Latissimus dorsi musculocutaneous flap model in the rabbit: a hemodynamic and anatomical study

The rabbit island and peninsular axial pattern latissimus dorsi musculocutaneous (LDM) flaps were assessed for their appropriate use as experimental musculocutaneous flap models. Contralateral island and peninsular LDM flaps (10 X 20 cm) were constructed on rabbits, and their vascular anatomy, hemodynamics, and viability were compared. Anatomical dissections and fluorescein dye studies revealed that the skin overlying the latissimus dorsi muscle received its blood supply mainly from a direct cutaneous branch of the thoracodorsal artery before its entry to the latissimus dorsi muscle. A few small musculocutaneous arteries (perforators) were seen in the proximal portion of the latissimus dorsi muscle, but these perforators provided very little blood supply to the overlying skin. Results from hemodynamic and viability studies with rabbit peninsular and island LDM flaps also indicated that the blood supply from the musculocutaneous arteries to the overlying skin paddle was small and could not reliably support the survival of the cutaneous portion of these musculocutaneous flaps. We conclude that rabbit LDM flaps are different in vascular structure and blood supply compared with the human LDM flaps. Thus, discretion should be advised in applying the rabbit peninsular or island LDM flaps as experimental flap models for the study of the pathophysiology and pharmacology of the musculocutaneous flaps relevant to the clinical situation.     

应用阴囊筋膜血管网皮瓣的尿道再修复

目的：探讨阴囊筋膜血管网皮瓣在尿道下裂再修复中的应用。方法：阴囊皮肤存在多源性血供系统，4组血管终末支相互吻合，形成完整的动脉环路在肉膜内走行，通过筋膜层滋养皮肤。基于此项解剖学基础，术中设计不含知名动脉的阴囊筋膜血管网皮瓣，用于修复原已采用阴囊纵隔皮瓣或其他轴型皮瓣进行尿道下裂矫治而失败的病例。结果：本组20例患者，阴茎型5例，阴茎阴囊型8例，阴囊型7例。除1例出现尿瘘，经处理后痊愈，19例尿道重建成功，效果满意。结论：应用阴囊筋膜血管网皮瓣重建尿道是尿道下裂再修复较为理想的方法。     

THE FASCIOCUTANEOUS ISLAND FLAP: AN EXTENSION OF THE ANGIOTOME CONCEPT

The concept of the fasciocutaneous island flap (FCIF) has been established as a result of clinical experience in which over 180 cases have been compiled. It is a reconstructive design principle based on vascular and neural anatomy. Even though the flap pattern varies from region to region, it is the trilaminate composition of skin, fat and fascia supplied by fasciocutaneous, musculocutaneous and septocutaneous vessels, which is the basis for its success. Sometimes regional variations in this arrangement occur, for example: there is no deep fascia evident in the trigeminal nerve (CN-V); and in the hand and the foot, the local vascular anatomy still supports this island flap idea without any defined fascial lining. Following their use in the head and neck region, and as more successful ones were designed, the flaps seemed to follow the circumferential layout on the trunk and the longitudinal distribution in the limbs, similar to the dermatomal markouts. Such dermatomal charts thus became the basis of unexplored flap potentials with or without axial vessels. In the past, the clinical word ‘angiotome’ (which means a vascularized segment) has been used in world literature to describe flap vasculature with axial input. Thus flaps with a fasciocutaneous basis may well be described as a fasciocutaneous angiotome.     

An ideal and versatile material for soft-tissue coverage: experiences with most modifications of the anterolateral thigh flap

Free anterolateral thigh flaps are a popular flap used for the reconstruction of various soft-tissue defects. From April, 2002 to June, 2003, 32 free anterolateral thigh flaps were used to reconstruct soft-tissue defects. Twenty-three of these flaps were used for lower extremity reconstruction, and nine were used for head and neck reconstruction. There were 24 male and eight female patients, with ages between nine and 82 years. The size of the flaps ranged from 11 to 32 cm in length and 6 to 18 cm in width. Five flaps required reoperation for vascular compromise in four patients and for twisting of the pedicle in another patient. While four of these were salvaged, one flap was lost due to recipient vessel problems. Musculocutaneous perforators were found in 23 cases, and septocutaneous perforators were found in nine cases. In four cases, thinning of the flap was performed. The flap was used as a flow-through type for lower extremity reconstruction in three patients. In two patients, the flap was used as a neurosensory type for foot reconstruction. Eighteen cases underwent split-thickness skin grafting of the donor site and, in the remaining cases, the donor sites were closed primarily. In three patients, the donor areas required a partial skin regrafting procedure. No infections or hematomas were observed. Despite some variations in its vascular anatomy, the anterolateral thigh flap offers the following advantages: 1) it has a long and large-caliber vascular pedicle; 2) it has a wide, reliable skin paddle; 3) it may be harvested as a neurosensory flap; 4) it can be harvested whether its pedicle is septocutaneous or musculocutaneous; 5) it can be designed as a flow-through flap; 6) it can be elevated as a thin or musculocutaneous flap; and 7) the procedure can be performed by two teams working simultaneously, and no positional changes are required.     

