Aesthetic single-stage vermilion reconstruction using facial artery musculomucosal flap and radial forearm free flap following cancer resection: A case report

Reconstruction of defects measuring approximately two-thirds of the lower lip width is traditionally reconstructed utilizing loco-regional flap utilizing lip and cheek tissues. This often results in microstomia and unsatisfactory aesthetic outcome. This may hinder the psychosocial aspect of a recovering cancer survivor. Here we describe a single-stage reconstruction in a 79-year-old male patient who received lower lip resection for squamous cell carcinoma. The reconstruction was accomplished using a facial artery musculomucosal flap together with a free radial forearm flap for vermilion and soft tissue defect reconstruction after lip tumor resection with uneventful postoperative course. The patient remains disease-free after 2-year follow-up and does not require revision surgeries for functional or aesthetic reason. This approach may be considered a good option for reconstruction of missing lip and soft tissue simultaneously when the facial vessels are well-preserved during neck dissection. Aesthetically pleasing and functionally satisfactory outcomes may be produced.     

Reverse-Flow Retroauricular Island Flap in Facial Reconstruction

BACKGROUND Reconstruction of facial skin defects requires good-quality skin cover to satisfy aesthetic expectations of patient, especially when the skin defect is on the uncovered area of the face. Limitations in the available local tissue and donor-site morbidity restrict the options.
OBJECTIVE In an effort to solve these problems, we have begun to use a subcutaneous pedicled retroauricular reverse-flow flap.
METHODS Between January 1997 and December 2005, reverse-flow subcutaneous pedicled retroauricular island flap was used to cover facial defects in 12 patients who underwent surgical excision of skin tumor. The patients ranged in age from 44 to 81 years with a mean age of 58 years.
RESULTS Only one case experienced a superficial necrosis in the distal one-quarter part of the flap. The functional and aesthetic results were satisfactory for both patients and surgeons, and no tumor recurrence was observed during the 12 to 28 months (mean, 18.8 months) follow-up period.
CONCLUSIONS This flap can be used reliably for the reconstruction of facial skin defects of small and medium size. The preference of frontal branch pedicled flap enables more distal facial area defects to be covered, such as dorsal nasal, nasolabial, and upper lip, than flaps based on parietal branch.     

预扩张额部皮瓣用于鼻再造及修复面部缺损

目的　扩大额部扩张皮瓣应用范围 ,改进鼻再造及面部缺损的修复方法。　方法　对10例鼻缺损伴面部其他部位组织缺损的患者先行额部皮瓣供区预扩张术 ,在二期行扩张皮瓣移位鼻再造术同时修复面部其他部位组织缺损。　结果　治疗 10例鼻缺损及面部组织缺损者 ,疗效满意。行鼻再造的额部扩张皮瓣最大为 8 5cm× 10cm ,最小为 6 5cm× 8cm ;同时行面部缺损修复的额部皮瓣最大为 6cm× 4cm ,最小为 2cm× 6cm。　结论　预扩张额部皮瓣同时用于鼻再造及面部缺损修复是较理想的一种方法 ,可扩大额部扩张皮瓣的应用范围     

Free tensor fasciae latae flap for abdominal wall reconstruction: overview and new innovation

Extensive abdominal wall defects may result from tumor extirpation, traumatic injury, or soft tissue infections. Extensive traumatic injuries can often disrupt the soft tissue content of the abdomen as well as the bony support provided by the pelvis. Reconstruction of the lower abdomen should aim to recreate dynamic stability. Five patients with extensive lower abdominal wall disruption following traumatic injuries or infection were treated using a novel flap for functional reconstruction. We devised a free neurotized osteomyocutaneous tensor fasciae latae (TFL) flap that would restore bony continuity by providing a vascularized bone graft and simultaneously maintain the integrity of the attachment of the tensor fascia latae muscle to the iliac crest, reestablishing musculofascial continuity. A branch of the superior gluteal nerve was harvested with this composite flap and coapted to an intercostal nerve for reinnervation, thereby creating a dynamic muscle in these patients. All patients underwent successful free tissue reconstruction with 100% flap survival. The lower abdominal wall and bony integrity of the pelvis were successfully reconstructed. Reinnervation has shown clinical signs of maintained dynamic stability. The innervated TFL osteomyocutaneous flap is an ideal option for lower abdominal reconstruction in patients with complex abdominoperineal defects with loss of bony integrity.     

