Treatment of complex metacarpal defects with free chimeric iliac osteocutaneous flaps

Objective: The aim of this report is to present the clinical results of using free chimeric iliac osteocutaneous flaps based on the periosteal branch of the superficial circumflex iliac artery (SCIA) in complex metacarpal reconstructions.

Methods: Reconstruction using free chimeric iliac osteocutaneous flaps was performed in a series of seven patients who underwent metacarpal reconstruction for complex metacarpal defects between March 2009 and March 2012. The procedure was performed for bone and soft tissue losses associated with posttraumatic infections (four patients) and posttraumatic bone and soft tissue defects (three patients).

Results: The skin paddles of the chimeric flaps had a median size of 3?×?7?cm, and the iliac segments had a mean size of 1?×?1?×?3?cm. The median follow-up time was 18 months. All the flaps survived completely with no signs of infection. Osseous union occurred within a mean period of 3 months, and the range of motion achieved for the metacarpal phalangeal joints was 0–80°. The patients were satisfied with the aesthetic outcome.

Conclusions: Chimeric iliac osteocutaneous flaps may be a useful alternative for treating complex metacarpal defects because they yield a thinner skin paddle and less bulky bone segment than traditional flaps.     

The transversely split gracilis twin free flaps

The gracilis muscle is a Class II muscle that is often used in free tissue transfer. The muscle has multiple secondary pedicles, of which the first one is the most consistent in terms of position and calibre. Each pedicle can support a segment of the muscle thus yielding multiple small flaps from a single, long muscle. Although it has often been split longitudinally along the fascicles of its nerve for functional transfer, it has rarely been split transversely to yield multiple muscle flaps that can be used to cover multiple wounds in one patient without subjecting him/her to the morbidity of multiple donor areas.     

Experiences in the use of eight cutaneous and osteocutaneous superficial and deep circumflex iliac free flaps

Eight patients underwent free tissue transfers involving groin cutaneous or osteocutaneous flaps using the superficial and deep circumflex iliac arteries and veins. Four were used for head and neck reconstruction, two for severe neck scar contractures, and two for composite skin and mandibular reconstruction. Three were used in lower extremity reconstructions, all in situations requiring bone and skin reconstruction. One was used for skin cover alone in an upper extremity reconstruction for wrist cover. One of the head and neck cases sustained vascular thrombosis requiring a second successful free flap coverage for a 12.5% failure rate. One required re-exploration with successful salvage. The average operating time was 12 hours. The anatomy and surgical techniques are discussed. The main values of the procedure are the presence of a double vascular supply of both arteries and veins for complex reconstructions, and the fact that a large area of skin and subcutaneous tissue can be procured, with a relatively inconspicuous donor site.     

Large tongue flaps to close massive palatal defects

Ten patients with large palatal fistulae due to various etiologies are presented. The surgical technique used to close these defects and the perioperative management are both discussed. Closure was successful in all but one. Two patients had small fistulae which required minor repairs. Two patients had bone grafts which were inserted through the flap at a second stage, with subsequent placement of osseointegrated dental implants. Received: 4 February 1999 / Accepted: 25 February 1999     

Reconstruction of the wide palate defects with temporal osteocutaneous island flaps

Summary The temporal osteocutaneous island (TOCI) flap was first performed in reconstruction of palatal defects by Furnas [8]. It consists of temporoparietal fascia, galea, pericranium and the cortical layer of parietal bone covered with pericranium. In this study, we present five patients with wide palatal defects treated by TOCI flaps. The causation of the wide palatal defects were gun-shot wounds in two patients and unsuccessful reconstruction of congenital cleft palate during early childhood in three patients. All patients were adult. TOCI flaps were performed in two stages. At first, the TOCI flap was elevated and covered with a split thickness skin graft. In the second stage (approximately 1.5 months later), the flap was elevated based on the superficial temporal artery as an island flap. It was then transferred to the palatal defect via a cheek tunnel and sutured to the edges of the defect. There was no need for bone fixation. The length of the pedicle of the flap was sufficient in size to easily reach the anterior part of the palate. No serious complications were seen. One minor oronasal fistula occurred; this was repaired by local flaps. The TOCI flaps improved speech only partially. In conclusion, we believe this procedure is a good method for reconstruction in wide palatal defects which need three layer closure. This procedure is not a satisfactory solution for complete correction of speech defects.     

