Thoracodorsal artery perforator flap: Indeed a versatile flap

Introduction:

The thoracodorsal artery perforator (TDAP) flap has emerged as one of the ideal perforator flaps. We, hereby, describe its versatility in indications (free/pedicled), methods of harvest (patient position and paddle orientation) and perforator consistency.

Materials and Methods:

We have performed a total of six TDAP flaps-five free and one pedicled, over a period of 1-year from March 2014 to February 2015 at a single centre. Our indications have been: Reconstruction of oral cavity, breast and upper and lower extremities.

Results:

We had neither any failures nor any re-explorations. The average perforator length is about 6 cm and the pedicle length can be extended to 12-14 cm by including the thoracodorsal artery. There is inconsistency in perforator position; however, the presence of a perforator is certain. It can be harvested in lateral, prone or supine position, thus, does not require any position change allowing a two-team approach to reconstruction. The paddle can be oriented vertically or horizontally, both healing with scars in inconspicuous locations. Apart from providing a good colour match for extremities, this flap can be thinned primarily.

Conclusion:

The versatility of TDAP has several advantages that make it a workhorse flap for most reconstructions requiring soft tissue cover. Further, the ease of harvest makes it a good perforator flap for beginners. Its use in chimerism with the underlying latissimus dorsi muscle provides reconstruction for coverage and volume replacement.KEY WORDS: Ideal perforator flap, septocutaneous perforator, versatile, chimerism     

Free style perforator based propeller flaps: Simple solutions for upper extremity reconstruction!

Background:

The introduction of perforator flaps by Koshima et al. was met with much animosity in the plastic surgery fraternity. The safety concerns of these flaps following the intentional twist of the perforators have prevented widespread adoption of this technique. Use of perforator based propeller flaps in the lower extremity is gradually on the rise, but their use in upper extremity reconstruction is infrequently reported, especially in the Indian subcontinent.

Materials and Methods:

We present a retrospective series of 63 free style perforator flaps used for soft tissue reconstruction of the upper extremity from November 2008 to June 2013. Flaps were performed by a single surgeon for various locations and indications over the upper extremity. Patient demographics, surgical indication, defect features, complications and clinical outcome are evaluated and presented as an uncontrolled case series.

Results:

63 free style perforator based propeller flaps were used for soft tissue reconstruction of 62 patients for the upper extremity from November 2008 to June 2013. Of the 63 flaps, 31 flaps were performed for trauma, 30 for post burn sequel, and two for post snake bite defects. We encountered flap necrosis in 8 flaps, of which there was complete necrosis in 4 flaps, and partial necrosis in four flaps. Of these 8 flaps, 7 needed a secondary procedure, and one healed secondarily. Although we had a failure rate of 12-13%, most of our failures were in the early part of the series indicative of a learning curve associated with the flap.

Conclusion:

Free style perforator based propeller flaps are a reliable option for coverage of small to moderate sized defects.

Level of Evidence:

Therapeutic IV.KEY WORDS: Hand defects, perforator flaps, propeller flaps, perforator based propeller flaps, upper extremity, wrist defects     

Anatomical study of terminal peroneal artery perforators and their clinical applications

Introduction:

Peroneal artery gives off plenty of perforators that pass through fascial septum to supply skin and tenosynovium of peroneal muscles.

Aim:

The aim of this study was to study the anatomical basis of perforators from terminal part of peroneal artery axiality and to make use of this knowledge in reconstructing defects of posterior heel with the advantage of reducing the morbidity of conventional flaps.

Materials and Methods:

Our study was conducted at Department of Plastic surgery, Madras Medical College and Rajiv Gandhi Government General Hospital, India. We have carried out eleven cadaver dissections (from six cadavers-four fresh cadavers and two preserved cadavers) and delineated all septocutaneous and septosynovial perforators of distal peroneal axis and studied their relation with short saphenous vein (SSV) and sural nerve. Using this anatomical knowledge we have fashioned perforator based flaps in 13 patients (three propeller, four V-Y advancement, six tenosynovial flaps) for reconstruction of defects over tendo achilles and pericalcaneal region.

