer. Despite the multitude of options for coverage, the authors have found four flaps to provide reliable coverage for most elbow deficits within their practice; these flaps are the latissimus dorsi flap, the radial forearm flap, the anconeus flap, and the free anterior lateral thigh flap. This article provides an overview of treatment options for elbow coverage, with specific emphasis on the use of these four specific flaps.     

带蒂联合皮瓣移植修复上肢广泛软组织缺损

目的 探讨上肢广泛软组织缺损皮瓣修复方法的选择.方法 12例肘部、前臂及腕掌部高压电烧伤、热压伤及碾压伤患者,清创后4例应用背阔肌肌皮瓣与髂腰部皮瓣联合修复,将背阔肌肌皮瓣部分形成岛状,胸背血管蒂通过腋窝,上臂内侧皮下,髂腰部皮瓣部分以旋髂浅血管为蒂,皮瓣的蒂部形成皮管,位于腹股沟处,3周后再行断蒂;2例背阔肌肌皮瓣与侧胸皮瓣联合,将胸背动静脉游离出置于侧胸皮瓣内后形成皮管.蒂部位于侧胸上部;6例以巨大胸腹部联合皮瓣带蒂转移修复,以脐旁血管及肋间血管外侧皮支为轴,形成巨大皮瓣包绕前臂环形创面.结果 1例皮瓣远端局限坏死2 cm及皮瓣下感染,余全部成活,效果满意.结论 上肢创伤广泛软组织缺损,早期清创,应用带蒂联合皮瓣、肌皮瓣修复是一种简单、安全、可靠的方法.     

The use of pedicled perforator flaps for reconstruction of lumbosacral defects

Large lumbosacral defects remain a difficult challenge in reconstructive surgery, especially in the nonparaplegic patient. Traditional options for closure include local rotation or transposition flaps and musculocutaneous flaps. These flaps, however, are not an optimal option in previously irradiated or operated areas, or in cases of large defects. Application of the perforator principle to the traditional musculocutaneous flap creates perforator flaps, which are an additional tool in the treatment of these defects in the nonparaplegic patient. A large amount of healthy, well-vascularized tissue can be transferred on one perforator without sacrificing important underlying muscles. The arc of rotation is also larger than in traditional flaps. The authors present an anatomic overview of three types of pedicled perforator flaps: the superior gluteal artery perforator flap, the lumbar artery perforator flap, and the intercostal artery perforator flap. They also report 4 patients in whom a pedicled perforator flap was used to reconstruct a large lumbosacral defect.     

The medial arm pedicled perforator flap: Application of phenomenon of one perforator perfusing multiple perforator angiosomes

BackgroundThe medial arm is an optimal potential donor site for treating skin defects around the elbow. However, whether a reliable pedicled perforator flap could be harvested from the medial arm remains unanswered. The purpose of this study was to report the technique and our results using the medial arm pedicled perforator flaps.MethodsA total of eight flaps in seven patients underwent the medial arm pedicled perforator flaps to treat skin defects around the elbow. The flap was pedicled on one perforator 1.3 ± 0.3 mm in diameter within 3 cm above the medial epicondyle. The flap size varied between 10 and 20 cm in length and between 6 and 10 cm in width.ResultsOf the eight flaps in seven patients, seven flaps survived uneventfully except that one suffered venous insufficiency. Six patients were followed up for 1 month to 2 years. One patient was lost to follow-up after 7 days. The wounds in all patients healed satisfactorily. No deep wound infection and wound dehiscence developed. No revision surgery was performed in the survived flaps.ConclusionsThe survival of the medial arm pedicled perforator flap confirms the phenomenon of one perforator perfusing multiple perforator angiosomes in the medial arm, although this study has the retrospective clinical nature and limited number of the patients. The medial arm pedicled perforator flap is a useful tool to treat skin defects around the elbow.     

Modified free nipple graft reduction mammaplasty to increase breast projection with superior and inferior dermoglandular flaps

Classic free nipple graft reduction mammaplasty often yields flat, boxy breasts with poor projection. The authors modified this technique using superior and inferior pyramidal dermoglandular flaps to increase the fullness and projection of the breast. Six patients (12 breasts) with gigantomastia underwent breast reduction by this method. The results were aesthetically pleasing, with conically shaped breasts and good projection. The technique is easy to perform and it is possible to switch from pedicled nipple-areolar transposition to this method intraoperatively in patients in whom perfusion of the nipple is questionable.     