Gracilis muscle split into two free flaps

A case is presented in which the gracilis muscle was transversely split into two free flaps for coverage of two separate defects in a patient with a multi-segment fracture of the metatarsal bones and the ankle joint.     

Temporal osteocutaneous island flaps for complete reconstruction of cleft palate defects

In each of four patients, closure of a wide cleft palate was performed with a temporal osteocutaneous island flap (TOCI flap) based on the superficial temporal artery. These were fabricated island fasciocutaneous flaps composed of temporoparietalis fascia and galea with pericranium, surfaced with split skin grafts. Two flaps carried with them a segment of vascularized parietal bone (TOCI-I). In the other two flaps, the osseus component was supplied by placing an osteogenic powder in a pericranial pocket: a temporal artery "osteogenic" cutaneous flap (TOCI-II). In each case the flap closed the defect and lengthened the palate without the need for elevation of palatal mucoperiosteum. Growth of the parietal bone segment has been observed in the first patient (the only one to have a follow-up CT scan). This patient, the eldest, is developing normal speech so far. The others are still too young for evaluation.     

The thoracodorsal artery perforator-scapular osteocutaneous (TDAP-SOC) flap for reconstruction of palatal and maxillary defects

Despite technical advances over the past 3 decades, subtotal, total, and extended total maxillectomy defects remain challenging reconstructive problems. In particular, postoncologic resection of the maxilla results in complex 3-dimensional defects of the midface, which cause severe functional and esthetic deformities. Such defects generally require composite tissue flaps for reconstruction. Rebuilding the palate and maxilla is especially challenging because it requires reconstitution of the facial buttresses, occlusion, replacement of bony hard palate, and the thin intraoral and intranasal lining which normally constitute the soft palate. Various methods of reconstruction have been applied to this area in search of an ideal soft tissue-bone flap to restore the bony framework of the maxilla and palate while providing an internal lining. Osteocutaneous and osteomuscular flaps such originating from the scapular, iliac, peroneal, and radial vascular systems have been attempted with good success.We devised an osteocutaneous flap based on the scapular vascular system, which provided bone and soft tissue to successfully reconstruct the palate and maxilla in 2 patients. The skin paddle received its blood supply from the major perforating vessels of the thoracodorsal artery, and the scapular bone was nourished by the angular vessels. Although free tissue transfer using thoracodorsal perforator flaps has been described, this flap has not been previously reported in the literature as an osteocutaneous tissue transfer. With the use of rigid fixation, excellent results have been obtained with this technique for palatal and maxillary reconstruction.     