Complete orbit and forehead reconstruction using a free latissimus dorsi flap and MEDPOR implants

BACKGROUND: Reconstruction of enormous composite defects of the face in the presence of meningitis is a difficult problem. We present a case of a 29-year-old man with a huge, posttraumatic bone and soft tissue defect of the upper half of the left side of the face (orbit-zygoma-frontal-partial temporal bones), frontal lobe of the brain, and enucleated eye with intact facial skin. METHODS: An initial reconstruction using cement was complicated by multiple episodes of meningitis. In a multiple-stage procedure, we used a free latissimus dorsi muscle flap to re-construct the soft tissue defect and control the infection, a complete left orbit and frontal MEDPOR implant for the bone defect, and also an orbital sphere MEDPOR implant for the eyeball. RESULTS: In a 2-year follow-up, no infection was observed, and the cosmetic result is satisfactory. CONCLUSION: The combination of free flap and MEDPOR implants demonstrates an alternative method for reconstruction of complicated facial defects.     

Cross-leg latissimus dorsi free flap with chimeric serratus anterior bridge for lower extremity trauma: Case report and reconstructive algorithm

Gustilo Grade IIIB and IIIC open fractures of the lower extremity often involve complex wounds requiring bony fixation and soft tissue reconstruction. We present a case of a 32 year-old male who suffered a traumatic Gustilo Grade IIIB open fracture of the tibia and fibula with an extensive soft tissue defect. Reconstruction was first attempted with a turbocharged anterolateral thigh flap that failed due to venous thrombosis. Due to vascular injury, limited reconstructive options were available from the ipsilateral leg. Limb salvage was subsequently achieved with a chimeric cross-leg latissimus dorsi-serratus anterior (LD-SA) free flap based off the contralateral healthy leg, using the serratus for pedicle bridge coverage so that the latissimus could be fully used for defect coverage. Though not extensively described in the literature, this flap is a versatile reconstructive option for limb salvage in patients with Gustilo IIIB or IIIC injuries to the lower extremity.     

The use of combined radial forearm cutaneous and radial forearm fascial flaps in head and neck reconstruction: a case series

Introduction?Reconstruction of complex head and neck cases involving bony and dural defects poses many issues. The primary aims of reconstruction are to provide a tight dural seal with good cranial support while also achieving a satisfactory cosmetic result.Aims?This study describes the use of combined radial forearm cutaneous flap and radial forearm fascial flaps for reconstruction of complex skull defects where each component is used for a distinct reconstructive purpose. The benefits of this technique are illustrated in the cases of three patients requiring reconstruction following tumor resection.Methods?The fascial component was used as a seal for dural defects. The cutaneous flap was then used to reconstruct the concomitant cutaneous defect.Conclusion?The combined use of the fascial and cutaneous components of the radial forearm flap, where each is used for a distinct reconstructive purpose, increased the reconstructive versatility of this commonly used flap. The fascial flap was a thin, pliable, and highly vascularized piece of tissue that was effectively used to provide a watertight seal for the dural defect. The simultaneous use of the cutaneous flap gave support to the bony defect while providing a good cosmetic result.     

Reconstruction of Facial Gunshot Wound by the Cervicopectoral Flap

Background: Reconstruction of large facial defects secondary to shotgun blast to the face is a very difficult task in surgery. Case Study: We report on a 34-year-old female patient with suicidal shotgun injury to her face delivered by a hunting rifle at close range into her mouth. She showed a large right cheek defect and a mandibular fracture. The defect was closed by a cervicopectoral fasciocutaneous flap; the mandibular fracture was managed with a titanium reconstruction plate. Good aesthetic and functional results were achieved 1 year after reconstruction. Conclusion: Early definitive reconstruction of shotgun injuries is still controversial. The cervicopectoral flap has many advantages. It is easy and secure to harvest and possesses skin properties similar to the face. The flap is quite thin allowing soft tissue coverage without a bulky view. This is the first study in the literature using a cervicopectoral flap for closure of a facial gunshot wound. We conclude that in patients with facial gunshot wounds, early reconstruction with a cervicopectoral flap offers a very important alternative.     

Reconstruction of extensive abdominal wall defect using an eccentric perforator‐based pedicled anterolateral thigh flap: A case report

Reconstruction of extensive abdominal wall defects is a challenge for reconstructive surgeons. In this report, a case of reconstruction of a large abdominal wall defect using an eccentric perforator‐based pedicled anterolateral thigh (ALT) flap is presented. A 30‐year‐old man presented with recurrent desmoid‐type fibromatosis in the abdominal wall. The recurrent tumor was radically excised, and the en bloc excision resulted in a full‐thickness, large abdominal wall defect (25 cm × 20 cm). An eccentric perforator‐based pedicled ALT flap, including wide fascial extension, was transferred to the abdominal defect; fascial portions were sutured to the remnant abdominal fascia. Plication of the fascia along the sutured portion was performed to relieve the skin tension between the flap and the marginal skin of the abdominal defect. Eight months after surgery, the reconstructed abdomen had an acceptable esthetic appearance without tumor recurrence or hernia. The use of an eccentric perforator‐based pedicled ALT flap may be an alternative method for the reconstruction of extensive abdominal wall defects. © 2013 Wiley Periodicals, Inc. Microsurgery 33:482–486, 2013.     