皮肤软组织深度损伤的外科治疗

目的 探讨皮肤软组织深度损伤的治疗方法.方法 2006年7月-2008年1月,笔者单位共收治皮肤软组织深度损伤患者56例,其中火焰烧伤23例、电击伤17例、热压伤7例、撕脱伤6例,其他原因(交通伤、挤压伤、皮肤软组织感染)致伤3例.共应用各类皮瓣65个修复创面,其中局部皮瓣21个、远位带蒂皮瓣18个、游离皮瓣26个,皮瓣面积1.5 cm×1.0 cm～39.0 cm×23.0 cm.结果 60个皮瓣完全成活,3个部分坏死,2个完全坏死.局部皮瓣成活率为95.2%,远位带蒂皮瓣成活率为88.9%,游离皮瓣成活率为92.3%.各类皮瓣成活率比较,差异无统计学意义(P>0.05).结论 皮瓣移植仍然是修复深度皮肤软组织损伤的有效方法,在保证成活率的前提下,采用游离皮瓣进行修复具有一定的优越性.     

Clinical study of the recurrent flaps of the arm for resurfacing of elbow defects

Defects around the elbow region are often irregular with exposed nerves, tendons, bones/joint, and implants. Skin grafts, though possible in some cases, must be avoided, as it requires prolonged splintage and physiotherapy to prevent recurrence and elbow stiffness. Distant flaps require multiple stages, and free flaps are rarely indicated for elbow defects. Muscle flaps are bulky. To overcome these problems, distally based fasciocutaneous flaps from medial and lateral sides of the arm based on posterior ulnar recurrent artery and radial recurrent artery, respectively, were used. Ten patients were studied. Age of the patients ranged from 10 to 40 years. Five were male, and five were female. Radial and ulnar recurrent flaps were used in five patients each. The largest flap size was 18 × 8 cm, and the smallest was 10 × 6 cm. The flaps were islanded in four cases, and in six cases, they were used as pedicled flaps. Skin grafts were used in 90% of the patients because large flaps were required for resurfacing; also, our patients had thinner arms with less girth. All flaps survived well. One island flap had venous congestion and marginal necrosis, which eventually healed. A significant improvement of mobility and elbow movement was noted in all patients. These flaps can be raised even from the previously burnt skin, as the pedicle is located deep. These flaps have the following advantages: The flap is reliable (deeply located consistent vascular pedicle), can cover both the flexor and extensor surface of the elbow joint, avoids prolonged splintage, elbow stiffness, and recurrence, good aesthetic, and has functional results.     

阴囊后动脉外侧支血管蒂阴囊皮瓣的临床应用

目的：提供一种理想的阴茎腹侧创面修复材料。方法：在有囊皮肤血供解剖学研究基础上，对合并阴囊分裂、阴茎、阴囊转位的尿道下裂，应用以阴囊后动脉外侧支为血管蒂的阴囊皮瓣修复尿道再造完成后阴茎腹侧遗留创面9例。结果：9例皮瓣全部成活，效果满意。结论：对于阴囊分裂合并阴茎阴囊转位的尿道下裂，应用阴囊后动脉外侧支为血管蒂的阴囊皮瓣，不但可修复阴茎腹侧创面，亦可同期矫正阴囊分裂和阴茎阴囊转位。     

应用背阔肌肌皮瓣保留高压电烧伤后肘关节及功能

目的 探索上肢严重高压电烧伤患者保留肘关节及其功能的手术方法。方法 １９８４年以来，设计背阔肌肌皮瓣单极移位修复肘部深度烧伤创面，同时以背阔肌作动力重建屈肘功能，使既往不得不被截除的肘关节得以保留，并恢复功能。结果 运用该方法共治疗８例病人，１０个肢体，移位肌皮瓣全部成活；６个肢体肘部创面甲级愈合，４个肢体经换药后愈合，５个肢体肘关节功能恢复良好，２个肢体经进一步肘关节松解术后，功能亦得以恢复，余     

应用背阔肌肌皮瓣保留高压电烧伤后肘关节及功能

目的探索上肢严重高压电烧伤患者保留肘关节及其功能的手术方法。方法 1984年以来,设计背阔肌肌皮瓣单极移位修复肘部深度烧伤创面,同时以背阔肌作动力重建屈肘功能,使既往不得不被截除的肘关节得以保留,并恢复功能。结果运用该方法共治疗8例病人,10个肢体,移位肌皮瓣全部成活;6个肢体肘部创面甲级愈合,4个肢体经换药后愈合;5个肢体肘关节功能恢复良好,2个肢体经进一步肘关节松解术后,功能亦得以恢复,余3个肢体(2例)失访,结果不详。结论该手术方法优点显著,效果良好。     