Results:

In all cases, SSV and sural nerve were preserved and donor site was closed primarily. No total flap loss was noted.

Conclusion:

Perforator based flaps from distal most part of peroneal artery provide a good and reliable method for reconstruction of pericalcaneal and tendo achilles region defects with preservation of SSV and sural nerve. It also avoids contour deformity of the grafted donor site of the classical lateral calcaneal artery axial flap.KEY WORDS: Terminal peroneal artery, lateral calcaneal artery, perforator-based flaps, peroneal tenosynovial sheath, propeller, V-Y advancement     

Thoracodorsal artery perforator fasciocutaneous flap: A versatile alternative for coverage of various soft tissue defects

Objective:

The thoracodorsal artery perforator (TDAP) flap has contributed to the efficient reconstruction of tissue defects that require a large amount of cutaneous tissue. The optimal reconstruction method should provide thin, and well-vascularized tissue with minimal donor-site morbidity. The indications for the use of this particular flap with other flaps are discussed in this article.

Materials and Methods:

Thirteen patients underwent soft tissue reconstruction using TDAP flaps between 2009 and 2011. Of those, there were four cases of antecubital burn contracture, three cases of axillary burn contracture, two cases of giant hair cell nevus of upper extremity, two cases of axillary reconstruction following severe recurrent hidradenitis, and two cases of crush injury. All patients were male and their ages ranged from 20 to 23 (average, 21 years). The mean follow-up period was 8 months (range, 4-22 months).

Results:

All reconstructive procedures were completed without any major complications. Minor complications related to transfered flaps were wound dehiscence in one case, transient venous congestion in two cases. Minor complication related to the donor site was seroma in one case. The success rate was 100%, with satisfactory cosmetic results.

Conclusions:

The TDAP flap is a safe and extremely versatile flap that offers significant advantages in acute and delayed reconstruction. Although the vascular anatomy may be variable, free and pedicled TDAP flap is a versatile alternative for soft tissue defects. It adapts very well to the soft tissue defects with acceptable donor site scar.KEY WORDS: Burn contracture, hidradenitis suppurativa, soft tissue defects, the thoracodorsal artery perforator, thoracodorsal artery perforator flap     

Perforator plus flaps: Optimizing results while preserving function and esthesis

Background:

The tenuous blood supply of traditional flaps for wound cover combined with collateral damage by sacrifice of functional muscle, truncal vessels, or nerves has been the bane of reconstructive procedures. The concept of perforator plus flaps employs dual vascular supply to flaps. By safeguarding perforators along with supply from its base, robust flaps can be raised in diverse situations. This is achieved while limiting collateral damage and preserving nerves, vessels, and functioning muscle with better function and aesthesis.

Materials and Methods:

The perforator plus concept was applied in seven different clinical situations. Functional muscle and fasciocutaneous flaps were employed in five and adipofascial flaps in two cases, primarily involving lower extremity defects and back. Adipofascial perforator plus flaps were employed to provide cover for tibial fracture in one patients and chronic venous ulcer in another.

Results:

All flaps survived without any loss and provided long-term stable cover, both over soft tissue and bone. Functional preservation was achieved in all cases where muscle flaps were employed with no clinical evidence of loss of power. There was no sensory loss or significant oedema in or distal to the flap in both cases where neurovascular continuity was preserved during flap elevation. Fracture union and consolidation were satisfactory. One patient had minimal graft loss over fascia which required application of stored grafts with subsequent take. No patient required re-operation.

Conclusions:

Perforator plus concept is holistic and applicable to most flap types in varied situations. It permits the exercise of many locoregional flap options while limiting collateral functional damage. Aesthetic considerations are also addressed while raising adipofascial flaps because of no appreciable donor defects. With quick operating times and low failure risk, these flaps can be a better substitute to traditional flaps and at times even free tissue transfers.     

