Technical refinements of composite thoracodorsal system free flaps for 1-stage lower extremity reconstruction resulting in reduced donor-site morbidity

A multitude of local flaps has been suggested for lower extremity reconstruction. However, the gold standard for defect coverage remains free tissue transfer. In this regard, the scapular vascular axis is a well-established source of expendable skin, fascia, muscle, and bone for use in free flap reconstruction of defects requiring bone and soft tissue in complex 3-dimensional relationships.Composite bone and soft-tissue flaps derived from the subscapular vascular axis include the osteocutaneous scapular flap, the "latissimus/bone flap," and the thoracodorsal artery perforator-scapular osteocutaneous flap.Patient outcome following reconstruction of lower extremity defects with composite free flaps from the thoracodorsal system were analyzed. Here, we demonstrate the execution of technical refinements on free composite flap transfers based on the thoracodorsal vascular axis, thus resulting in a stepwise reduction of donor-site morbidity.     

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 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.     

Viability and versatility of arterialized venous perfusion flaps and prefabricated flaps: an experimental study in rabbits.

The purpose of this study was to investigate the viability of two types of unconventional flaps: 1) the arterialized venous perfusion (AVP) flap; and 2) the prefabricated flap. Four experimental groups were studied: an AVP flap group with assessment of the viability of single and paired flaps nourished by the same vascular pedicle; a prefabricated flap group with the abdominal flap pedicled on the epigastric artery and vein; a prefabricated flap group in which the flap was supplied by an arterialized vein graft (A-V shunt), and paired flaps of different designs, but based on the same vascular pedicle, were investigated; and a free composite graft group. Survival of the skin flaps exceeded 92 percent in each group, except in the free composite group which showed complete necrosis. Results of the study validated that flap viability was independent of flap size (large or small), type (AVP flap or prefabricated flap), and the number of flaps on each vascular pedicle (single or paired).     

Combined V figure-shaped scapular osteocutaneous and latissimus dorsi myocutaneous flap for composite mandibular reconstruction

Background. As early as 1981, the scapular crest was reported as a versatile donor site of vascularized bone flap. In our institute, much attention has been paid to applying a compound flap based on the subscapular vascular system for composite mandibular reconstruction. Methods. The combined V figure-shaped scapular osteocutaneous and latissimus dorsi myocutaneous flap has been used for primary or secondary reconstruction of the mandible, intraoral mucosa and/or external skin following major ablation of the malignant tumors in seven patients. Results. There was one total flap failure. Satisfactory results were obtained in the remaining patients. Conclusions. The V figure-shaped scapular bone flap supplied by the angular branch provides a long rotation arc of vascular pedicle, a long bony segment of more than 14 cm, and a good contour of mental protuberance. The combination of the scapular osteocutaneous flap with latissimus dorsi myocutaneous flap allows reliable reconstruction of massive and three-dimensional composite mandibular defects. © 1995 Jons Wiley & Sons, Inc.     

Prefabricated flap size limitations utilizing an omental carrier

Several researchers and clinicians have taken advantage of the omentum's rich vascular arcades to support skin grafts. We have previously described an experimental model using the omentum as a vascular carrier for prefabricated free flaps in the rat. In this study, we used this model to compare three different sizes of free flaps using the same size omental carrier. Twenty-four male Sprague-Dawley rats were used for this study. A 2.5 × 4 cm patch of omentum with gastroepiploic vessels and its rich vascular arcades was transferred under a bipedicled 2.5 × 6 cm (group I), a 2.5 × 8 cm (group II), and a 4 × 10 cm (group III) right abdominal panniculocutaneous flap. On the seventh postoperative day, the skin pedicles were divided and the skin flap raised as a composite island flap vascularized only by the underlying omental patch. The composite flap was then sutured back in place. Prefabricated flaps examined 7 days postoperatively demonstrated a dye florescence index percent (DFI) of 38.19 ± 7.52 and 98.13 ± 3.72% flap survival (FS) in the 6 ± 2.5 cm skin flap group; a DFI of 39.96 ± 6.81% and FS 94.88 ± 7.08% in the 8 ± 2.5 skin flap group (P > 0.05) and a DFI 29.71 ± 2.85% and FS 57.06 ± 9.52% in the 10 × 4 cm skin flap group (P < 0.05). India ink injection study and histologic examination confirmed revascularization of the overlying skin at 7 days. This study confirms that omentum can be used as a vascular carrier for prefabricated flaps. However, there is a limit to the size of the flap. A 10 cm² carrier can support 57% of a 40 cm² (10 × 4 cm) flap for a total area of 22.8 cm², more than twice the area of the carrier. © 1994 Wiley-Liss, Inc.     

