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.     

The antecubital fascio-cutaneous flap

A clinical case is reported in which a fascio-cutaneous forearm pedicled flap was used. The flap was based on the previously described inferior cubital artery. Anatomical studies suggested that this vessel could be the basis for a fascio-cutaneous free flap possessing an exceptionally long vascular pedicle. This flap is described and its implications discussed in relation to the radial forearm (Chinese) flap.     

Extranasal Applications of the Bilobed Flap

Background. The bilobed flap has proven its utility in the reconstruction of distal nasal defects. The mechanics and geometry of the bilobed flap must be clearly understood to achieve these reproducible results. The novelty of the bilobed flap as it is applied to extranasal reconstruction is that the surgeon has some degree of variance in designing the size of the individual lobules of the flap, with a lower risk of secondary tissue distortion. Several variations of the bilobed flap are described, with emphasis on technique and the unique issues involved in its extranasal application.
Objective. Our experience with the multiple extranasal applications of the bilobed flap is described to demonstrate the usefulness of this reconstructive technique.
Methods. The general technique of the bilobed flap is described, with emphasis on the extranasal variations. Five anatomic locations are presented, with unique considerations and photographs.
Results. The bilobed flap as it is applied to extranasal reconstruction allows the surgeon some degree of variance in designing the size of the individual lobules of the flap (compared with the distal nose), with a lower risk of secondary tissue distortion. The flap must be carefully designed to place the incision lines as close to relaxed skin tension lines as possible. A meticulous suture technique is important in camouflaging the complex suture line of this flap, which in no circumstance completely parallels the relaxed skin tension lines.
Conclusion. We hope to expand the use of this versatile flap to extranasal locations. It can produce the equivalent excellent functional and esthetic results compared with its more common nasal application.     

Supratrochlear artery flap for the repair of lower eyelid defects

An island pattern flap in the treatment of lower eyelid cicatricial ectropion is described. The flap is based on the supratrochlear artery and its associated veins. The donor site can be closed easily primarily. The very thin thickness of the pedicle increases the rotational arc of the flap. However, this procedure requires two stages and there is a slight bulkiness of the flap, both of which are major drawbacks of this method. This flap was used to restore missing supporting soft tissue of the lower eyelid in the clinical cases described herein.     

An easy and versatile method of coverage for distal tibial soft tissue defects

BACKGROUND: The distally based superficial sural artery flap, first described as a distally based neuroskin flap by Masquelet et al., is a skin island flap supplied by the vascular axis of the sural nerve. In the difficult area of defects in the lower leg and the ankle and heel region, it has a wide variety of indications, even in the vascularly compromised patients. It has the largest arc of rotation of all flaps that have been described in this region. The most important advantage is that it does not compromise a major artery. It is simple to dissect and has a low donor morbidity. METHODS: We reported our experience with this new flap in 15 cases and also described a new indication for the patients with neglected ruptures of the Achilles tendon. RESULTS: In 13 patients, the flap was successfully transferred. In two cases, partial necrosis of the flap ensued, which healed with secondary intention. CONCLUSION: This flap deserves a high degree of interest in the reconstructive armamentarium of the trauma surgeon.     

Free tensor fasciae latae musculofasciocutaneous flap in reconstructive surgery: a series of 85 cases.

The use of tensor fasciae latae was first described as a rotation or island flap and evolved into a free flap in the late 1970s. This series of 85 patients undergoing free tensor fasciae latae transfer includes complex head and neck, abdominal wall and lower limb reconstruction. The overall success rate was 93% (79 patients), partial flap loss, 5% (four cases), and flap failure, 2% (two patients). Twelve patients (14%) required unplanned return to theatre for exploration resulting in a 75% salvage rate. We believe this series demonstrates the great versatility of this flap and highlights particular indications for its use.     