Reconstruction of complex thoraco-abdominal defects with extended anterolateral thigh flap

Background:

The reconstruction of complex thoraco-abdominal defects following tumour ablative procedures has evolved over the years from the use of pedicle flaps to free flaps. The free extended anterolateral thigh flap is a good choice to cover large defects in one stage.

Materials and Methods:

From 2004 to 2009, five patients with complex defects of the thoracic and abdominal wall following tumour ablation were reconstructed in one stage and were studied. The commonest tumour was chondrosarcoma. The skeletal component was reconstructed with methylmethacrylate bone cement and polypropylene mesh and the soft tissue with free extended anterolateral thigh flap. The flaps were anastomosed with internal mammary vessels. The donor sites of the flaps were covered with split-skin graft.

Result:

All the flaps survived well. One flap required re-exploration for venous congestion and was successfully salvaged. Two flaps had post operative wound infection and were managed conservatively. All flap donor sites developed hyper-pigmentation, contour deformity and cobble stone appearance.

Conclusion:

Single-stage reconstruction of the complex defects of the thoraco-abdominal region is feasible with extended anterolateral thigh flap and can be adopted as the first procedure of choice.     

Reverse peroneal artery flap for large defects of ankle and foot: A reliable reconstructive technique

Background:

Large soft tissue defects around the lower third of the leg, ankle and foot always have been challenging to reconstruct. Reverse sural flaps have been used for this problem with variable success. Free tissue transfer has revolutionised management of these problem wounds in selected cases.

Materials and Methods:

Twenty-two patients with large defects around the lower third of the leg, ankle and foot underwent reconstruction with reverse peroneal artery flap (RPAF) over a period of 7 years. The mean age of these patients was 41.2 years.

Results:

Of the 22 flaps, 21 showed complete survival without even marginal necrosis. One flap failed, where atherosclerotic occlusion of peroneal artery was evident on the table. Few patients had minor donor site problems that settled with conservative management.

Conclusions:

RPAF is a very reliable flap for the coverage of large soft tissue defects of the heel, sole and dorsum of foot. This flap adds versatility in planning and execution of this extended reverse sural flap.KEY WORDS: Distally based peroneal flaps, extended reverse sural flaps, foot reconstruction, peroneal artery, reverse peroneal flaps     

An assessment of the anatomical basis of the thoracoacromial artery perforator flap

BACKGROUND:

Musculocutaneous perforator flaps offer advantages over musculocutaneous flaps, including reduced donor site morbidity, more predictable reconstruction of soft tissue deformities, and a wider variety of flap options. Perforator flaps are becoming increasingly popular for many applications. In the present study, we set out to examine the various perforators of the thoracoacromial axis through the pectoralis major (PM) muscle with respect to their suitability for transfer to the head and neck region as a pedicled flap.

METHODS:

A series of 10 fresh cadavers were injected with lead oxide, gelatin and water (250 mL/kg) through the femoral vessels. The cadavers were cooled and the integument was removed. Perforating vessels from the underlying muscles were marked and the resulting angiograms of the integument and deep tissues were compared with the dissection notes describing the course, size and distribution of the perforating vessels.

RESULTS:

The perforators through the PM muscle to the overlying skin included three regional groups: perforators of the thoracoacromial axis; perforators of the medial intercostal vessels; and perforators of the lateral thoracic artery. The major group of perforators supplying the overlying skin was from the intercostal vessels. However, the thoracoacromial axis did consistently give rise to perforators in the upper portion of the PM muscle. In particular, there were reliable perforators from the clavicular and deltoid branches of the thoracoacromial artery.

DISCUSSION:

The present study illustrates the potential clinical applications of a series of perforator flaps based on the thoracoacromial axis, which may be useful in head and neck reconstructive surgery.     