Changes in the peroneal flap and its use in reconstructive surgery of the lower limb. Apropos of an experience of 10 cases]

A peroneal fasciocutaneous flap supplied by the peroneal septocutaneous vessels and raised from the lateral side of the lower leg was reported by Yoshimura in 1983. This flap which can be used as a proximally or distally pedicled or free flap is very useful for leg skin coverage. This flap has a great potential for skin cover and composite reconstruction of the lower limb due to its multiple structural facets (cutaneo-aponevrotic or composite flap), its possible extensions to other vascular territories and the variable geometry of its mode of transfer. 8 reconstructions have been performed. Their indications are described: 4 proximally pedicled flaps (3 with the fibula), 4 reverse-flow island flaps (1 with Soleus and Peroneus longus muscles). The authors stress the importance of preoperative assessment of the feasibility of a given flap which may be limited by post-traumatic, surgical or anatomic modifications. In particular, the uppermost septocutaneous artery which corresponds inconstantly to the "circumflex peroneal artery" can only be visualized by preoperative arteriography. This artery supplies a proximal peroneal flap which can be used as an island or a free flap. We have used this new variety as a free flap in 2 cases and were satisfied with the results. These various clinical applications without any significant complication or flap failure confirm the biological performance and the safe procedure of peroneal flaps.     

Versatility of the free anterolateral thigh flap for reconstruction of soft-tissue defects: review of 140 cases

From August 1995 to June 1999, 140 free anterolateral thigh (ALT) flaps were transferred to reconstruct a variety of soft-tissue defects. The size of ALT flap ranged from 10 to 33 cm in length and 4 to 14 cm in width. Based on the anatomic variations of the perforators, the blood supply to the skin island came from the septocutaneous perforators only in 19 patients (13.6%), arising from the descending or transverse branch of the lateral circumflex femoral artery (LCFA), or originating directly from LCFA. The other flaps were supplied by musculocutaneous perforators that were elevated as a true perforator flap via intramuscular dissection (N = 34, 24.3%), or used a cuff of vastus lateralis muscle for added bulk (N = 87, 62.1%). The overall success rate was 92% (129 of 140). After a 2-year follow-up, all flaps have healed unevenffully and donor thigh morbidity is minimal. Anatomic variations must be considered if the ALT flap is to be used safely and reliably.     

Combined cremaster muscle and inner thigh skin composite flap: a novel experimental flap model in the rat

Unlike the composite musculocutaneous flap models, the combined composite muscle-skin flap model allows evaluating muscle and skin viability independently, because it has an independent blood supply to the muscle and skin component. However, to our knowledge, only two combined muscle-skin flaps have been reported to date. During our cremaster dissection in our laboratory, we perceived a new vessel as a terminal continuation of the pudic-epigastric artery (PEA) on which the cremaster muscle flap is raised. Therefore, we designed this study to determine whether the scrotal and inner thigh skin can be harvested with the cremaster muscle as a combined cremaster muscle-skin composite flap. Thirty male Sprague-Dawley rats were used in this experiment. In five rats, ink study selective to the PEA marked a skin territory. In 15 rats, cremaster muscle and 4 x 3 cm ipsilateral scrotal and medial thigh skin flap was raised on the PEA. Fluorescein study after 4 hours showed fluorescein stain in the skin island. On postoperative day 7, both muscle and skin components of the flaps were viable. Microangiographic study after the flap elevation revealed the vascularity of all components of the flap and clearly identified the branch to the skin island. To the best of our knowledge, this is the first report describing the combined flap model including the cremaster muscle. Our flap seems to have an important advantage over the other combined muscle-skin flap models in terms of the cremaster muscle being suitable for the intravital microscopy. Additionally, the two components of the flap have separate nutrient vessels with adequate length, which gives the flap flexibility in the placement of the skin component in a location distant from the muscle component. The flap may be also be raised as a skin flap without the cremaster muscle. It can be used for different applications, including microcirculatory, pharmacological, physiological, biochemical, and immunological studies as well as for transplantation studies.     