Assessment of donor site morbidity for free radial forearm osteocutaneous flaps

Purpose: Assessment of donor site morbidity and recipient site complications following free radial forearm osteocutaneous flap (FRFOCF) harvest and evaluation of patient perceived upper limb disability for free radial forearm osteocutaneous versus fasciocutaneous flaps (FRFF). Methods: First a case series was undertaken of 218 patients who underwent an FRFOCF at two tertiary referral centers between February 1998 and November 2010. Outcomes included forearm donor site morbidity and recipient site complications. Second, the disability of the arm, shoulder, and hand (DASH) questionnaire assessing patient perceived arm disability was administered by phone to 60 consecutive patients who underwent an FRFOCF or FRFF. Results: Mean patient age was 63 years with male predominance (62.8%). Median bone length harvested was 8 cm (range, 3–12 cm) with prophylactic plating of the radius following harvest. Donor site morbidity included fracture (1 patient, 0.5%) and sensory neuropathy (5 patients, 2.3%). Mean DASH scores were comparative between groups and to established normative values. Mandibular malunion rate was 3.2% and hardware extrusion at the recipient site occurred in 15.6%. Conclusion: Reluctance to perform FRFOCF by surgeons usually centers on concerns regarding potential donor site morbidity and adequacy of available bone stock; however, we identified minimal objective or patient perceived donor site morbidity or recipient site complications following harvest of FRFOCFs. Mild wrist weakness and stiffness are common but do not impede ability to perform activities of daily living. Data from this and other reports suggest this flap is particularly useful for midfacial and short segment mandibular reconstruction. © 2012 Wiley Periodicals, Inc. Microsurgery, 2012.     

The early use of free flaps in burns

Fourth degree burns of the extremities, that is, burn wounds that go down to denuded bone or tendon, frequently necessitate either amputation of the involved limb or multistage reconstructive procedures involving prolonged hospitalization so that the limb may be salvaged. It is our belief that in these patients free flaps should be considered as a means of initial wound closure. Microvascular procedures under these circumstances may well represent the most expeditious means of salvaging an extremity even when more conventional techniques are available. Studies of a series of patients illustrating this point are presented.     

Reconstruction of through-and-through osteocutaneous defects of the mouth and face with subscapular system flaps

BACKGROUND: Major ablative surgery in the head and neck region may create composite defects involving the oral mucosa, bone and the overlying facial skin. The large surface area and the three-dimensional nature of these defects pose a difficult reconstructive challenge requiring adequate bone and large, positionally versatile skin flaps. PATIENTS AND METHODS: From September 1993 to May 2000, 19 patients with through-and-through osteocutaneous defects of the mouth and face were reconstructed with composite subscapular artery system flaps. The evaluated parameters included: (i) site and dimensions of the tissue defect; (ii) specific flap properties; and (iii) review of the recipient and donor site morbidity. RESULTS: 10 variants of scapular osteocutaneous flaps, eight latissimus dorsi with serratus anterior and rib osteo-myocutaneous flaps, and one combination of an osteocutaneous scapular and myocutaneous latissimus dorsi flap were used to reconstruct composite facial defects with mean dimensions of: skin 54.4 cm(2), mucosa 56.2 cm(2) and bone of 8.2 cm. Ischaemic complications occurred in three patients including one total flap failure and one failure of the bony component in previously irradiated patients. The third flap was successfully salvaged. No significant long-term donor site morbidity was noted. CONCLUSION: Composite flaps based on the subscapular artery system are a versatile reconstructive modality for large through-and-through defects of the mouth and face.     

The indications and outcomes in the use of osteocutaneous radial forearm free flap

INTRODUCTION: Whether secondary to cancer surgery ablation or trauma, surgeons are faced with defects of the mandible or maxilla that would be best reconstructed with a thin, pliable soft tissue component and vascularized bone. A subset of these challenging wounds do not require the bicortical bone necessary to reestablish structural integrity or to retain a dental prosthesis, because the soft tissue needs are more critical than the bony needs. It is this niche that the radial forearm osteofaciocutaneous free flap (RFOFF) fulfills well. In the past, potential and real donor site morbidity has precluded the routine use of this flap. New methods to reduce this morbidity have rekindled our use of this flap. PROCEDURES USED: A retrospective review of patients with defects of the mandible or maxilla treated with the RFOFF from July 1, 1997, to December 31, 2000, was performed. After flap harvest, the donor site was rigidly fixated. A skin graft was placed, and a volar splint was applied for 7 days. The arm was then fully mobilized. Parameters examined were defect location, donor site complications, flap survival, fistula occurrence, plate fracture, and/or extrusion. RESULTS: Thirty-four patients were reconstructed with the RFOFF with a follow-up of 10-54 months. Seven patients had an anterior maxillectomy defect, and 27 patients had a lateral mandibulectomy defect with associated tongue/tonsillar fossa and/or palate defect. There were no cases of flap failure or donor site radius fracture. During the follow-up period, there were no plate fractures or intraoral exposures as evidenced by clinical and radiographic evaluation. Fistulas occurred in five patients; all healed without surgical intervention. CONCLUSION: With rigid fixation of the residual radius, donor site morbidity has been minimized, and indications for this flap have expanded. Specifically the anterior maxillary arch and the ascending ramus, angle, and posterior body of the mandible (nontooth-bearing areas) are the sites most amenable to the thin bony stock of the harvested radius. The pliable forearm skin is ideal for the soft tissue defects. We believe that the RFOFF with bone has a definite role in the reconstruction of select head and neck defects.     