Cephalic vein: Saviour in the microsurgical reconstruction of breast and head and neck cancers

Background:

Reconstruction with microvascular free flaps is considered the reconstructive option of choice in cancer of the head and neck regions and breast. Rarely, there is paucity of vessels, especially the veins, at the recipient site. The cephalic vein with its good caliber and constant anatomy is a reliable recipient vein available in such situations.

Materials and Methods:

It is a retrospective study from January 2010 to July 2012 and includes 26 patients in whom cephalic vein was used for free-flap reconstruction in head and neck (3 cases) and breast cancers (23 cases).

Results:

All flaps in which cephalic vein was used survived completely.

Conclusion:

Cephalic vein can be considered as a reliable source of venous drainage when there is a non-availability/unusable of veins during free-flap reconstruction in the head and neck region and breast and also when additional source of venous drainage is required in these cases.KEY WORDS: Breast reconstruction, cephalic vein, free flap, head and neck reconstruction     

Intraoperative venous congestion in free transverse rectus abdominis musculocutaneous and deep inferior epigastric artery perforator flaps during breast reconstruction: A systematic review

BACKGROUND:

Even with patent deep inferior epigastric vein anastomoses, venous congestion can occur during free transverse rectus abdominis musculocutaneous (TRAM) or deep inferior epigastric artery perforator (DIEP) flap surgery and lead to flap compromise if not recognized and managed.

OBJECTIVES:

To identify the incidence of intraoperative venous congestion and describe the best available prevention and treatment methods.

METHODS:

Systematic electronic searches of the PubMed database including Medline were performed to identify studies published until 2014. The following keywords were used: “DIEP” or “free TRAM” and “venous insufficiency” or “venous congestion”. Supplemental searches were conducted to identify referenced studies. Statistical analysis using the χ² test was performed.

RESULTS:

Nine studies representing 4747 free abdominal flaps cases were included and demonstrated an overall incidence of intraoperative venous congestion of 2.8%. The incidence in DIEP flaps (3.3%) was significantly higher than that in the free TRAM flaps (1.0%). All nine articles reported using the superficial inferior epigastric vein to treat venous insufficiency.

CONCLUSION:

The risk for developing intraoperative venous congestion following free abdominal flap breast reconstruction is influenced by inadequate perforator selection and persistent dominance in the superficial venous system. The solution is establishing another venous draining route using the superficial inferior epigastric vein.     

Microvascular free flap reconstruction for head and neck cancer in a resource-constrained environment in rural India

Introduction:

Reconstruction with free flaps has significantly changed the outcome of patients with head and neck cancer. Microsurgery is still considered a specialised procedure and is not routinely performed in the resource-constrained environment of certain developing parts of India.

Materials and Methods:

This article focuses on the practice environment in a cancer clinic in rural India. Availability of infrastructure, selection of the case, choice of flap, estimation of cost and complications associated with treatment are evaluated and the merits and demerits of such an approach are discussed.

Results:

We performed 22 cases of free flaps in a six-month period (2008-2009). Majority (17) of the patients had oral cancer. Seven were related to the tongue and eight to the buccal mucosa. Radial forearm free flap (RFF: 9) and anterolateral thigh flap (ALT: 9) were the most commonly used flaps. A fibula flap (1) was done for an anterior mandible defect, whereas a jejunum free flap (1) was done for a laryngopharyngectomy defect. There were six complications with two re-explorations but no loss of flaps.

Conclusion:

Reconstruction with microvascular free flaps is feasible in a resource-constrained setup with motivation and careful planning.KEY WORDS: Free flap, head and neck cancer, microvascular surgery, reconstruction, resource constrained, reconstruction of head and neck     

Correlating the deep inferior epigastric artery branching pattern with type of abdominal free flap performed in a series of 145 breast reconstruction patients

INTRODUCTION

The deep inferior epigastric perforator (DIEP) flap is currently viewed as the gold standard in autologous breast reconstruction. We studied three-dimensional computed tomography angiography (CTA) in 145 patients undergoing free abdominal flap breast reconstruction to try to correlate deep inferior epigastric artery (DIEA) branching pattern with the type of flap performed and patient outcome. Today, reconstructive breast surgeons have become more experienced in raising DIEP flaps and operative times are becoming more acceptable. However, there remains significant interest in finding ways to aid this challenging dissection.

