Experience with the forearm septofascial flap

Summary Fascia has a well vascularized surface, and when it is covered with a split skin graft, it provides the thinnest possible flap. The authors present their own experience with the use of the forearm septofascial flap in 23 patients. A free septofascial flap was used in 15 patients and an island flap in 8 patients. Seven days later, only 25% of the patients had complete take of the split skin graft, while in 60% of the cases, there was only partial take of the graft. The results at 6 months, regarding appearance of the flap and donor site, were good. In 2 patients, a composite osteofascial flap was used for reconstruction of the mandible. In those patients, the viability of the bone was assessed with scintigraphy. There were no significant complications with the donor site. The forearm septofascial flap proved to be a good and reliable method of reconstruction in those parts of the body where thin cover was required. Constant anatomy and minimal postoperative complications are great advantages of the forearm septofascial flap when compared with other fascial flaps.     

Alternative techniques for pedicle transfer of an island flap and a free flap

Alternative techniques for pedicle transfer of a reverse radial forearm flap for hand coverage, and a latissimus dorsi myocutaneous free flap for pelvic wound coverage, are illustrated. Exteriorization of the vascular pedicle of a reverse radial forearm flap allows a greater arc of movement of the flap for more distal coverage, and avoids the potential vascular compromise of tunnelling under a tight skin bridge. Two-stage transfer of a latissimus dorsi myocutaneous free flap on a wrist carrier pedicle may be useful in circumstances when local recipient vessels are inadequate for free flap transfer. Although both of these vascular pedicle modifications have drawbacks, they may be of value in limited circumstances. Their advantages and limitations are discussed.     

Analysis of 75 forearm flaps

Summary Seventy-five forearm flap transfers have been used for various reconstructive procedures over the past 6/12 years; these cases were analyzed from various points of view. The flap is extremely reliable, since the vascular anatomy is constant. There were two total flap necrosis due to technical problems on the arterial side, but there was no problem on the venous side, in spite of the fact that in 24 cases (32%) only one subcutaneous or one vena comitans was anastomosed. In head ans neck reconstruction, especially in secondary cases, subcutaneous veins in the forearm are often destroyed due to previous IV chemotherapy, but the flap can be safely transferred if only one of the venae comitantes is available for venous anastomosis.     

游离穿支皮瓣的临床应用

目的采用游离穿支皮瓣进行体表瘢痕切除术后缺损的修复,探索穿支皮瓣应用的方法、技巧和有效性。方法2005年1月至2006年10月,施行6例游离穿支皮瓣移植,均用于瘢痕切除术后缺损的修复。其中,应用上臂内侧血管穿支3例,应用股前外侧血管穿支3例。修复面部3例,下肢3例。结果所有皮瓣均顺利成活,皮瓣质地良好。结论应用游离穿支皮瓣可以较好地修复体表组织缺损,并减少供区的并发症,是体表缺损修复的较好方法。     

耳后游离皮瓣移植修复鼻部分缺损

目的 应用能携带耳廓软骨，色泽与鼻部相近的小型游离皮瓣修复鼻部分缺损。方法 采用以耳后动、静脉为血管蒂的耳后游离皮瓣行吻合血管的移植，对5例鼻部缺损进行了修复。结果 3例术后皮瓣血运完全正常，2例术后1－4d内有不同程度的静脉回流障碍。5例皮瓣最终全部成活，术后效果较为满意。结论 本手术供区隐藏，皮瓣不臃肿，色泽与鼻部相近，1次手术即可达到较满意的修复效果，是修复鼻尖、鼻翼大部缺损可供选择的一种方法。     

游离穿支皮瓣的临床应用

目的采用游离穿支皮瓣进行体表瘢痕切除术后缺损的修复,探索穿支皮瓣应用的方法、技巧和有效性。方法2005年1月至2006年10月,施行6例游离穿支皮瓣移植,均用于瘢痕切除术后缺损的修复。其中,应用上臂内侧血管穿支3例,应用股前外侧血管穿支3例。修复面部3例,下肢3例。结果所有皮瓣均顺利成活,皮瓣质地良好。结论应用游离穿支皮瓣可以较好地修复体表组织缺损,并减少供区的并发症,是体表缺损修复的较好方法。     

小腿内侧(胫骨滋养血管皮支)游离皮瓣

通过对10具新鲜成年尸体(20侧)的下肢解剖观察及5具(10侧)小腿内侧皮瓣透明标本观测,见胫骨滋养动脉本干起自胫后动脉后壁,沿腘肌下缘或深面紧贴胫骨斜向下行,在胫骨粗隆平面下61.62±15(42～98)mm处分出筋膜皮支,其外径为2.04±0.6(1.3～3.5)mm,于胫骨与比目鱼肌间隙内下行至胫骨粗隆平面以下96.47±28(67～190)mm,穿出深筋膜、浅筋膜达真皮下血管丛,是小腿内侧皮瓣的主要血供来源之一。我们以胫骨滋养动脉筋膜皮支为血管蒂,进行了小腿内侧游离皮瓣吻合血管的移植并获得成功。此皮瓣具有薄,质佳,面积中等,切取方便,不牺牲小腿主要动脉等优点。     