Latissimus dorsi muscle and its short perforator-based skin compound free flap

Some authors have described the latissimus dorsi muscle and its short perforator-based skin compound flap based on the same thoracodorsal vessels. This flap procedure involves separating the skin island from the underlying latissimus dorsi muscle and rotating the skin island over the musculocutaneous perforator emerging from the latissimus dorsi muscle. As with all surgical procedures, there are various advantages and disadvantages. However, to the best of the authors' knowledge, there are no reports on the use of the flap in a consecutive series.Between 1997 and 2005, the flap was used to reconstruct below-knee structures in 26 patients (23 males and 3 females) by the 2 senior authors at the Chonnam National University Medical School. The clinical outcomes of this procedure were evaluated.Satisfactory results were obtained in most patients. However, there were 2 marginal necroses in the excessively large skin flaps, 1 partial necrosis over the distal edge of a skin flap, and 1 total flap failure caused by infection. The marginally and partially necrotized skin flaps were treated successfully with split-thickness skin grafts. However, another flap procedure was required to cover the defect in the case of flap failure. The donor sites were closed primarily in all patients, and the skin flaps were rotated between 40 degrees and 180 degrees. This flap allows the surface of the latissimus dorsi musculocutaneous flap to be expanded without additional donor morbidity. In addition, the flap procedure is safe and easy to perform. Moreover, the flap provides sufficient flexibility, even though it has less independent flap mobility than the chimeric flap. Therefore, the flap may be a convenient and reliable alternative for the reconstruction of large and irregular-shaped wounds.     

New nomenclature concept of perforator flap.

Confusion regarding the perforator flap concept has arisen partly from the use of ill-defined nomenclature without consistency; flaps have been named according to either the proximal vessel, the location harvested or the muscle dissected. Since, a variety of conflicting terms can distort the exact understanding of the flap and the true perforator concept, a precise and scientific system of nomenclature is promptly needed. In order to remedy such confusion, the author reviewed 54 recently published articles and 38 abstracts for vague or inaccurate nomenclatures, and compared the perforator flaps with the conventional flaps. A new nomenclature was then drawn up according to three perforator types: direct cutaneous, septocutaneous and musculocutaneous perforator. Even though only musculocutaneous perforators were considered to be true perforators in the initial concept, some perforator flaps have subsequently been added based on septocutaneous or direct cutaneous perforators. Discrimination is necessary and made possible by use of the following nomenclature: a perforator flap based on a musculocutaneous perforator is named according to the name of the muscle perforated, and perforator flaps based on other types of perforators, are named according to the name of the proximal vessel. The term 'perforator based' further defines those flaps harvested without sacrificing the proximal vessel. This new nomenclature concept would be a great help in discriminating among the various patterns of perforator flaps and also in preventing confusion arising from the misnaming of new perforator flaps in the future. Furthermore, the perforator pattern used in the flap can easily be comprehended, and especially in extremities, various perforator flaps, based on the musculocutaneous or septocutaneous perforator, can plainly be distinguished with this new nomenclature concept.     

Optimal management of the 3- to 6-centimeter anterior urethral stricture

The optimal management of anterior urethral stricture that does not respond to an endoscopic urethrotomy or is found to be unsuitable for excision and anastomotic repair remains controversial. Genital skin island onlay flaps or buccal mucosal grafts are presently the most dependable single stage procedures used for strictures more than 3 cm in length. Nonhirsute penile island fasciocutaneous flaps constitute the most durable substitution technique for pendulous stricture disease, with long-term studies reporting 90% to 96% success. The complex proximal bulb and bulbomenbraneous stricture with a compromised proximal fibrous avascular bed is ideally managed with either a penile or scrotal island flap or some combination of partial urethral excision with a dorsally placed genital skin island. The buccal mucosal onlay graft is a promising addition to this reconstructive paradigm, and early outcomes have been favorable. The graft is presently used for bulbar strictures, avoiding the transsphincteric on pendulous location, or a compromised recipient bed. The present standard of care for proximal bulb strictures is wide bulbospongiosal mobilization, partial urethral excision, a floor strip anastomosis, and placement of an augmenting flap on the graft in a dorsal location.     