Scapular free flap for repair of massive lower facial composite defects

The scapular osteocutaneous free flap provides excellent tissue for reconstruction of massive lower facial defects. Five cases of full-thickness cheek and lip defects associated with mandibular loss were successfully repaired with sandwiched osteocutaneous scapular flaps plus a parascapular or latissimus dorsi flap. In two instances the osteocutaneous scapular flap was harvested along with a parascapular skin paddle. The other three patients had latissimus dorsi myocutaneous units taken with the scapular osteocutaneous flap from the same subscapular pedicle.     

Vascularized iliac osteocutaneous flap based on the deep circumflex iliac vessels: experience in 13 cases

We have carried out 13 vascularized iliac osteocutaneous flaps (VIOF) based on the deep circumflex artery (DCIA) and accompanying veins for cases with compound skin and bone defects. Ten of 13 cases obtained bony union at both ends of the iliac crest with only VIOF. Two of the remaining 3 cases obtained bony union at one end only with the VIOF but united at another end with an additional conventional bone grafting procedure. The final case, a traumatic bone defect of the tibia, failed to obtain bony union at either end of the iliac segment. In 5 of 11 patients in which an osteocutaneous flap was used, complete skin flap survival occurred. Of the remaining 6, one flap went on to complete necrosis, and five flaps were complicated by superficial or partial necrosis. The incidence of flap complications was analysed according to the size of flap. Five flaps with complete survival averaged 6.8 x 10.6 cm in size; however, five flaps with superficial or partial necrosis averaged 10.0 x 15.8 cm. These results suggest that the maximal safe skin flap dimension from the DCIA supply alone is probably 10 x 15 cm.     

游离肩胛区骨皮瓣在舌和口底及下颌骨联合缺损修复中的应用

目的：介绍游离肩胛区骨皮瓣在舌、口底和下颌骨缺损修复中的临床实践。方法：应用肩胛区骨皮瓣游离移植修复因舌癌行扩大根治切除术后的舌、口底、下颌骨联合缺损病人2例,术中根据下颌骨、牙槽、口底和舌缺损的大小设计肩胛区骨皮瓣;术中顺向或逆向寻找血管蒂,掀起肩胛区骨皮瓣,游离移植于口内,吻合血管,固定肩胛骨瓣于颌骨缺损内,将皮瓣与口内缺损创缘缝合,覆盖牙槽、口底、再造舌。结果：骨皮瓣全部成活。患侧颌面形态和舌外形恢复满意。其中1例患者术后5天死亡,死因疑为消化道大出血。结论：肩胛区骨皮瓣具有血管恒定、切口隐蔽、对供区功能影响小、可供组织种类和组织量多、修复范围广等特点,是修复头颈部复合缺损的一种比较满意的方法。     

The prefabricated superficial temporal fascia flap in noma surgery

In a series of 15 patients with facial deformity due to noma, the authors report their experience with a prefabricated superficial temporal fascia (PTF) flap performed in an African hospital. The operative method has been simplified as compared with methods described by others. In the first stage, the temporal fascia is skin grafted and the wound is closed over the graft. After only 1 week, this prefabricated flap is harvested. One of 15 flaps was discarded because of damage to the vascular pedicle. Later this situation was prevented by including a rim of deep temporal fascia in the flap. All other 14 flaps, including four osteocutaneous flaps and one flap with double sided skin grafts, survived and healed without major complications at both the recipient and the donor site. The prefabricated temporal fascia flap is a pliable and well vascularized flap with a reasonably long vascular pedicle, which can be used successfully, even under suboptimal conditions. Received: 11 November 1999 / Accepted: 20 January 2000     