游离复合皮瓣一期修复腕晚期电烧伤畸形

目的 探讨应用游离复合皮瓣移植，在一次手术中完成多种组织缺损的修复，以提高晚期腕电烧伤的治疗效果。方法 设计以胫后动、静脉为滋养血管的皮瓣，保留其到跖肌腱的筋膜分支切取跖肌腱；通过小腿筋膜携带腓肠神经，从而达到带血供移植肌腱、神经、筋膜和皮肤的目的。同时，从足背切取趾长伸肌腱，将3～4条肌腱分别植人皮瓣深筋膜浅面，将复合皮瓣行吻合血管的游离移植到受区，用以一期修复受区的肌腱、神经、血管的长段缺损。术后定期随访，并对治疗效果进行评价。结果 本组5例，皮瓣移植均成活，随访3～12个月。其中3例在术后3～6个月达到屈指主动屈距掌纹4～5cm，伸指伸距水平3～4cm。2例术后6个月屈指主动屈距掌纹6cm，伸指伸距水平5cm，经补充手术，松解肌腱及功能锻炼，屈指主动屈距掌纹4cm，伸指伸距水平4cm。指腹感觉6个月时均达到S2级，患手皮温明显提高。结论 小腿内后侧胫动、静脉蒂游离复合皮瓣移植，可一次手术修复腕电烧伤后皮肤、肌腱、神经、血管等多种组织缺损，减少了手术次数，治疗效果良好。     

The indications and reliability of vein graft use in free flap transfer

BACKGROUND:

Adequate recipient vessels are critical for free flap success. There are, however, situations in which the local recipient vessels are inadequate. In these situations, vein grafts are required to allow pedicle extension to recipient vessels.

OBJECTIVES:

To determine the indications, technique, reliability and outcome of vein graft use in free flap transfer.

METHODS:

A retrospective review of 198 consecutive free flaps by a single surgeon.

RESULTS:

Vein grafts were required in 9.6% of free flaps. The most common indication was vein graft use in a planned preoperative fashion. The vein graft was most commony placed as an arteriovenous fistula loop. There was no statistically significant difference in survival between flaps with or without vein grafts.

CONCLUSION:

Vein graft use in free flap transfer is reliable, effective and often necessary for free flap survival.     

Infrared surface temperature monitoring in the postoperative management of free tissue transfers

BACKGROUND:

Early identification of failing free flaps may allow for potential intervention and flap salvage. The predictive ability of flap temperature monitoring has been previously questioned. The present study investigated the ability of an infrared surface temperature monitoring device to detect trends in flap temperature and correlation with anastomotic thrombosis and flap failure.

METHODS:

Postoperative measurement of surface temperature was obtained in 47 microvascular free flaps. Differences in temperature between survival and failure groups were evaluated for statistical significance using Student’s t test (P<0.05). In addition, a single variable analysis was performed on 30 different flap characteristics to evaluate their prediction of flap failure.

RESULTS:

In total, eight flaps failed. Five of these were re-explored, of which one was salvaged. The three other flaps died a progressive death secondary to presumed thrombosis of the microcirculation despite adequate Doppler signals. Temperatures of the flap failure group during the last 24 h yielded a mean difference of 2°C (3.56°F) compared with surviving flaps (P<0.05). The temperature of the failing flaps began to decline at the eighth postoperative hour. Single variable analysis identified prior radiation to be a predictor of flap failure.

CONCLUSIONS:

A surface temperature measurement device provides reproducible digital readings without physical contact with the flap. Technical difficulties encountered in previous research with implantable or surface contact temperature probes are obviated with this noncontact technique. Flap temperature monitoring revealed a trend in temperature that correlates with anastomotic thrombosis and eventual flap failure.     

