Impairment of the brachial plexus after harvest of the latissimus dorsi muscle for reanimation of a paralysed face

The one-stage neurovascular pedicled latissimus dorsi muscle transfer with a long thoracodorsal nerve for dynamic reanimation of long-standing facial paralysis offers several advantages over other options. However, extensive dissection of the thoracodorsal nerve risks injury to the brachial plexus. We reviewed 264 consecutive cases to assess the extent of the risk of impairment of the brachial plexus and to elicit factors that could possibly induce complications. Six patients had impairment of brachial plexus, but both sensory and motor disturbance disappeared about 11 months postoperatively. All symptoms had completely vanished by 18.5 months. The complications were thought to have resulted from positioning and excessive retraction in four cases. Direct invasion of the brachial cord may not be the main cause. Proper knowledge of the anatomy and optimum attention minimise the risk of severe complications associated with harvesting of the latissimus dorsi muscle.     

The use of cross-leg free muscle flaps in the reconstruction of lower extremity injuries

The cover of soft tissue and bone defects of the distal one-third of the leg resulting from crush injuries is a challenging problem. In such injuries healthy recipient vessels for free tissue transfer are frequently unavailable. Three cases of gunshot wounds and a mine explosion were managed successfully with cross-leg free muscle flaps, two latissimus dorsi and one rectus abdominis. The disadvantages of this technique are patient discomfort due to immobilization between the main and the flap division procedures together with the long hospital stay.     

Locoregional and free flap reconstruction of the lateral skull base

Lateral temporal bone reconstruction after ablative surgery for malignancy, chronic infection, osteoradionecrosis, or trauma presents a challenge for the reconstructive surgeon. This complexity is due to the 3D nature of the region, potential dural exposure, and the possible need for external surface repair. Successful reconstruction therefore requires achieving separation of the dura, obliteration of volume defect, and external cutaneous repair. There is significant institutional bias on the best method of reconstruction of these defects. In this review, the advantages and disadvantages of reconstructive options will be discussed as well as the potential pitfalls and complications. © 2014 Wiley Periodicals, Inc. Head Neck 37: 1387–1391, 2015     

Free musculocutaneous and muscle flaps for foot reconstruction: a clinical and gait analysis study

Between 1986 and 1995, 48 microvascular flaps (14 fasciocutaneous, 13 muscle, and 21 musculocutaneous) were performed on 47 patients with foot defects. The study group consisted of 19 patients who successfully underwent weightbearing surface reconstruction with free musculocutaneous flaps or muscle flaps with a skin graft. The groups were identified on the basis of the free flap used. Group 1: Latissimus dorsi musculocutaneous flaps (11 patients); group 2: Skin grafted muscle flaps (8 patients: latissimus dorsi - 6, gracilis - 1, rectus abdominis - 1). The follow-up period was 1–11 years (average: 8.3 years). Follow-up included documentation of foot pain, presence of ulceration, sensory recovery, the ability to wear normal shoes, and the need for a second operation. In group 1, debulking operations were necessary (8 patients, 72.7%). Debulking was not required in group 2. Ulceration occurred in four (36.4%) group 1 patients and in one (12.5%) group 2 patient. All patients had good deep pressure sensation. All the group 2 patients could wear normal shoes. Four (36.4%) of the group 1 patients had to wear special orthopedic shoes. The gait analysis consisted of two parts: footprint analysis with the Harris mat technique and plantogram of Parotec system by Kraemer. Foot analysis with the Harris mat showed that the pressure on the muscle flap is less than the pressure on the musculocutaneous flap. Gait analysis by the Parotec system showed that in patients with musculocutaneous flaps, static load distribution on the reconstructed bare foot is nearly normal, but dynamic load distribution is pathological. In patients with muscle flaps, both static and dynamic load distribution were close to normal. Received: 19 May 1997 / Accepted: 8 November 1999     

Non-anatomical reconstruction of lateral ulnar collateral ligament of the elbow after tumor resection