Simultaneous reconstruction of large maxillary and mandibular defects with a fibular osteocutaneous flap combined with an anterolateral thigh flap

This article reports the simultaneous reconstruction of maxillary and mandibular defects caused by a close-range gunshot blast to the face with one fibular osteocutaneous flap combined with an anteroateral fasciocutaneous flap. A fibular osteocutaneous flap was used for both mandibular and maxillary defects, using multiple osteotomies and discarding a central bony segment and an oral floor defect. An anterolateral thigh flap was used to cover a three-dimensional defect of both the intraoral mucosal region, as well as external skin and soft tissue defects, including some on the upper and lower lips. The results demonstrated that the method was a good choice in the reconstruction of large composite facial defects, both aesthetically and functionally.     

The simple modification of the reverse Karapandzic flap for reconstructing the subtotal upper lip including the columellar defect: a case report

Reconstruction of the subtotal upper lip with a columellar defect is still a problem for reconstructive surgeons. Various techniques have been reported for this purpose. Each technique has its own drawbacks, and few can be performed in one stage. Although Karapandzic describes the standard procedure that functionally reconstructs large defects in the upper and lower lip, the Karapandzic flap is not sufficient for the columellar defects. It is a simple and safe technique; results are satisfactory, functional, and aesthetically well tolerated, sacrifice less tissue, and are effective for repairing defects. We report a 74-year-old male who presented with a large, fungating, pus-discharging ulcerative mass on his upper lip including the columella. Biopsy results confirmed squamous cell carcinoma. The tumor was excised and defects were reconstructed using a simple modification of the Karapandzic flap. This modification of the Karapandzic flap provides adequate tissue for the subtotal upper lip defect including the columellar defect.     

The split orbicularis myomucosal flap for lower lip reconstruction

OBJECTIVES: To describe the split orbicularis myomucosal flap and to review our center's experience with this technique for large defects of the lower lip. METHODS: All patients presenting to the senior author (Y.D.) for lower lip reconstruction using this flap were reviewed in a retrospective fashion. RESULTS: A total of 14 patients with a minimum follow-up of 6 months (mean, 3.4 years; range, 6 months to 5 years) underwent lower lip reconstruction using the split orbicularis myomucosal flap from May 1999 to May 2004. Twelve of the defects arose as a result of cancer resection (squamous cell carcinoma [n = 8], basal cell carcinoma [n = 3], and melanoma [n = 1]), and 2 arose secondary to trauma. The defect crossed the vermilion in two thirds of the cases, extending for a variable distance onto the cutaneous portion of the lower lip. The defect size varied from 50% to 80% of the transverse dimension of the lower lip (mean, 68%) and involved the commissure in 4 patients. There were no flap failures, facial nerve palsies or paralyses, oral incompetence, or need for scar revision in any of our study population. CONCLUSION: The split orbicularis myomucosal flap is a reliable method of reconstructing significant defects of up to 80% of the lower lip with minimal risks of microstomia or functional impairment.     

Modified bilateral neurovascular cheek flaps: a new technique for reconstruction of extensive upper lip defects.

The authors present a modified bilateral neurovascular cheek flap as a new technique for extensive upper lip reconstruction. The technique is modified from the bilateral neurovascular cheek flap for lower lip reconstruction described by Vatanasapt and colleagues in 1987 by designing rectangular and triangular flaps in the cheek tissues lateral to the lip defect on both the skin and the mucosal sides. This method has the advantage of preserving neurovascular structures as well as the original position of the oral commissure. Five patients are presented with acceptable surgical results. The technique is a good choice for functional reconstruction of near-total or total upper lip defects.     