Variations in perforators of anterolateral thigh flap

In our study of anterolateral thigh flaps, ten patients had musculocutaneous perforators (58%), four patients had septocutaneous perforators (24%), and three patients had both types of perforators (18%). Average number of perforators found in each flap was 1.9 (range 1–4). The maximum number of perforators in a single case was four. A single perforator was found in seven patients. In patients with both types of perforators, larger flaps could be harvested and there were no complications. The study was carried out over a period of 3 years and included 17 patients treated with free anterolateral thigh flaps in our hospital from April 2004 to August 2007. All age groups and both sexes were included in the study. A cadaveric study was done on ten fresh cadavers in the anatomy department of the same hospital. Although the majority of free anterolateral thigh free flaps are based on musculocutaneous perforators and fewer flaps are based on septocutaneous perforators, our study shows that this versatile free flap can be based on a combination of both septocutaneous and musculocutaneous perforators. Though our cadaveric study did not show any flap to be based on the combination of both types of perforators, our clinical study in which we had three cases of this type definitely shows that the ALT flap can be based on a combination of both septocutaneous and musculocutaneous perforators. Further in these cases with both types of perforators, larger flaps could be harvested and with greater flap success.     

Gangrena de Fournier: de urgencia urológica hasta el departamento de cirugía plástica

Fournier's gangrene (FG) is a rare and potentially fatal infectious disease characterised by necrotic fasciitis of the perineum and abdominal wall in addition to the scrotum and penis in men and the vulva in women. Skin loss can be very damaging and difficult to repair. This condition must be treated aggressively. Several techniques are used to reconstruct lost tissue: skin grafts, transposition of the testicles and spermatic cords to a subcutaneous pocket in the upper thigh, scrotal musculocutaneous flaps, fasciocutaneous flaps and several other types of pediculated myocutaneous flaps are all employed.The supero-medial thigh skin flap is a likely arterial flap and has been shown to be an effective method for reconstructing large scrotal defects.     

Single-stage repair of urethral fistula by vascular island groin flap

A new technique for the repair of a urethral fistula at the penoscrotal junction is presented. Under local anaesthesia we have successfully repaired six of these fistulae using a groin island pedicle flap. The urethra is repaired by mobilising the mucous lining around the fistula and closing it longitudinally, using absorbable 4/0 chromic catgut sutures. The groin island pedicle flap which is based on superficial circumflex iliac vessels is used to cover the repaired lining. The donor defect is closed primarily. In all six cases there was primary healing. This procedure is recommended for cases where the skin around the fistula is badly scarred or where previous attempts at closure have failed. Moderate defects of penile and scrotal skin can also be repaired by this type of flap.     

股前外侧组织瓣临床应用112例分析

目的 总结分析股前外侧组织瓣解剖规律及其在组织缺损修复重建中的适应证和应用价值。方法1985年3月-2004年8月，对112例股前外侧组织瓣移植进行临床总结。其中男67例，女45例。年龄5～65岁，平均38．5岁。针对受区不同情况，将股前外侧组织瓣切取分为4类：吻合血管的游离皮瓣移植78例；吻合血管的游离脂肪筋膜瓣移植22例；带蒂顺行岛状皮瓣移位5例；远端为蒂逆行岛状皮瓣移位7例。对面、颈、肢体、躯干等部位的软组织缺损所致功能障碍或外观缺陷进行修复，并对术后效果和供区恢复情况进行评价。结果营养股前外侧组织瓣的动脉皮支出现率100％，具有肌间隙皮穿支（33％）和肌皮穿支（67％）两种基本解剖类型。组织瓣源血管均为旋股外侧动脉降支或横支。皮瓣移植成活107例，成活率达95．6％。术后33例获随访6个月～11年，远期随访效果满意率91％，供区无功能受限。结论股前外侧组织瓣解剖恒定，具有多种突出优点，是修复软组织缺损的理想材料。尤其是穿支皮瓣形式，可保持受区形态，降低供区损伤，成为应用趋势。     

Dorsal foot resurfacing using free anterolateral thigh (ALT) flap in children

Very limited literature described the use of the free anterolateral thigh (ALT) among other flaps for pediatric lower limb reconstruction. The aim of this study is to present our experience using the free ALT flap for reconstruction of soft tissue defects over the dorsum of the foot and ankle in children. The study included 42 children aged 2.5–13 years with a mean of 6.18 years. Three children had crush injuries while the rest were victims of run over car accidents. All of the flaps were vascularized by at least two perforators; 88.23% were musculocutaneous and 11.77 were septocutaneous perforators. All flaps were raised in a subfascial plane. Initial thinning was performed in five flaps and 35% required subsequent debulking. Mean Flap surface area was 117.11 cm². The recipient arteries were the anterior tibial artery in 38 cases and posterior tibial artery in four cases. Venous anastomosis was performed to one vena commitant and in nine cases the long saphenous vein was additionally used. Mean ischemia time of the flap was 2 hours while total operative time averaged 6.3 hours. About 41% of donor sites were closed primarily while 59% required skin grafting. Primary flap survival rate was 92.8% (39/42 cases). Three flaps showed venous congestion. After venous reanastomosis, two flaps showed partial loss and one flap was lost completely. Post‐operative hospital stay averaged 7.5 days. The free ALT flap could be as safe, reliable, and aesthetically appealing option for foot/ankle resurfacing in children after traumatic soft tissue loss. © 2012 Wiley Periodicals, Inc. Microsurgery, 2013.     