四肢带表浅静脉干的局部皮瓣在创伤修复中的应用

设计4种带表浅静脉干的局部皮瓣用于修复四肢创面14例,获得了满意的效果。该皮瓣所包含的一条浅静脉干,不仅有利于静脉回流,且其血流对皮瓣亦有营养作用。因此,该皮瓣容易成活,长宽比值可大于传统任意型皮瓣。并具有操作简便,不损伤主要动脉等优点。文中介绍了皮瓣的设计及手术方法,并对该皮瓣的血液循环特点、适应证及供区选择等进行了讨论。     

四肢带表浅静脉干的局部皮瓣在创伤修复中的应用

设计４种带表浅静脉干的局部皮瓣用于修复四肢创面１４例，获得了满意的效果。该皮瓣所包含的一条浅静脉干，不仅有利于静脉回流，且其血流对皮瓣亦有营养作用。因此，该皮瓣容易成活，长宽比值可大于传统任意型皮瓣，并具有操作简便，不损伤主要动脉等优点。文中介绍了皮瓣的设计及手术方法，并对该皮瓣的血液循环特点、适应证及供区选择等进行了讨论。     

A rare case of anterior chest closure only with omental flap after devastating mediastinitis: case report

Abstract   We describe a case of 73-year-old patient who has been operated in emergency on triple coronary artery bypass graft (CABG), which was complicated with respiratory insufficiency and devastating mediastinitis. The anterior mediastinum was closed with an omental flap that was allowed to epitelize spontaneously. The patient was discharged after 110 days. Despite the large number of cases with mediastinitis described in the literature, the chest closure with only an omental flap without closure of subcutaneous tissue and skin is rare.     

Preliminary report: the distally pedicled dorsoulnar forearm flap for hand reconstruction.

In this paper, a new flap for the coverage of soft tissue defects in the hand is described. To obtain a distally pedicled dorsoulnar flap, the dissection of the standard dorsoulnar flap is continued distally under the descending branch of the dorsal branch of the ulnar artery onto the dorsum of the wrist after the dorsal branch of the ulnar artery is ligated and divided. Our modification of the standard dorsoulnar flap converts this flap to a distally based flap, which provides a potentially longer pedicle and increases the arc of rotation of the flap. Two successful cases are reported.     

A new experimental flap design: the saphenous artery periosto-fasciocutaneous flap of the rat

Vascularized periosteal graft is a frequently applied flap model for bone prefabrication studies due to its inhabitance of osteoprogenitor cells and osteoinductive potential. Various bones such as rib and fibula are reported as a potential source for the harvest of the periosteal flap in experimental studies on higher species such as dogs and pigs, which necessitates a rather complicated and expensive experimental setting. Therefore a reliable and inexpensive small animal model on vascularized periosteal flaps is necessary for future research. A new saphenous artery based periosto-fasciocutaneous flap model in rats is described here, which is easily dissected and monitorized. In this experimental study, 15 male Sprague Dawley rats were operated and killed following a 3-month-long follow-up period . The histological analysis revealed heterotopic osteoneogenesis in 12 of 15 flaps (80%), whereas 14 flaps (93.3%) exhibited signs of angioneogenesis originating from the periostofasciocutaneous flap. The presented flap model promises to be an appropriate alternative for new studies where bone prefabrication methods are evaluated.     

W-plastic rotation flap to cover nasal defect

Keeping in mind the direction of the relaxed skin tension lines (RSTL), we used a local W-plastic rotation skin flap from the cheek to cover a large nasal defect resulting from the excision of a benign skin lesion. This technique, first described by Imre [7], is superior to the direct single-pedicle advancement flap from the cheek, or to any nasolabial flap, for repair of such nasal defects.     

Anterolateral thigh flap technique in hand and upper extremity reconstruction

The anterolateral thigh flap is an extremely versatile flap first described in 1984. The flap is based on either a septocutaneous or musculocutaneous perforator of the descending branch of the lateral circumflex femoral system. It can be designed as a skin and subcutaneous flap, fasciocutaneous, or musculocutaneous flap. Furthermore, it can be harvested as a sensate flap by taking the lateral cutaneous nerve of the thigh. Technique for harvesting the flap is described in detail. Complications include flap failure and donor site morbidity. Due to its versatility, the anterolateral thigh flap is particularly useful for upper extremity reconstruction.     