Retrospective review of 400 consecutive free flap reconstructions for oncologic surgical defects

Background: Free tissue transfer has become an important method for reconstructing complex oncologic surgical defects, allowing single stage reconstruction in most instances. The purpose of this study is to review a single center's experience with free flap reconstruction and describe trends that have evolved with respect to technique and donor site selection. Methods: A retrospective review of 400 consecutive free flap reconstructions performed in 396 patients over 10 years was done. Regional applications include the head and neck (63%), trunk and breast (16%), lower extremity (16%), and upper extremity (5%). Donor sites include the fibula (109), rectus abdominis (93), forearm (72), latissimus dorsi (51), scapula (26), gluteus (25), jejunum (16), and five others (8). Microvascular anastomoses were performed to large-caliber vessels using a continuous suture technique; end-to-end anastomoses were preferred. Flaps were designed to avoid the need for vein grafts. Postoperative flap monitoring included clinical observation, conventional Doppler ultrasonography, surface temperature probes, and pinprick testing. Results: The overall free flap success rate was 97%. Twenty-eight flaps (7%) were reexplored, of which seventeen were salvaged (61%). Surviving flaps resulted in a healed wound that did not delay postoperative radiation or chemotherapy. The complication rate was 14%. The mean duration of hospitalization was 21 days, with an average cost of $40,000. Conclusions: The use of fewer, reliable donor sites to reconstruct the vast majority of oncologic defects and the simplification of the microsurgical process have contributed to the success of free tissue transfer in this series. Presented at the 50th Annual Cancer Symposium of the Society of Surgical Oncology, Chicago, Illinois, March 20–23, 1997.     

游离皮瓣一期阴道再造术

目的　探索游离皮瓣一期阴道再造术的可行性。方法　自 1992年以来 ,设计应用足背游离皮瓣与小腿后侧游离皮瓣行一期阴道再造术 2 5例。结果　手术均获成功 ,随访 6个月～ 6年 ,再造之阴道宽度、深度、柔软度及弹性均符合解剖结构及生理要求。结论　游离皮瓣一期阴道再造术切实可行 ,术后外阴部无手术痕迹 ,易为患者接受     

内镜辅助下肌瓣剥离转移术

目的：探讨整形外科用内镜在肌瓣剥离和切取中应用的可行性和其优缺点。方法：对5例外伤后胫骨外露、1例头皮撕脱伤所致颅骨外露患者,在内镜辅助下切取肌瓣,其中背阔肌和腹直肌各3例,游离肌瓣吻合血管移植之后,肌瓣表面植薄中厚皮,对临床资料进行回顾分析。结果：全部伤口一期愈合。结论：内镜辅助下的肌瓣剥离方法较传统肌瓣切取方法有可以明显缩小供区切口长度和减轻手术创伤的优点。     

游离皮瓣缺血耐受实验研究

目的：研究游离皮瓣的缺血耐受极限,为减少皮瓣并发症提供理论依据。方法：成年家猪10只,制作颞部。肩胛、胸三角及下腹部血管蒂皮瓣,阻断血管蒂、观察不同缺血时间皮瓣的成活情况。结果：实验组均出现部分或全部坏死,对照组均成活良好,结论：游离皮瓣有一相应缺血耐受极限,如超出此时间,必将出现皮瓣不可逆转并发症甚至坏死。     

小腿内侧（胫骨滋养血管皮支）游离皮瓣

通过对１０具新鲜成年尸体（２０侧）的下肢解剖观察及５具（１０侧）小腿内侧皮瓣透明标本观测，见胫骨滋养动脉本于起自胫后动脉后壁，沿肌下缘或深面紧贴胫骨斜向下行，在胫骨粗隆平面下６１．６２±１５（４２～９８）ｍｍ处分出筋膜皮支，其外径为２．０４±０．６（１．３～３．５）ｍｍ，于胫骨与比目鱼肌间隙内下行至胫骨粗隆平面以下９６．４７±２８（６７～１９０）ｍｍ，穿出深筋膜、浅筋膜达真皮下血管丛，是小腿内侧皮瓣的主要血供来源之一。我们以胫骨滋养动脉筋膜皮支为血管蒂，进行了小腿内侧游离皮瓣吻合血管的移植并获得成功。此皮瓣具有薄，质佳，面积中等，切取方便，不牺牲小腿主要动脉等优点。     

The versatility of a glycerol-preserved skin allograft as an adjunctive treatment to free flap reconstruction

Skin allografts have been used in medical practice for over a century owing to their unique composition as a biological dressing. Skin allografts can be obtained in several preparations such as cryopreserved, glycerol-preserved, and fresh allograft. A glycerol-preserved allograft (GPA) was introduced in the early 1980s. It has several advantages compared with other dressings such as ease of processing, storage and transport, lower cost, less antigenicity, antimicrobial properties, and neo-vascularisation promoting properties. Skin allografts are mainly used in the management of severe burn injuries, chronic ulcers, and complex, traumatic wounds. Published reports of the use of skin allografts in association with free flap surgery are few or non existent. We would like to share our experience of several cases of free tissue transfer that utilised GPA as a temporary wound dressing in multiple scenarios. On the basis of this case series, we would like to recommend that a GPA be used as a temporary dressing in conjunction with free flap surgery when required to protect the flap pedicle, allowing time for the edema to subside and the wound can then be closed for a better aesthetic outcome.