Elective spare parts free flap—calcaneal fillet of foot flap

Severe lower limb trauma with significant soft tissue injury can be managed with reconstruction or, if this is impossible, amputation. If amputation is considered, below-knee amputation preserving limb length is optimal for long-term functional outcome. At times, soft tissue/bony injury can limit the ability to preserve limb length, particularly with proximal tibial injuries. We present a case of elective below-knee amputation where leg length and adequate soft tissue coverage was only possible by using an osteocutaneous fillet of foot and lower leg spare parts free flap, maintaining the tibial nerve pedicle for sensation and the posterior tibial artery for vascularity of the nerve. The procedure was technically challenging and required follow-up debulking operations. However, the technique provided the significant advantage of immediate sensation of robust glabrous distal stump cover and optimising leg length to enhance functional outcome.     

Recovery of forehead sensation after extended coronal flap or ”dismasking flap”

By using an extended coronal flap or ”dismasking flap,” a large area of the cranio-orbitofacial region can be viewed directly. To achieve this, the supraorbital nerves must be sectioned. The sensory recovery in the forehead of patients treated with ”dismasking flaps” was studied as was that in normal adult controls. In the patient who had nerve anastomosis, the Semmes-Weinstein (S-W) test result was 2.36 monofilament number (follow-up period: 9 months). Static 2-PD and moving 2-PD were 15 and 14 mm, respectively. In the patients who did not have nerve anastomosis, the mean S-W test result was 5.46 (n=10, mean follow-up period: 25 months). Five points in three patients showed no recovery of static and moving 2-PD,and two points in two patients showed 25 and 22.5 mm, respectively. Of the patients whose nerves were resected, two did not show recovery of the S-W test results, and one patient showed 6.45 (mean follow-up period: 19 months ). In conclusion, the supraorbital nerve should be anastomosed to obtain good sensory recovery. Received: 12 July 1999 / Accepted: 11 October 1999     

The gracilis (medial circumflex femoral) perforator flap: a medial groin free flap?

The superior medial thigh skin territory has previously been successfully transferred as a free flap as part of a gracilis musculocutaneous flap. However, muscle bulk can be avoided and its function preserved by instead retaining only the musculocutaneous perforators arising from the gracilis pedicle like in a true perforator flap. A clinical example of this new perforator flap is described as the gracilis (medial circumflex femoral) perforator flap. This could become an ideal skin flap because no muscle is included, a well-defined segment of skin can be reliably harvested, closure of the donor site leaves a scar in the groin that can be readily concealed, and its dominant vascular pedicle is consistent in location and already familiar to most reconstructive surgeons.     

Retrospective study of reverse dorsal metacarpal flap and compound flap： a review of 122 cases

SincethereversedorsalmetacarpalflapisreportedbyLUetalinChina,QuabaetalandMaruyamainBritainin1990,14thisflapanditscompoundflaphavebeenappliedtorepairsofttissuedefectson fingersuniversallyduetoitstextureandcolormatched withnormalfingers.Inordertogainbetterapplianceofthiskindo flap,weanalyzedrespectivelytheoperativeindications andtherangeofrepairingbasedonfollow upof122casesfor112years.METHODS ClinicaldataFrom1990to2003,weappliedthereversedorsa metacarpalflapanditscompoundflapin122cases,whic…     

Chimeric superficial temporal artery based skin and temporal fascia flap plus temporalis muscle flap �C An alternative to free flap for suprastructure maxillectomy with external skin defect

Flaps from temporal region have been used for mid face, orbital and peri-orbital reconstruction. The knowledge of the vascular anatomy of the region helps to dissect and harvest the muscle/fascia/skin/combined tissue flaps from that region depending upon the requirement. Suprastructure maxillectomy defects are usually covered with free flaps to fill the cavity. Here we report an innovative idea in which a patient with a supra structure maxillectomy with external skin defect was covered with chimeric flap based on the parietal and frontal branches of superficial temporal artery and the temporalis muscle flap based on deep temporal artery.KEY WORDS: Chimeric flap, orbital floor defect, suprastructure maxillectomy, superficial temporal artery     

The study of expanded tri-lobed flap in a rabbit model: possible flap model in ear reconstruction?

Background  

Local flaps are widely used in reconstructive surgery. Tri-lobed skin flap is a relatively new flap and there has been no experimental model of this flap. This flap can be used for repair of full thickness defects in the face, ears and alar region. Based on the size of ears in a rabbit, we designed a model of ear reconstruction using expanded tri-lobed flap. Local flaps are more advantageous in that they provide excellent color and texture matching up with those of the face, adequately restore ear contour, place scars in a favorable location and ideally accomplish these goals in a single stage with minimal donor site morbidity.     

Complex anal fistulas: plug or flap?

Background: Rectal mucosal advancement flaps (RMAF) and fistula plugs (FP) are techniques used to manage complex anal fistulas. The purpose of this study was to review and compare the results of these methods of repair. Methods: A retrospective review of all complex anal fistulas treated by either a RMAF or a FP at Auckland City Hospital from 2004 to 2008. Comparisons were made in terms of successful healing rates, time to failure and the use of magnetic resonance imaging. Results: Overall, 70 operations were performed on 55 patients (55.7% male). The mean age was 44.9 years. Twenty‐one patients (30%) had had at least one previous unsuccessful repair. Indications for repair included 57 high cryptoglandular anal (81%), 4 Crohn's anal (6%), 7 rectovaginal (10%), 1 rectourethral (1%) and 1 pouch‐vaginal fistula (1%). All patients were followed up with a mean of 4.5 months. Forty‐eight RMAFs (69% of total) were performed with 16 successful repairs (33%). Twenty‐two FPs (31% of total) were performed with 7 successful repairs (32%, P= 0.9). In failed repairs, there was no difference in terms of mean time to failure (RMAF 4.8 months versus FP 4.1 months, P= 0.62). Magnetic resonance imaging was performed in 21 patients (37%) before the repair. The success rate in these patients was 20%. Conclusions: The results of treatment of complex anal fistulas are disappointing. The choice of operation of either a RMAF or a FP did not alter the poor healing rates of about one third of patients in each group.     