METHODS

We retrospectively evaluated consecutive patients between January 2007 and August 2008. CTAs were analysed using the Moon and Taylor (1988) classification of the DIEA branching pattern. Data gathered included pre-operative morbidity, type of abdominal wall free flap performed, length of operation, length of stay and complications.

RESULTS

Some 150 breast reconstructions were performed in 145 patients. There were 67 DIEP flaps, 69 MS-2 transverse rectus abdominis myocutaneous (TRAM) flaps and 14 MS-1 TRAM flaps (where MS-1 spares the lateral muscle and MS-2 spares both lateral and medial segments). Proportionally more DIEP flaps were performed in patients with a type 2 branching pattern. There was one flap loss (0.67%).

CONCLUSIONS

In this large CTA series, we found a type 1 (single artery) DIEA pattern most frequently, in contrast to the predominance of the type 2 bifurcating pattern observed previously. The higher proportion of DIEP flaps performed in the type 2 pattern patients is consistent with the documented shorter intramuscular course in this group. We have found CTA useful for faster selection of the best hemiabdomen for dissection and flap loss rates in our unit have reduced from 1.5% to 0.67%.     

Anthropomorphic and perforator analysis of anterolateral thigh flap in Indian population

Background:

Anterolateral thigh (ALT) flap is one of the most common flaps in the reconstruction armamentarium of plastic surgeons, but there is no published data about the flap characteristics in the Indian population. The aim of this study is to analyse the anthropomorphic characteristics of the ALT flap and the perforator details in Indian population.

Materials and Methods:

ALT flap details were studied in 65 patients of Indian origin comprising 45 males and 20 females. The study period is from August 2011 to July 2012. A prospective database of the Doppler findings, perforator and pedicle details and the flap morphology were maintained. The variables are analysed by using the SPSS, PASW statistics 18 software IBM^®.

Results:

In nearly 75% of cases, the perforator was found within 4 cm of the pre-operative Doppler markings. The percentage of musculocutaneous and septocutaneous perforators was 61.8% and 38.2% respectively. The pedicle variation was found in 6 cases (9.23%). The average thickness of the thigh skin in Indians is similar to the western people, but thicker than the other Asian people. Flap thinning was performed in nine patients without any major complications.

Conclusion:

The perforator details and type in the Indian population are similar to the published reports from other parts of the world. We advise pre-operative Doppler examination in possible cases. The variation in pedicle anatomy should not be overlooked to avoid complications. The thickness of subcutaneous tissue of the flap is higher in Indians, but still can be safely thinned. The data of this study will serve as a guide for the ALT flap characteristics in Indian patients.KEY WORDS: Anterolateral thigh flap, flap characteristics, Indian population     

Experience with peroneus brevis muscle flaps for reconstruction of distal leg and ankle defects

Objective:

Peroneus brevis is a muscle in the leg which is expendable without much functional deficit. The objective of this study was to find out its usefulness in coverage of the defects of the lower leg and ankle.

Patients and Methods:

A retrospective analysis of the use of 39 pedicled peroneus brevis muscle flaps used for coverage of defects of the lower leg and ankle between November 2010 and December 2012 was carried out. The flaps were proximally based for defects of the lower third of the leg in 12 patients and distally based for reconstruction of defects of the ankle in 26 patients, with one patient having flaps on both ankles.

Results:

Partial flap loss in critical areas was found in four patients requiring further flap cover and in non-critical areas in two patients, which were managed with a skin graft. Three of the four critical losses occurred when we used it for covering defects over the medial malleolus. There was no complete flap loss in any of the patients.