Dorsal Bipedicled Island Skin Flap: A New Flap Model in Mice

Mice are popular animals for biomedical studies, but few skin flap models have been reported in them. To investigate the ischaemia/reperfusion phenomenon in skin flaps, we first investigated the vascular anatomy of murine dorsal skin and then designed a suitable murine dorsal skin flap model. In 120 mice, six distinct vascular patterns were identified, one being seen in 111 mice (93%). Based on this finding, in Part 2 of the study, 15 mice had flaps (4 &#50 4 cm) raised based on the two caudal vascular pedicles of the left and right deep circumflex iliac vessels as a bipedicled flap in which the mean (SD) survival was 96 (5)%. In a further 10 mice, flaps were raised based on a single pedicle, the left deep circumflex iliac vessel, as a monopedicled flap, in which the mean (SD) survival was 71 (12)%. The bipedicled flap model was then used to study ischaemia/reperfusion injury. Twenty flaps were subjected to eight hours of ischaemia and subsequent reperfusion, and their mean (SD) survival was 43 (26)%. Histological assessments were also carried out using neutrophil and leucocyte counts, and significant differences between groups were observed.     

Dorsal bipedicled island skin flap: a new flap model in mice.

Mice are popular animals for biomedical studies, but few skin flap models have been reported in them. To investigate the ischaemia/reperfusion phenomenon in skin flaps, we first investigated the vascular anatomy of murine dorsal skin and then designed a suitable murine dorsal skin flap model. In 120 mice, six distinct vascular patterns were identified, one being seen in 111 mice (93%). Based on this finding, in Part 2 of the study, 15 mice had flaps (4 x 4 cm) raised based on the two caudal vascular pedicles of the left and right deep circumflex iliac vessels as a bipedicled flap in which the mean (SD) survival was 96 (5)%. In a further 10 mice, flaps were raised based on a single pedicle, the left deep circumflex iliac vessel, as a monopedicled flap, in which the mean (SD) survival was 71 (12)%. The bipedicled flap model was then used to study ischaemia/reperfusion injury. Twenty flaps were subjected to eight hours of ischaemia and subsequent reperfusion, and their mean (SD) survival was 43 (26)%. Histological assessments were also carried out using neutrophil and leucocyte counts, and significant differences between groups were observed.     

The free medial scapular osteofasciocutaneous flap for head and neck reconstruction

A modification of the scapular free flap has been developed using the medial ridge of the scapula. This variation preserves the advantages of the previously described lateral scapular flap, providing abundant hairless skin and soft tissue, adequate bone for mandibular reconstruction, and a primarily closed asymptomatic and inconspicuous donor site. It adds the advantage of a longer vascular pedicle and enhanced versatility because it is independent of the parascapular artery. Furthermore, it eliminates the disadvantage of rotator cuff muscle weakness associated with the lateral scapular flap. Multiple skin paddles subtended by the common circumflex cutaneous scapular artery and the interconnecting dorsal thoracic fascia were used in 4 of the 9 patients in our series. The ability of this somewhat thinner bone to incorporate biointegrable implants is unproven.     

Clinical application of a free scapular fascial flap

The free scapular fascial flap based on the circumflex scapular vessels with skin graft on top has been used to cover the soft-tissue defects in 6 cases--5 hands and 1 foot, over the past one year. The size of the fascial flap ranged from 10 x 6 to 13 x 7 cm. Five flaps were survival completely and one with loss of a small portion due to infection. Compared with the cutaneous flap, myocutaneous flap or muscular flap, the fascial flap is thinner, showing no bulkiness on the recipient site, and also no impairment was noted in the donor site. The shortcoming is darker colour of the skin graft overlying it. The authors consider that the free fascial flap is mainly indicated for the soft-tissue defects of the extremities and those sites where no augmentation is required.     

Donor side selection in mandibular reconstruction using a free fibular osteocutaneous flap

While the free fibular osteocutaneous flap is indispensable for mandibular reconstruction, reliable setting is often difficult because relative positions of the bone, skin island, and vascular pedicle are critical. We have an algorithm for donor-side selection of free fibular osteocutaneous flap.From July 2002 to March 2004, we performed 15 mandibular reconstructions using free fibular osteocutaneous flaps. We retrospectively classified these procedures as follows. In type I (flap harvested ipsilaterally to defect, n = 5), the skin island was fixed to the oral cavity, and the vascular pedicle emerged from the anterior aspect of the fibula. In type II (flap contralateral to defect, n = 5), the skin island was fixed to the oral cavity, and the vascular pedicle arose from the posterior aspect. In type III (flap contralateral to defect, n = 4), the skin island was fixed to the facial skin and the vascular pedicle arose from the anterior aspect. In type IV (flap ipsilateral to defect, n = 1), the skin island was fixed to the facial skin and the vascular pedicle arose from the posterior aspect. Flaps took completely except in 1 group II case with partial necrosis. Close attention to geometric characteristics of a free fibular osteocutaneous flap facilitates reconstruction of mandibular defects and selection of donor side.     