We present the case of an 80-year-old man with a tumor recurrence on his right arm 6 years after initial treatment. The lateral aspect of the elbow joint, involving overlaying skin, muscles, tendons, joint capsule, lateral collateral ligament complex, the lateral 1/3 of the capitellum, and lateral epicondyle of humerus were excised in the tumor resection. Intraoperative assessment revealed multidirectional instability of the elbow, and joint stabilization was needed. Because the lateral epicondyle was resected, graft placement in an anatomical position was impossible to carry out. Therefore, non-anatomical reconstruction of lateral ulnar collateral ligament with palmaris longus tendon graft was performed. The skin was reconstructed using an antegrade pedicled radial forearm flap. For wrist extension reconstruction, the pronator quadratus tendon was transferred to the extensor carpi radialis brevis tendon. One year after the operation, elbow range of motion was 5–130°. The patient remains symptom free. The Mayo elbow performance score is good. The Musculoskeletal Tumor Society rating score is excellent. To our knowledge, this is the first report of an elbow lateral ulnar collateral ligament reconstruction after tumor resection.     

Prognosis as a determinant of free flap utilization for reconstruction of the lateral mandibular defect

BACKGROUND: The purpose of this study was to determine whether patients with a poor prognosis for survival were more likely to undergo reconstruction with a pectoralis flap versus a free flap and whether the use of a pectoralis flap offered any perioperative advantage, such as a reduction in medical complications. METHODS: Fifty-five consecutive patients who underwent immediate reconstruction after a lateral mandibulectomy were retrospectively reviewed. RESULTS: Age >or=70 years (p = .03), moderate or severe comorbidity (p = .02), and involvement of the base of tongue by tumor (p = .04) were significantly associated with decreased utilization of a free flap (n = 36). Comorbidity was the main determinant of medical complications (p = .001) and length of hospital stay (p = .03). CONCLUSIONS: Expectations of prognosis bias the surgeon's decision regarding flap selection. Reconstruction with a pectoralis flap does not necessarily contribute toward the desired outcome of reduced medical complications. Any functional comparison between reconstructive groups needs to account for those differences in health status and prognosis that might explain any observed postoperative differences.     

Restoration of finger and thumb movement using one-stage free muscle transplantation

Objective: Functional reconstruction following severe traumatic muscle loss may cause problems for reconstructive surgeons. In such situations, functioning free muscle transplantation (FFMT) represents an important alternative treatment option.

Methods: The clinico-demographic characteristics of 11 patients receiving modified FFMT between 2005–2013 were retrospectively reviewed. The muscle strength, range of joint motion (ROM), total active motion (TAM) of the fingers, and Disability of Arm Shoulder and Hand (DASH) score were adopted to assess the functional results.

Results: All FFMTs were performed in the secondary stage. The authors found that the mean ROM, TAM, ratio of TAM compared with the contralateral side, and DASH score were 112 degrees, 150 degrees, 62%, and 22.8, respectively; and eight and nine patients achieved greatly improved grip function and M4 muscle strength, respectively.

Conclusion: Using one-stage free muscle transplantation to restore finger and thumb movement simultaneously is an effective method for functional restoration following traumatic multi-muscle loss.     

C4副神经移位重建斜方肌功能的实验研究

目的探讨以C4神经前支主干作为动力神经移位修复副神经重建大鼠斜方肌功能的可行性,为临床用于副神经缺损的动力性修复提供理论依据。方法取36只成年雄性SD大鼠,体重200～250 g;随机分为实验组与对照组(n=18)。实验组左侧行C4副神经移位重建术,对照组左侧行副神经切除术;两组右侧不做任何处理,作为正常对照。术后1、2、3个月实验组行复合肌肉动作电位(compound muscle action potential,CMAP)及肌肉功能检测,计算潜伏期延迟率、最大波幅恢复率及肌张力恢复率;取两组斜方肌行HE染色,计算肌细胞截面积恢复率;取实验组神经吻合口远端神经行甲苯胺蓝染色,计算吻合口远端有髓神经纤维恢复率。并于术后1、3个月取实验组斜方肌及神经行透射电镜观察。结果随时间延长,实验组斜方肌CMAP最大波幅逐渐增加,潜伏期缩短,肌张力逐步恢复;神经吻合口远端有髓纤维逐渐增加。至术后3个月肩、背斜方肌CMAP最大波幅恢复率为63.61%±9.29%、73.13%±11.85%,潜伏期延迟率为130.45%±37.27%、112.62%±19.57%,肌张力恢复率为77.27%±13.64%、82.47%±22.94%,有髓纤维通过率为82.55%±5.00%。随神经支配恢复,实验组肌细胞截面积亦逐渐增大,且各时间点与对照组比较差异均有统计学意义(P<0.05)。术后1个月时斜方肌肌节排列紊乱,3个月时逐步趋于整齐。结论 C4副神经移位重建术可有效重建大鼠斜方肌的运动功能。     