Use of microvascular flaps including free osteocutaneous flaps in reconstruction after composite resection for radiation-recurrent oral cancer.

Fourteen patients underwent microsurgical free flap procedures for reconstruction after composite resection of radiation-recurrent oral cancer. The use of attached metatarsal bone in nine patients for mandibular reconstruction is in our view a significant advance in this field. Two failures occurred, one due to sepsis and one to delayed thrombosis. Our experience indicates that this procedure deserves a place in the surgical treatment of patients afflicted with oral malignancy.     

The osteocutaneous free fibular graft

Free osteocutaneous fibular grafts, revascularised by microvascular anastomoses, have been used for one-stage reconstruction of extensive bone and skin loss in the lower leg in seven patients. The addition of an integral skin flap to a vascularised fibular graft makes reconstruction of bone defects with significant skin loss possible, and the technique for designing and raising such a flap is presented. The advantages of this transfer over other microvascular osteocutaneous flaps are the available length of straight cortical bone, the large thin skin flap, the good diameter of the vascular pedicle and the fact that dissection is carried out under a tourniquet.     

The use of free microvascular flaps in the leg

Summary After discussing the conventional techniques available for covering skin defects in the leg with associated complex orthopaedic problems the value of the free flap is emphasised. The technique is discussed briefly and six cases are presented. The advantages of this method are outlined and the improvement in healing afforded by the extra blood supply in cases where there is infection and exposure of bone or plate is stressed. Where large complicated skin defects can be predicted, early co-operation between orthopaedic and plastic surgeons is advised.

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Zusammenfassung Nach der Diskussion der konventionellen Techniken zur Behebung von Hautschäden am Bein und der damit verbundenen komplexen orthopädischen Probleme wird die Bedeutung des freien Lappens betont. Diese Technik wird kurz beschrieben und über 6 Fälle berichtet. Es werden die Vorteile dieser Methode hervorgehoben und die verbesserte Heilungsquote, die durch eine extra Blutzufuhr erzielt wird in Fällen, wo eine Infektion eintritt und das Freilegen des Knochens oder der Platte angezeigt ist.

     

Application of microvascular free osteocutaneous flaps in the management of post-radiation recurrent oral cancer

Fifty-nine patients underwent free flap osteocutaneous reconstruction that consisted of flaps of the dorsum of the foot in 26 patients and iliac crest flaps in 33 with a success rate of 92 percent and a mortality rate of 1.6 percent. These flaps, which require the expertise of microvascular surgeons, are time-consuming and complicate operating room and time management, but they represent a remarkable advance in reconstruction that can facilitate cosmetic and functional recovery of the patient. In particular, they promote healing in radiation-recurrent oral cancer and represent a definitive form of management for established radionecrosis of the mandible. The large volume of tissue available with iliac crest osteocutaneous grafts permits the management of patients with extensive cancer involving the skin, mucosa, and bone, but cancer control may still be disappointing and there is a need for improved adjuvant chemotherapy protocols. This technique appears to be a dependable, repeatable, and significant advance in management of the patient with head and neck cancer.