Conclusion:

This flap has a unique vascular pattern and fails to fit into the classification of the vasculature of muscles by Mathes and Nahai. The unusual feature is an axial vessel system running down the deep aspect of the muscle and linking the perforators from the peroneal artery and anterior tibial artery, which allows it to be raised proximally or distally on a single perforator. The flap is simple to raise and safe for the reconstruction of small-to moderate-sized skin defects of the distal third of the tibia and all parts of the ankle except the medial malleolus, which is too far from the pedicle of the distally based flap. The donor site can be closed primarily to provide a linear scar. The muscle flap thins with time to provide a good result aesthetically at the primary defect.KEY WORDS: Ankle defects, lateral malleolus defects, lower leg defect, muscle flap, peroneus brevis flap, pedicle flap, tendo achilles defects     

Non-microsurgical skin flaps for reconstruction of difficult wounds in distal legand foot

Purpose

To express the versatility of a variety of non-microsurgical skin flaps used for coverage of difficult wounds in the lower third of the leg and the foot over 4 years period. Five kinds of flaps were used. Each flap was presented with detailed information regarding indication, blood supply, skin territory and technique.

Modification of VY flap to preserve fingertip contour

Background

VY flap is a reliable treatment for fingertip amputation injuries. Insetting the flap to replicate fingertip contour can be challenging with the conventional method of using sutures. We propose a modification of inset technique with K-wire to simplify contouring during flap inset.

Methods

Seven patients underwent VY flap reconstruction with the modified inset technique for fingertip defects ranging from 10 × 15 to 20 × 15 mm. The flaps were advanced between 6 and 10 mm and inset with K-wires. The donor site is allowed to heal by secondary intention. At 6 months, static two-point discrimination, sensitivity, and flap appearance were assessed.

Results

All flaps healed uneventfully, and each patient returned to work between 8 and 10 weeks. Fingertip and nail contour were satisfactory in every case.

Conclusion

This modification simplified contouring during flap inset and provided a viable alternative to flap inset and contour adjustment.     

Skin paddle vascularity of free fibula flap �C A study of 386 cases and a classification based on contribution from axial vessels of the leg

Objective:

The skin paddle of the free fibula flap receives its vascular supply from septocutaneous perforators, musculocutaneous perforators or from both, and these perforators might originate from the peroneal or posterior tibial vessels or from both. The objective of this study was to classify the skin paddles based on the dominance of vascular contribution by these axial vessels through their different perforator systems.

Materials and Methods:

A retrospective analysis of 5-year data of 386 free fibula flaps used in oro-mandibular reconstruction was done and the skin paddle vascularity was studied. While majority of the skin paddles received their blood supply from the peroneal septocutaneous perforators, a few had their dominant supply from the soleus musculocutaneous perforators in addition to peroneal septocutaneous perforators. In few cases, the soleus musculocutaneous perforators were the sole source of blood supply to the skin paddle. The limitation in this study was the inability to augment the clinical observation with cadaveric study.

Results:

The skin paddle of the free fibula flap was classified into four different types (a–d) based on the dominance of vascular contribution by axial vessels of the leg.

Conclusion:

The skin paddle of the free fibula flap has reliable blood supply, but a thorough knowledge of the variations in vascular pattern of the skin paddle is required especially to salvage the larger paddles used in the reconstruction complex oro-mandibular defects.KEY WORDS: Free fibula flap, musculocutaneous perforators, septo cutaneous perforators, skin paddle, vascular supply     

A simple method for predicting survival of pedicled skin flaps before completely raising them

Background:

Pedicled skin and fasciocutaneous flaps are commonly used in plastic surgery. Once such a flap is completely raised on its pedicle it becomes defenceless against any possible necrosis.

Aim:

To use a simple method for raising such a flap in a manner that can predict the vascularity better, offering additional protection against necrosis.