Effects of microneedle length and duration of preconditioning on random pattern skin flaps in rats

To date, the surgical delay of skin flaps is the most common and reliable method that increases skin flap survival. In this study, we aimed to increase skin flap viability using preconditioning by microneedling. Seventy-two Sprague Dawley rats were randomly divided into control, surgical flap delay (SFD), and four microneedling groups (7 or 14 days of preconditioning with 0.5 mm or 1 mm needles). Modified McFarlane flaps were raised on the back of rats. In Group I, a caudal pedicled skin flap was raised and the flap survival rate was assessed on postoperative day 14. In the SFD group, a bipedicled flap was created and after 14 days of surgical delay, all skin flaps were raised. In the microneedling groups, 0.5 mm or 1 mm needles were used for 7 or 14 days. The flap survival rates of all microneedling and SFD groups were significantly higher than the control group. The plasma levels of vascular endothelial growth factor (VEGF) did not significantly differ between groups, but the VEGF level of skin samples in the SFD group was higher than the control group. The vessel counts of all microneedling and SFD groups were statistically higher than the control group in all skin samples taken before raising the flaps, but skin samples taken 14 days after raising the skin flap did not show any difference between groups. We showed that preconditioning by microneedling can be used to improve the viability of critical ischemic skin flaps at a level similar to surgical delay.     

小腿外侧皮瓣修复胫前和足软组织缺损

目的 报道应用小腿外侧皮瓣修复胫前和足软组织缺损的方法和临床效果。方法 1999年8月～2004年12月应用小腿外侧岛状皮瓣顺行修复胫前软组织缺损5例，逆行修复足跟、足背软组织缺损10例，游离小腿外侧皮瓣修复足背软组织缺损3例。结果 术后皮瓣全部成活。其中2例术后出现动脉危象，经拆除蒂部缝线，注射利多卡因注射液，危象解除；1例因术中意外损伤腓静脉出现皮瓣静脉危象，术后切开皮瓣边缘皮肤放血并局部滴注肝素液1周，皮瓣成活。本组均获随访2个月～1年，皮瓣无臃肿，弹性好。结论 小腿外侧皮瓣具有血管解剖恒定、厚薄适中、供区隐蔽等优点，是修复胫前和足软组织缺损的有效方法。     

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 fasciovascular pedicle for revascularization of other tissues.

A fasciovascular pedicle based on the epigastric vessels was developed in a rat model to determine if it could be used as a "universal carrier" to revascularize a new composite flap. The effects of time course, carrier size, and flap ischemia on the revascularization process were studied. A 2.5 x 4-cm or 1 x 4-cm fascial patch pedicled on the vessels was transferred under bipedicled 2.5 x 4-, 6-, or 8-cm abdominal panniculocutaneous flaps. At different time intervals, the flap was raised as an island flap connected only by it vascular bundle and then sutured back in place. The skin perfusion by dermofluorometry and flap survival were both markedly increased on day 5 (p less than 0.001). The wide carrier had a 93% survival area, whereas the narrow carrier had only 71%. The wide carrier induced relatively faster and better revascularization (p less than 0.05). Moderate ischemia promoted revascularization (p less than 0.01). An india ink injection study and histological examination provided visual evidence of revascularization. This fasciovascular pedicle is a promising model for prefabrication of complex new composite flaps and for studying the process of revascularization between the layers. Based on these findings and further investigations, a thin, prefabricated abdominal free flap was successfully transferred for facial resurfacing in humans.     

Vascularised osteocutaneous scapular flap in the reconstruction of mandibular defects after war wounding

Vascularized osteocutaneous scapular flaps belong into the most convenient ones in reconstruction of mandibular defects followed by massive loss of adjacent skin and mucous membrane due to its vascular supply, bulkiness, suitability and mobility of cutaneous component of the flap. In seven wounded patients such defects of the mandible and adjacent soft tissues after war wounding have been reconstructed at the Clinic for Maxillofacial Surgery of the Military Medical Academy - Belgrade during the six years period with vascularized osteocutaneous scapular grafts. Here we present localization and structure of the defect, features of harvested compound graft, the procedure of reestablishment of mandibular continuity, immediate and late complications during the consolidation period, as well as the analysis of the success rate.