股后侧岛状皮瓣和肌皮瓣的临床应用

目的 探讨应用股后侧岛状皮瓣修复大转子、骶部等处软组织缺损的临床效果.方法 应用顺行股后侧岛状皮瓣修复大转子软组织缺损4例、骶部2例;逆行股后侧岛状皮瓣修复腘窝部皮肤缺损2例;肌皮瓣修复坐骨结节褥疮4例;供区直接缝合.结果 除 1例岛状皮瓣远端发生尖部坏死经植皮愈合外,余病例术后全部成活.随访1～5年,供区愈合良好、受区外形、质地及厚薄均较满意.结论 该皮瓣以臀下动脉股后皮支及股深动脉穿动脉为其血供,解剖恒定,具有血运丰富、血管蒂长和切取容易等优点,适宜修复大转子、骶部坐骨结节及腘窝部等处软组织缺损.     

Skin paddle vascularity of free fibula flap �C A study of 386 cases and a classification based on contribution from axial vessels of the leg

Objective:

The skin paddle of the free fibula flap receives its vascular supply from septocutaneous perforators, musculocutaneous perforators or from both, and these perforators might originate from the peroneal or posterior tibial vessels or from both. The objective of this study was to classify the skin paddles based on the dominance of vascular contribution by these axial vessels through their different perforator systems.

Materials and Methods:

A retrospective analysis of 5-year data of 386 free fibula flaps used in oro-mandibular reconstruction was done and the skin paddle vascularity was studied. While majority of the skin paddles received their blood supply from the peroneal septocutaneous perforators, a few had their dominant supply from the soleus musculocutaneous perforators in addition to peroneal septocutaneous perforators. In few cases, the soleus musculocutaneous perforators were the sole source of blood supply to the skin paddle. The limitation in this study was the inability to augment the clinical observation with cadaveric study.

Results:

The skin paddle of the free fibula flap was classified into four different types (a–d) based on the dominance of vascular contribution by axial vessels of the leg.

Conclusion:

The skin paddle of the free fibula flap has reliable blood supply, but a thorough knowledge of the variations in vascular pattern of the skin paddle is required especially to salvage the larger paddles used in the reconstruction complex oro-mandibular defects.KEY WORDS: Free fibula flap, musculocutaneous perforators, septo cutaneous perforators, skin paddle, vascular supply     

应用阴囊肉膜平滑肌肌皮瓣修复阴茎延长术中的阴茎创面

目的 提供理想的阴茎延长术中阴茎创面的修复组织。方法 在阴茎1阴阜区皮肤交界处切开、切断阴茎浅悬韧带和部分阴茎深悬韧带行阴茎延长术后，应用以阴囊前动、静脉为血管蒂的阴囊膜平滑肌肌皮瓣（下简称阴囊皮瓣）转移修复在阴茎根部所形成的创面。结果 1996年以来共应用于16例患者，阴茎平均延长4－4．5cm，阴囊皮瓣全部成活，阴茎形态满意，阴囊无明显变形。结论 阴囊皮瓣血运丰富，薄而无皮下脂肪，有伸缩性，是阴茎延长手术中阴茎皮肤缺损较好的修复方法之一。     

前臂广泛软组织缺损的皮瓣修复

目的　探讨前臂广泛软组织缺损后皮瓣修复方法的选择。　方法　本组 2 1例肘部至腕部广泛高压电烧伤、热压伤及碾压伤患者 ,清创后即时应用带蒂的联合皮瓣、岛状背阔肌肌皮瓣及巨大胸腹部联合皮瓣修复前臂广泛软组织缺损。　结果　除 1例患者出现皮瓣远端局限坏死及皮瓣下感染外 ,其余皮瓣全部成活 ,效果满意。　结论　对于前臂广泛软组织缺损 ,早期清创后应用带蒂联合皮瓣、肌皮瓣修复是一种简单、安全、可靠的方法