Materials and Methods:

A total of 30 skin and fasciocutaneous flaps were raised in 27 patients. They were raised as bipedicle flaps; and the vascularity of the flap was tested by occluding the additional pedicle with a pedicle occlusion clamp. If the vascularity was found to be satisfactory the flap was primarily transferred; if found unsatisfactory it was either delayed or abandoned. The delayed flaps were again tested during transfer.

Results:

Nineteen (63.3%) flaps were primarily transferred, 11 (36.7%) flaps were delayed, and two (6.7%) delayed flaps displayed an unsatisfactory pattern during transfer. Twenty-two (73.3%) flaps fully survived and seven (23.3%) underwent partial thickness necrosis at the tip, which healed without any further surgical intervention, making 29 (96.7%) flaps clinically successful. There was major necrosis of one flap. All the flaps with a scar at the base survived.

Discussion:

The clinical success of 96.7% indicated a high-degree of predictability of flap survival through this method. Also, this method could safely assess the vascularity of flaps during primary transfer, during delayed transfer, and also those with a scar at the base.

Conclusions:

This technique is recommended in all major pedicled skin and fasciocutaneous flaps.KEY WORDS: Blood circulation, blood flow velocity, necrosis, skin transplantation, surgical flaps     

Free Boomerang-shaped Extended Rectus Abdominis Myocutaneous flap: The longest possible skin/myocutaneous free flap for soft tissue reconstruction of extremities

Background:

A soft tissue defect requiring flap cover which is longer than that provided by the conventional “long” free flaps like latissimus dorsi (LD) and anterolateral thigh (ALT) flap is a challenging problem. Often, in such a situation, a combination of flaps is required. Over the last 3 years, we have managed nine such defects successfully with a free “Boomerang-shaped” Extended Rectus Abdominis Myocutaneous (BERAM) flap. This flap is the slightly modified and “free” version of a similar flap described by Ian Taylor in 1983.

Materials and Methods:

This is a retrospective study of patients who underwent free BERAM flap reconstruction of soft tissue defects of extremity over the last 3 years. We also did a clinical study on 30 volunteers to compare the length of flap available using our design of BERAM flap with the maximum available flap length of LD and ALT flaps, using standard markings.

Results:

Our clinical experience of nine cases combined with the results of our clinical study has confirmed that our design of BERAM flap consistently provides a flap length which is 32.6% longer than the standard LD flap and 42.2% longer than the standard ALT flap in adults. The difference is even more marked in children. The BERAM flap is consistently reliable as long as the distal end is not extended beyond the mid-axillary line.

Conclusion:

BERAM flap is simple in design, easy to harvest, reliable and provides the longest possible free skin/myocutaneous flap in the body. It is a useful new alternative for covering long soft tissue defects in the limbs.KEY WORDS: Extended rectus abdominis free flap, longest myocutaneous free flap, soft tissue reconstruction of extremities     

Cross-leg flap: Its role in limb salvage

Background:

Pedicled cross-extremity flaps for lower limb wound coverage have been replaced by free tissue transfer in the last two decades. However, there are certain difficult situations where the free flap cannot be employed and alternative methods are needed. We describe our experience with cross-leg flap in 18 patients for the reconstruction of difficult leg defects in which no suitable recipient vessels were available for microvascular anastomosis in the vicinity of the defect.

Materials and Methods:

18 patients (17 men and 1 woman) with mean range 31.5 yrs(range 18-70 yrs) grade III B tibial fractures were included in the study. fasciocuteneous cross leg flap was employed and extremities were immobilized by external Fixator.

Results:

Fifteen flaps were completely available with two had marginal necrosis and one supsficial epidermal necrosis. No complications were related to the donor site, flap, or by immobilization are noted. Each patient resumed essentially normal gait and activity without any stiffness of joints related with the flap or external fixator.

Conclusion:

The addition of external fixator stabilization aids greatly in wound care, as well as for general ease of the patient mobility and positioning. Cross-leg flap offers the possibility of salvaging limbs that are otherwise nonreconstructable.