应用背阔肌肌皮瓣保留高压电烧伤后肘关节及功能

目的探索上肢严重高压电烧伤患者保留肘关节及其功能的手术方法。方法１９８４年以来，设计背阔肌肌皮瓣单极移位修复肘部深度烧伤创面，同时以背阔肌作动力重建屈肘功能，使既往不得不被截除的肘关节得以保留，并恢复功能。结果运用该方法共治疗８例病人，１０个肢体，移位肌皮瓣全部成活；６个肢体肘部创面甲级愈合，４个肢体经换药后愈合；５个肢体肘关节功能恢复良好，２个肢体经进一步肘关节松解术后，功能亦得以恢复，余３个肢体（２例）失访，结果不详。结论该手术方法优点显著，效果良好。     

Omentum is highly effective in the management of complex cardiothoracic surgical problems

OBJECTIVES: Vascularized, pedicled tissue flaps are often used for cardiothoracic surgical problems complicated by factors that adversely affect healing, such as previous irradiation, established infection, or steroid use. We reviewed our experience with use of the omentum in these situations to provide a yardstick against which results with other vascularized flaps (specifically muscle flaps) could be compared. METHODS: A retrospective review was undertaken of 85 consecutive patients in whom omentum was used in the chest. In 47 patients (group I), use of omentum was prophylactic to aid in the healing of closures or anastomoses considered to be at high risk for failure. In 32 patients (group II), omentum was used in the treatment of problems complicated by established infection. In 6 patients (group III), omentum was used for coverage of prosthetic chest wall replacements after extensive chest wall resection. RESULTS: Overall, omental transposition was successful in its prophylactic or therapeutic purpose in 88% of these difficult cases (75/85). Success with omentum was achieved for 89% of patients (42/47) in group I, 91% of patients (29/32) in group II, and 67% of patients (4/6) in group III. Three patients (3.5%) had complications of omental mobilization. Four patients (4.7%) died after the operation as a result of failure of the omentum to manage the problem for which it was used. CONCLUSIONS: Results with omental transposition compare favorably with published series of similarly challenging cases managed with muscle transposition. Complications of omental mobilization are rare. We believe that its unique properties render the omentum an excellent choice of vascularized pedicle in the management of the most complex cardiothoracic surgical problems.     

Correction of the post-burn malpositioned nipple-areola complex by transposition of two subcutaneous pedicled flaps.

Symmetrical anatomy of the chest wall is the aesthetic goal in any technique for nipple-areola complex positioning in post-burn patients. In 15 patients, a new surgical technique was applied by transposition of two subcutaneously pedicled flaps, one of which carries the malpositioned nipple-areola complex. The long-term results of this procedure were found to be satisfactory in all patients.     

Latissimus dorsi pedicled flap for upper extremity soft-tissue reconstruction

The latissimus dorsi often is used as a functional muscle transfer to restore elbow and shoulder motion. Although less common, its use as a pedicled muscle flap with a split-thickness skin graft provides excellent soft-tissue coverage of large upper extremity wounds. Seven male patients ranging in age from 6-71 years were treated with a pedicled latissimus dorsi muscle flap and split-thickness skin graft for coverage of open wounds of the shoulder, arm, or elbow with exposed vital structures (mean wound size: 15x10 cm). The flap also was used as a functional muscle transfer in one patient to replace destroyed anterior and middle portions of the deltoid. Wounds resulted from trauma in three patients, infection following trauma in two, and sarcoma excision in two. All flaps healed well, and donor site morbidity was minimal. At mean 16-month follow-up (range: 3-41 months), all muscle flaps had contoured well, producing satisfactory cosmesis. Functional results were good, and all patients were satisfied with their outcome. The tendinous insertion is left intact to guard against excessive traction on the pedicle when the flap is used for soft-tissue coverage only.     

The use of chest wall muscle flaps to close bronchopleural fistulas: experience with 21 patients

Nineteen patients with bronchopleural fistulas associated with tuberculosis and 2 patients with fistulas following resection for bronchiectasis underwent closure of the fistulas with pedicled flaps of chest wall muscle. The muscle grafting was combined with a limited thoracoplasty in 13 patients. The initial myoplasty produced prompt fistula closure in 15 patients and delayed closure in 2 others. A repeat myoplasty was successful in 2 patients in whom the initial myoplasty failed. Compared with other methods of treating bronchopleural fistulas used during the same period, muscle grafting carried a higher rate of successful fistula closure and a lower mortality rate.     