Free flap neovascularization: myth or reality?

The blood supply of 17 free flaps was studied several months after surgery. The aim was to see whether or not the free flaps acquired blood flow through vessels across the flap inset independently of the main vascular anastomoses. A color Doppler flowmeter was used to identify the original arterial and venous anastomoses, the vessels in the margin of the flap, and also across the flap inset. The main vascular pedicle was then manually compressed for 2 min and blood flow was again examined in the vessels at the margin of the flap. The flap vessels (post-anastomotic), the anastomoses, and the recipient vessels (pre-anastomotic) could be identified in every case. There was no evidence of anastomotic stenosis. No vessels (neo-vascularization) greater than 0.5 mm could be identified across the flap inset. Small arteries could be identified in the flap near the inset. These vessels emptied completely on manual compression of the vascular pedicle for 2 min and did not refill until the compression was released. This evidence suggests that the free flaps do not receive significant blood flow through vessels across the flap inset, and are therefore significantly dependent for vascularity on the original anastomoses even 1 year after surgery.     

Nipple reconstruction using the “inchworm” flap

A new method of nipple reconstruction called the inchworm flap is described. The name comes from the manipulation method used to position the flap for nipple projection. Experience with over 50 patients and including 58 breasts has been reviewed. There was adequate followup for 36 breasts in which overall maintenance of projection was 78% for this technique. When used after submuscular expansion for breast reconstruction, maintenance of projection reached 89%. The technique of flap manipulation is described in detail. This flap appears to be a reliable method for obtaining moderate nipple projection, particularly in the submuscular expansion breast reconstruction cases. It is not recommended for use in TRAM flap cases.Presented at the annual meeting of the American Society of Aesthetic Plastic Surgery, Chicago, IL, April 1990     

Free flap neovascularization: Fact or fiction?

The dependence of free flaps on the original vascular anastomosis was investigated using color duplex . Although functional and morphological changes in flaps have been previously documented, showing the formation of new vessels across the flap inset, this was not observed in this study. Even after 1 year after surgery the free flaps were still dependent on the original anastomoses for their blood supply, with no other significant vessels obvious on duplex to supply the flap. This evidence as well other published reports suggest that at least the lower extremity and the chest wall do not develop collateral circulation to a free tissue transfer. Late postoperative division of the vascular pedicle either in the lower limb or the chest wall should be approached with the knowledge that neovascularization across the flap margins is the exception rather than the rule.     

Cranioplasty: why throw the bone flap out?

Patients who undergo decompressive craniectomy for intracranial hypertension often require interval cranioplasty. Many cranioplasty agents are currently in use. The authors suggest that storage of the patient's own bone flap in the subcutaneous tissue of the abdominal wall, is a safe, efficacious and cost-effective alternative to use of synthetic cranioplasty materials.     

Is the reversed fourth dorsal metacarpal flap reliable?

We have carried out a study to determine if a flap based on vessels in the fourth metacarpal space could be used safely. We studied ten fresh cadaver specimens and used the flap in nine patients. In the anatomical study, we confirmed the presence of a suitable artery in nine out of the ten hands, arising from a piercing artery at the metacarpal bases, running distally under the fascia. The pivot point is located at the metacarpal heads, where the artery anastomoses to palmar branches and dorsal digital branches. In the clinical setting, the flap was reliable in eight patients. There was one case of flap necrosis. The flap seems to be reliable but several technical points are stressed to avoid complications.     

The serratus anterior scapular flap —A new osteomuscular unit

Summary Dye and contrast studies of 32 scapular regions have demonstrated a reliable blood supply of the scapula based on a terminal branch of the serratus anterior artery. This artery, called the angular branch in our paper, provides the vascular supply of a new osteomuscular flap. The anatomical study also illustrated the relationship between this angular branch and the circumflex scapular and dorsal scapular arteries. The features of this flap are as follows: 1) a constant and long pedicle based on the subscapular-thoracodorsal axis; 2) the possibility of a bony shape similar to the anterior part of the mandible and the hard palate, the maximum length being 22 to 26 cm; 3) the malleable muscular component, suitable for cover of adjacent defects alone or in combination with other regional flaps. The use of the flap for partial reconstruction of the hard palate is described.This paper was presented at the XVII Congreso Argentino de Cirugia Plastica in Buenos Aires, Argentina, September 1–4, 1987, and at the International Symposium on New Techniques of Heterotopic Reconstruction in Bonn, Germany on October 16, 1987     

Bilateral V–Y rotation advancement flap for fingertip amputations

Background  

Fingertip amputation is the most common type of injury in the upper limb. Goals in fingertip amputation reconstruction are covering the defect, establishing maximum tactile gnosis, keeping the length of the finger, protecting the joint function, acquiring a well-padded pulp tissue, providing a bed for growing nail, obtaining a satisfactory cosmetic appearance and allowing the patient to return to work as soon as possible. Adjacent skin and soft tissue are the best covers for fingertip injuries. However, local homodigital flaps lack enough tissue to cover the defect. To solve this problem, we used V–Y rotation advancement flap bilaterally in fingertip amputations which meets all the reconstruction goals. Rotation besides advancement makes this flap more mobile and easier to cover larger defects in all amputation planes.