Reverse temporalis muscle flap for the reconstruction of orbital exenteration defects

Orbital exenteration is a surgical procedure that results in devastating functional and aesthetic losses. Many reconstructive techniques, ranging from spontaneous epithelialization to free flaps, have been described for orbital exenteration defects. The temporalis muscle flap is one of the most frequently used flaps to obliterate the orbital cavity, but only a small portion of the muscle can be used for this purpose because most of the muscle is used as the pedicle. The reverse temporalis muscle flap based on the superficial temporal vessels is a versatile flap by which the entire temporalis muscle can be elevated and carried to defects beyond the midline. The authors have used this flap for orbital reconstruction after exenteration in 6 patients with successful results. This flap enables placement of highly vascularized tissue that provides the reconstructive goals of primary healing, obliterates dead space with separation of the orbit from the nasal cavity or sinuses, provides the potential for early postoperative radiotherapy, and offers possible flaps that can be used in combination for complex, wide defects.     

颅眶截骨前移结合游离皮瓣整复放疗后眶畸形

目的探讨经颅眶截骨前移结合足背游离皮瓣串联胫前筋膜瓣整复放疗后眼眶凹陷及结膜囊狭窄畸形的临床疗效。方法自2004年以来,共收治5例视网膜母细胞瘤手术及放疗后眼眶及结膜囊严重凹陷畸形,应用冠状切口经颅眶前部截骨前移,钛钉钛板坚强固定后,复原头皮瓣,再在狭窄的结膜囊中部切开向四周分离,根据结膜囊缺损的大小及颞部的凹陷范围设计足背游离皮瓣串联胫前筋膜瓣,分别移植于结膜囊及颞部凹陷部位,血管蒂与颞浅动静脉或面动脉及颈外静脉吻合。结果皮瓣全部成活,经3-6个月随访,眶外形满意,颞部凹陷明显改善。结膜囊内义眼模固定3个月后3例配戴义眼外形良好;2例较差,其中1例眼窝凹陷仍较明显,二期行义眼座置入术,另1例结膜囊挛缩,术后下穹隆过浅,二期行自体硬腭黏膜移植。上述2例经二期修整后1个月安戴义眼,外形也达到满意效果。足部供区4例愈合良好,1例延期愈合。结论经颅眶截骨前移结合游离足背皮瓣串联胫前筋膜瓣转移整复放疗后眼眶及颞区凹陷及结膜囊狭窄畸形具有可行性,一期手术即可完成。     

Rectovaginal fistula repair using a gracilis muscle flap

Introduction and hypothesis

This video demonstrates a technique for using a pedicled gracilis muscle flap to repair rectovaginal fistula.

Methods

We present the case of a 48-year-old woman diagnosed with rectal cancer 2 years earlier. She underwent neoadjuvant chemoradiation followed by ultralow anterior resection. Six weeks after surgery, a fistula was identified at the anastomotic site. Preoperative planning with urogynecology, plastic surgery, and colon and rectal surgery teams deemed a pedicled gracilis muscle flap to be the best approach for this patient due to the rich blood supply and the patient’s prior history of pelvic irradiation. The gracilis muscle is suitable due to the proximity of its vascular pedicle to the perineum, length, and minimal functional donor-site morbidity. We discuss techniques used to interpose a gracilis muscle flap between the rectum and vagina to repair a rectovaginal fistula.

Conclusion

Using the gracilis muscle is a viable option for repairing rectovaginal fistulas, especially in the setting of prior pelvic radiation. A multispecialty approach may be beneficial in complex cases to determine the optimal approach for repair.

     

Secret scar free gracilis flap

The gracilis free flap is a workhorse in plastic surgery. We present a modified technique that relies on a single horizontal thigh-lift-type approach, which (1) gives wide pedicle exposure, (2) provides material for skin grafting, and (3) allows for distal flap transection without an additional incision. Eighteen gracilis free flaps were performed from 2007 to 2009 for lower extremity reconstruction. Complete flap survival was observed in 17 patients with one partial necrosis distally. Our approach allowed access to divide the distal gracilis tendon without a second incision in all cases. The mean scar length was 16 ± 3 cm and no hypertrophic scars were observed. In 15 patients, no visible scar was observed in the upright position, and in three patients, the scar was visible dorsally (2 ± 1 cm). No sensory deficits were observed 6 months postoperatively. In addition, the split-thickness skin graft harvested from the skin paddle was sufficient to cover all defects.     