Bernard瓣修复下唇癌术后缺损的临床观察

目的：探讨应用Bernard瓣修复下唇癌术后缺损的临床疗效。方法：对我院5例下唇癌患者分别行传统和改良的Bernard瓣即刻修复缺损,并进行术后随访观察其形态和功能恢复情况。结果：5例患者中3例应用传统的bernard瓣手术方法,2例使用改良的Bernard瓣修复。术后形态和功能恢复良好,无并发症发生。结论：Bernard瓣修复下唇癌术后1/2～2/3的缺损可取得满意效果。其中传统Bernard瓣主要适用于缺损更接近于1/2的病例,而改良的Bernard瓣主要用于缺损更接近于2/3的病例。     

Extension of the facial artery musculomucosal flap to reconstruct a defect of the soft palate

Abstract

Reconstruction after resection of a large oropharyngeal tumour poses a difficult challenge. This case illustrates an extension of the previously described facial artery musculomucosal (FAMM) flap, whereby a defect of the soft palate is replaced with a similar trilaminar structure in the form of irradiated, redundant lower lip. This allows not only the treatment of the palatal defect, but also management of dribbling secondary to a marginal mandibular palsy.     

Reconstruction of large upper lip defects by free tissue transfer

Reconstruction of a large upper lip defect is a demanding procedure and can be performed by a variety of local flaps or by microvascular free tissue transfer. We present our experience in reconstructing near total or total upper lip defects by free tissue transfer. In 11-year period seven patients underwent microvascular reconstruction of upper lip, six with non-innervated radial forearm flap and one with non-innervated anterolateral thigh flap. In all patients good functional and acceptable aesthetic results, with oral competence at rest and during eating and speaking, were achieved. Deglutition and articulation were not affected in any patient. Sensory evaluation of reconstructed upper lips was performed in four patients and in three a reasonable recovery of sensation was recorded. In our opinion subtotal or total upper lip reconstructions with folded thin fascio-cutaneous free flaps produce very good functional and aesthetically acceptable results and avoid additional scars on lower lip and cheek. Further, because the size of the mouth is not altered, microstomia is avoided, which is especially important for patients using dentures. The remaining disadvantage of this method is non-competence of orbicularis oris muscle sphincter.     

应用SMAS蒂岛状皮瓣修复面部皮肤缺损

目的探讨以SMAS为蒂的岛状皮瓣修复眼睑及口周皮肤缺损的方法。方法根据皮肤缺损的部位,设计以SMAS为蒂的远位岛状皮瓣修复眼睑及口周皮肤软组织缺损。结果自1998年8月起,临床应用已14例,最大皮瓣面积为5cm×3cm,术后皮瓣全部成活,效果满意。结论应用设计供区部位较隐蔽的以SMAS为蒂的岛状皮瓣,远位转移修复眼睑及口周皮肤及软组织缺损,血供良好,皮瓣颜色质地与受损区域皮肤协调,效果满意。     

应用上唇外侧组织瓣旋转修复下唇缺损

目的:探求上唇外侧组织瓣在修复较大面积下唇缺损中的作用。方法:根据患者下唇缺损情况,设计上唇外侧组织瓣,旋转后插入缺损组织,同时在缺损吻合处,将上层外侧旋转瓣内侧粘膜肌肉向外牵拉形成部分新的红唇,然后逐层相对缝合,修复缺损。结果:自2003年1月应用此方法修复患者6例,术后随访1～2年,唇部外形好,无流涎,无口闭合不全,效果满意。     

Lip Reconstruction of Comparatively Large Defect Including the Commissure Using Remaining Lip Tissue: A Modification of Reconstructed Method

We present two reconstructed cases after malignant skin tumor of comparatively large defects of lip including the commissure using remaining lip tissue alone. After resecting a tumor including wedge-shaped full-thickness lip tissue, a full thickness oblique incision is made at the site 5 mm distant from the contralateral commissure. The rhomboid-shaped lower lip flap is created, transposed to the defect, and sutured with the defect margin, including the upper lip, to reconstruct the commissure. The cross lip flap is created at the contralateral side of the lower lip, 5 mm from the commissure, and the defect is closed with the crosslip flap. Although our method is applicable only to selected cases, we believe that it is useful in terms of maintaining symmetry of the lip and function of the commissure in the reconstruction of comparatively large defects including the commissure.     

Reconstruction of an extensive thigh defect with the paraumbilical TRAM flap

Reconstruction of extensive defects after radical resection of soft-tissue sarcomas of the extremities has become an essential part of the limb salvage approach to the management of these tumors. The authors describe the successful use of a paraumbilical transverse rectus abdominis musculocutaneous flap with the pedicle based on the inferior epigastric artery for reconstruction of a 24- x 22-cm soft-tissue and skin defect of the anterior thigh after wide local excision of a recurrent malignant fibrous histiocytoma. The ability to mobilize a large amount of well-vascularized soft tissue from an acceptable donor site, the versatility of flap design, the extensive arc of rotation, and the dependability of the inferior epigastric vascular pedicle are all distinct advantages of using this flap in the reconstruction of massive defects of the thigh.