Post-traumatic extremity reconstruction with the use of free vastus lateralis flap

A series of eight patients is presented to demonstrate the use of the free vastus lateralis flap with or without the skin component for reconstruction of the extremities, over a period of 18 months. Six patients had defects due to a road traffic accident, one had a neurotrophic ulcer, and one post-traumatic osteomyelitis. There was complete survival of the flap in six patients, the remaining two had partial loss. This flap is very useful in extremity reconstruction due to its long vascular pedicle, availability of skin and muscle, ease in elevation and minimal donor flap morbidity.     

Tracheal reconstruction: mini-review and anatomical study on the use of antero lateral thigh fascial flap for heterotopical transplantation

BackgroundThe reconstructive tracheal options for extensive lesions still remain limited and although a valid substitute is required unfortunately, the biomechanical tracheal characteristics do not allow an easy replacement. In this study we reviewed the described options and investigated, in human cadaver model, whether thigh fascia can be used, as an alternative to forearm fascia, as recipient site for trachea graft heterotopical allotransplantation.Anatomical studyIn three fresh cadavers, 3 tracheal graft, 6 radial forearm (RF) fascial flaps and 6 antero-lateral thigh (ALT) fascial flaps were harvested. For each flap we simulated the heteretopical transplantation of the trachea in each fascial flap, and the harvesting of the composite graft as a free flap. The composite graft was finally decomposed at bench and the pedicle was injected to confirm fascial vascularization. The main measured outcomes were: flap fascia vascularization after pedicle injection, average time of flap harvesting, number of perforators included in ALT fascial flap and diameter of the vessels for anastomosis. Difficulties were noted, in order to compare RF flap and ALT flap.ResultsFascia vascularization was confirmed in all cases by pedicle injection. The main difficulty with radial flap was to harvest the fascial layer due to its thinness and its strong adherence to palmaris longus tendon, while the main difficulty with ALT flap was to prevent any traction on the perforators. The average time of flap harvesting and graft inset (by a junior plastic surgeon) was 1 h and 30 min for radial forearm flap and 2 h and 10 min for ALT flap.ConclusionDespite many different techniques proposed in the literature, tracheal heterotopical allotransplantation still seemed the most promising, and ALT flap promised be a feasible alternative for heterotopical transplantation of trachea.     

Combined use of medial thigh skin flaps and gracilis musculocutaneous flaps for the reconstruction of scrotum

Summary A case of combined use of bilateral medial thigh skin flaps and gracilis musculocutaneous flaps for the reconstruction of a scrotal defect resulting from Fournier's gangrene is presented. The procedure provided a sac-like scrotum, and the donor sites were successfully reconstructed using bilateral gracilis musculocutaneous V-Y advancement flaps.     

Versatile use of rectus abdominis muscle and musculocutaneous flaps for soft-tissue reconstruction: our clinical experiences in 25 cases

The rectus abdominis muscle and musculocutaneous flaps have contributed to the efficient reconstruction of tissue defects that require a large amount of cutaneous and muscular tissue. In this article, outcomes of soft-tissue defects after reconstruction with the rectus abdominis muscle and musculocutaneous flaps were retrospectively analyzed. From August 2003 to June 2009, 25 flaps were transferred to reconstruct a wide variety of soft-tissue defects in the breast, chest wall, groin, perineal, and head and neck regions, as well as the upper and lower extremities. The rectus abdominis muscle and musculocutaneous flaps were used as part of 11 different approaches in 25 cases. There were 13 male and 12 female patients; the mean patient age was 44.2 years. The mean follow-up period was 8 months (range, 4–15 months). The overall success rate was 100%, and all flaps healed uneventfully. All reconstructive procedures were completed without any major complications. Rectus sheets were repaired primarily, and no mesh application was used. Minor complications related to transferred flaps were wound infection and dehiscence in one case, wound dehiscence in two cases, and flap lymphedema in one case. Minor complications related to the donor site were seroma in one case and wound infection and dehiscence in another case. This study presents our experience with the rectus abdominis muscle and musculocutaneous flaps in a series of 25 cases. The indications for the use of this particular flap with other flaps are discussed.