Posterior superficial temporal artery island flap for intra-oral reconstruction: a case report

A case is presented in which a scalp island flap in an elderly bald male was used for intraoral reconstruction following tumour excision. The flap was based on the posterior branch of the superficial temporal vessels as its arteriovenous system. This flap when available has advantages over other flaps described for intra-oral reconstruction.     

A technique of undermining a V-Y subcutaneous island flap to maximise advancement

A method is described where the planned directional undermining of a subcutaneous triangular flap creates a long pedicle and in the process the flap is "unfolded" to increase its advancement. The flap can be undermined and advanced without any tension. This method is recommended where more conservative undermining is inadequate for mobilisation, particularly in larger defects and in the replacement of skin defects on the lower eyelid which needs to support the eyelid. This technique depends on the richness of the random blood supply in the head and neck regions and the availability of adequate depth of subcutaneous tissue for the development of a long pedicle. Using this method in 53 cases, it has been found possible to advance the flap way past the defect if so desired. Some minor disadvantages of this flap are also described.     

Moustache reconstruction using an extended midline forehead flap.

A new method for reconstruction of the upper lip and moustache is presented. An extended midline forehead flap is described, which is a modification of the classical midline forehead flap in which the flap is extended into the hair-bearing scalp. Simultaneously, a nasal alar defect was reconstructed using the non-hair-bearing forehead skin in a patient with cancrum oris. The flap is reliable, technically easy to raise, does not require any special expertise and causes minimal donor site deformity. However, it is a multistage procedure and hence causes prolonged morbidity.     

Middle turbinate vascularized flap for skull base reconstruction after an expanded endonasal approach

Introduction  

The expanded endonasal approaches to the skull base are modular approaches that arise from the sphenoidal sinus. The reconstructive techniques in these approaches are key to avoid postoperative complications. Available flaps for reconstruction include the pedicled nasoseptal flap, the transpterygoid temporoparietal fascia flap, and the posterior pedicle inferior turbinate flap (PPITF), among others. Recently, the middle turbinate flap has been described in a cadaveric study. We report our preliminary experience in the use of this middle turbinate vascularized flap for skull base reconstruction after expanded endonasal approaches.     

Reconstruction after resection of a large sacral neoplasm

The gluteus maximus musculocutaneous flap is a useful flap for sacral reconstruction. Many variations have been described. The flap can be raised simply, quickly and with minimal blood loss. This flap was used for closure of a large defect of the sacrum in a 44-year-old woman with an advanced neoplasia of the sacrum. The surgery, performed in a third world country, required a procedure which was unlikely to fail. The technique and the results are presented.     

Cryptotia repair: a modern update to the trefoil flap

Cryptotia is a congenital anomaly in which the superior aspect of the helical cartilage is buried beneath the scalp, resulting in an absence of the auriculocephalic sulcus. Treatments have included splinting, skin grafts, and a variety of local flaps. We present a modification of the trefoil flap, initially described by Wesser in 1972. The modifications include wider undermining of the opposing trefoil flap (≤ 2-4 cm), staggering the closure of the helical apices, and expanding the base of the auricular trefoil flap such that it extends over a larger circumference of the helical rim. The senior author (K.S.) has achieved excellent results with this method and has alleviated the need for skin grafts or local preauricular flaps to close the donor site.     

The anatomical basis of the lateral thoracic flap

Summary A modified Type B fasciocutaneous flap can be safely raised in the lateral thoracic region due to its rich vascularisation. This paper described the anatomical basis for such a flap, based on 18 dissections in 9 cadavers. The multiple direct cutaneous perforators which supply this region were found to be fairly constant and of adequate calibre to sustain a fasciocutaneous flap.