Latissimus dorsi-scapula free flap for reconstruction of defects following radical maxillectomy with orbital exenteration.

A total of 21 patients with latissimus dorsi-scapula free flap reconstruction immediately following radical maxillectomy together with orbital exenteration are presented. Orbital exenteration was performed in all patients due to tumour invasion at the time of diagnosis. There was no total flap failure. Two tissue components subdivided into separate flap units with individual vascular pedicles linked by a single vascular source provide an ideal reconstructive solution for massive defects of the mid-face and orbit. Separate arcs of rotation of each flap unit permit greater mobility necessary for complex three-dimensional reconstruction. A vertically positioned angle of the scapula enables simultaneous reconstruction of the malar eminence and alveolar ridge whereas spontaneous intraoral epithelialisation of the latissimus dorsi muscle requires no additional procedure. For these reasons, in our opinion, combined latissimus dorsi-scapula free flap should be considered the first choice in reconstruction of defects following total maxillectomy with orbital exenteration.     

Reconstruction after radical hemimaxillectomy using a free multidimensional latissimus dorsi myocutaneous flap

Summary A series of safe, simple and single-staged reconstructions following radical resection of maxillary antral carcinomas with soft tissue involvement is presented. These reconstructions were performed using free triple-folded latissimus dorsi myocutaneous flaps revascularised via the facial vessels. This technique can be safely used in irradiated patients and, when indicated, allows for the administration of early postoperative radiotherapy, thus improving the potential cure rate. Advantages and disadvantages of the technique are discussed.     

Transverse splitting of the gracilis muscle free flap: Maximal use of a single muscle

The gracilis muscle, based on the dominant pedicle, has been used extensively for free tissue transfer. Recent studies have described the constant anatomy, ease of dissection, and low donor-site morbidity of the distal segmental gracilis free muscle flap. We present three cases of free distal segmental gracilis muscle transfer. In one case, the gracilis muscle was divided transversely into one proximally based and one distally based free flap and used for coverage of two separate wounds in a patient with bilateral open calcaneal fractures. In two cases, the preserved proximal gracilis was used as a reoperative free flap after failure of the initial distal segmental gracilis free muscle. With recent advances in microsurgery and ever-growing demands for low donor-site morbidity, it is important to ensure each free muscle flap harvested is used efficiently. Use of the free distal segmental gracilis muscle flap maximally uses one muscle while minimizing donor site morbidity and retaining the proximal muscle for future uses.     

Surgical site infections after gracilis free flap reconstruction for facial paralysis

Compared with other free tissue transfer procedures, the gracilis free muscle transfer (GFMT) for facial reanimation is unique in that the recipient site is typically uninvolved by malignancy or infection. In this study, the authors examined the incidence, bacteriology, and outcomes of surgical site infection (SSI) after gracilis free muscle transfer for facial reanimation. From 2003 to 2011, 105 patients underwent 107 GFMT operations, with 6 SSIs. All cases of infection occurred in patients receiving clindamycin, levofloxacin, and/or cefazolin perioperatively. None of the patients who received ampicillin-sulbactam developed an SSI. Surgical site cultures grew oral flora, including α-hemolytic streptococci, Haemophilus parainfluenzae, Fusobacterium and Neisseria species, and coagulase-negative staphylococci. Notably, there were no methicillin-resistant Staphylococcus aureus (MRSA) infections. These data may have implications for the optimal perioperative antibiotic choice in facial reanimation cases. Further study is needed to determine the ideal antibiotic regimen for this category of free flap surgeries.     

Orbital reconstruction after exenteration: use of a transorbital temporal muscle flap