Microsurgical reconstruction of noma-related facial defects with folded free flaps: an overview of 31 cases

Noma is primarily affecting children in underprivileged countries and results in disfiguring facial defects, loss of mandibular movement, and subsequent social disintegration. Plastic surgery in West Africa traditionally uses pedicled flaps. In large, complex, or central facial defects, though, pedicled flaps are apt to be too small or have a significant donor site morbidity. Since 1999, we have been using free microvascular flaps in Nigeria. In 5 Interplast missions, 31 patients (age 5-45 years, median 20 years, female to male ratio 18:13) underwent 31 free flap procedures in Nigeria, 27 of them for primary treatment. The operative time ranged from 3.75-8.75 hours (mean 5.5 hours). An external distractor/fixator to maintain mouth opening was mounted in 13 cases. All anastomoses were done with loupe magnification. Three flaps failed completely, 1 partly, and 4 patients showed minor wound infections. No donor-site complications occurred. Free flaps can be a suitable and safe closure for complex noma defects even in underprivileged circumstances, if patient profile and own microsurgical routine allows it. Patient disfigurement can be less than in pedicled flaps regarding the donor sites.     

Reconstruction of the mandible with autogenous bone following treatment for squamous carcinoma

In a series of 24 patients treated for squamous carcinoma of the oral cavity and oropharynx, 26 mandibular reconstructions using 27 grafts or flaps were performed. Reconstruction was immediate in 23 cases and delayed in three. There were five 'simple' bone grafts, 10 pedicled compound myocutaneous flaps, and 12 vascularized free compound flaps. Operative mortality was 12% and complication rate 65%, but 70% of the grafts survived till death or follow-up of the patients. Three 'simple' bone grafts failed and were removed. Three of five compound pectoralis major flaps failed along with one of five pedicled compound latissimus dorsi flaps. Only one vascularized free compound flap was lost. The major cause of graft failure was intra-oral suture line dehiscence exposing the bone to saliva. Under these circumstances, bone graft necrosis occurred when blood supply to the bone was poor--viz. 'simple' grafts and compound pectoralis major flaps. The vascularized free compound flaps were most reliable but the need for jaw preservation where possible and better patient selection are recognized.     

Reconstruction in the axilla with a pedicled pectoralis minor muscle flap

Covering large defects in the axillary fossa can be challenging because of its complex shape. A variety of local skin, fasciocutaneous and musculocutaneous flaps have been described, with a number of inherent advantages and disadvantages. The use of the pectoralis minor muscle as a pedicled transposition flap has been described for immediate reconstruction of the breast, anterior shoulder reconstruction and the treatment of bronchopleural fistula. We now describe the use of a pedicled pectoralis minor muscle flap for soft tissue coverage of the axillary contents after wide excision of the axilla. This has not been previously described.     

Clinical use of a pedicled anterolateral thigh flap.

BACKGROUND: Anterolateral thigh flap is a safe and reliable flap for soft tissue reconstruction. It has successfully been used as free flap reconstruction for defects in the head and neck region, the upper extremities and lower extremities. However, there were only a few reports in the literature concerning the clinical application of this flap for regional reconstruction. METHODS: The authors describe their experience of using the pedicled island anterolateral thigh flap for reconstruction of soft tissue defects in neighbouring areas. Representative cases are presented for illustration. RESULT: Between July 2005 and September 2006, seven patients underwent an immediate reconstruction with pedicled anterolateral thigh flap. The patients were between 49 and 69 years old. The size of the flaps measured from 5 x 8 cm to 15 x 15 cm. They were prepared as myocutaneous flaps in three cases and as perforator flaps in four cases. One patient, who had the largest flap harvested, needed skin grafting of the donor site. Primary closure was performed for all other cases. All flaps survived without any vascular compromise and the donor site healed without complication. CONCLUSION: Our study has shown that the pedicled anterolateral thigh flap is a safe and reliable flap for repair of defects at the internal pelvis, lateral thigh, groin, and genitoperineal region. The long vascular pedicle and having no restriction to the arc of rotation are keys to the successful transposition of the flap for immediate reconstruction of soft tissue defects in neighbouring areas.     

Harvesting of forearm perforator flaps based on intraoperative vascular exploration: clinical experiences and literature review

The use of perforator flaps all over the body, as free microsurgical transfers, as well as pedicled or transposition flaps gained more and more importance in the surgery of tissue defects. When we consider harvesting such flaps at trunk level, in repeatedly traumatized areas, after previous surgery or when we plan to use the perforator flap as a free flap, it is very important to perform preoperative investigations aimed to precisely localize the perforator or perforators able to sustain such a flap. But, at limb level and, especially, at forearm level, the preoperative investigations cannot always have a complete justification. After a short review of the main preoperative investigations used in flap surgery and considering our color Doppler study, we will present in this article our technique of performing such flaps in the forearm, without any preoperative perforator vessel detection.