Orbital exenteration is a disfiguring operation that involves the total removal of the orbital contents with partial or total excision of the eyelids. Common methods of orbit reconstruction include pectoralis musculocutaneous pedicled flap and free tissue transfer. The purpose of this study is to illustrate that the entire temporalis muscle may be used by creating a large window in the lateral orbit, without resection of the lateral orbital rim. Orbital exenteration was performed on four cadavers. A window was created in the lateral orbit using a 4-mm pineapple burr. Three parameters were measured: (1) the distance between the zygomatic arch to the superior aspect of the temporalis muscle; (2) the width of the temporalis muscle; and (3) the length and width of the lateral orbit window. The free edge of the transposed temporal muscle was then sutured to the skin edge around the bony orbit. This procedure was then performed on a 73-year-old man who had undergone right orbital exenteration for ocular melanoma and then postoperative radiation. The dimensions of the bony windows in the cadavers were as follows: mean 3.3 cm (SD +/- 0.19 cm) x 1.9 cm (SD +/- 0.18 cm), n = 4. The dimensions of the temporalis muscle in the cadavers were the following: mean 8.45 cm (SD +/- 0.60 cm) x 10.5 cm (SD +/- 0.33 cm), n = 4. In the patient, the size of the bony window was 3.7 cm x 2.1 cm (n = 1), and the dimensions of the temporalis muscle were 8.1 cm x 10.2 cm (n = 1). The patient recovered well without complication, with a well-healed skin graft over the top of the muscle flap. An adequate bony window can be made to allow transfer of the entire temporalis muscle for orbital reconstruction without resecting the lateral orbital rim or entering the middle cranial fossa. This option is a good alternative to the other commonly performed methods of orbital reconstruction because of its completion in one operative stage, short operative time, and minimal donor site morbidity.     

Reconstruction of large orbital exenteration defects after resection of periorbital tumors of advanced stage

Orbital exenteration is a devastating procedure because of the social impact and psychological stress put upon the patient. Besides cancer ablative surgery, reconstruction after removal of the tumor constitutes a major problem and the final aesthetic result is quite important. Both obliteration of the orbital cavity and continuation of the epithelial lining are required. Free rectus abdominis muscle and musculocutaneous flaps are versatile flaps which both enable filling the cavity and reconstituting the skin defect with a cutaneous portion or with a skin graft. Both free rectus abdominis muscle and musculocutaneous flaps were used for reconstruction of orbital exenteration defects in 19 patients. All suffered partial maxillectomy as well. The flaps provided satisfactory aesthetic results in all patients.     

Reconstruction of the anophthalmic orbit by orbital osteotomy and free flap transfer.

It is challenging to perform an adequate reconstruction of the post enucleation irradiated orbit of patients with rentinoblastoma. Rebuilding of the orbital structure, reconstruction of the eye socket and restoration of periorbital volume are required. We reviewed 12 patients with hypoplastic orbital deformities, who have undergone orbital osteotomy and free flap transfer. Reconstruction of the orbital cavity was achieved using 'C' osteotomy of the lateral portion of the orbit in mild and moderate cases or transverse 'U' osteotomy of lateral wall, roof, and floor by intra-cranial approach in severe cases. Socket reconstruction and periorbital volume restoration was achieved using dorsalis pedis free flap transfer. From our experience the combination of orbital osteotomy and free flap transfer could meet the multi-requirements for the anophthalmic orbital reconstruction, including both orbital bony enlargement and soft tissue restoration.     

Reconstruction of through-and-through gunshot wounds to the feet with free gracilis muscle flaps

Reconstruction of a through-and-through gunshot wound (GSW) to the foot remains a challenging problem for plastic and orthopedic surgeons, because it is difficult to achieve reliable soft tissue coverage of the foot while at the same time optimizing foot contour and weightbearing. In the past year, four patients with such an injury were treated with initial wound debridement and stabilization of the metatarsals, followed by a free gracilis muscle transfer with a split-thickness skin graft. One patient also had a secondary iliac bone graft to the first metatarsal. All patients have completely healed wounds, are free of osteomyelitis, and have achieved an excellent contour and good ambulation of the foot without donor site problems. Thus, a free gracilis muscle transfer should be considered first for reconstruction of a through-and-through GSW to the foot, because it can provide reliable soft tissue coverage with excellent contour and minimal donor site morbidity.     

Muscle conserving free gracilis transfer (mini-gracilis free flap)

Gracilis is a commonly used muscle for free tissue transfer. It is also split into two based on its pedicles and used as two units. Use of distal part as a free flap in isolation has never been described in literature. We describe a technique of harvesting a small unit of gracilis based on its minor pedicle and maintaining the continuity and conserving the major bulk of muscle. Thus, the function of the muscle is preserved and the same is also available for transfer on its major pedicle later, if required.KEY WORDS: Major pedicle, minor pedicle, muscle conserving gracilis flap, split gracilis muscle flap