Temporal fascial flap: a versatile free flap for coverage of complex skin defects

The use of temporal fascial flap (TFF) as a microsurgical option permits the covering of skin defects which expose bones, nerves and vessels; it also provides a gliding surface which facilitates tendon excursion. Other advantages of the TFF are a reasonably constant surgical anatomy, minimal donor-site morbidity, and a thin and pliable surface which results in good cosmetic contour. In this paper we present our experience using TFF to cover wounds with significant exposed surfaces in different body areas (hands, feet, popliteal fossa); an average of 7 years follow-up is presented. Eleven patients with various wounds are presented: 91% had a successful surgery, and the TFF was able to solve the primary problem. On follow-up it was seen that the surgical aim had been reached, with excellent skin quality in terms of pliability, range of motion and protection from secondary ulceration. All patients were satisfied with the final result, and were able to return to their normal lifestyle. Scars secondary to flap harvesting were of good quality and were able to be hidden by the hair. No significant areas of alopecia were noticed.     

Fasciocutaneous flap coverage for periolecranon defects

Soft tissue defects in the periolecranon region are difficult to manage by standard techniques such as closure by approximation, split-thickness skin grafting, or healing by secondary intention. We employed cadaver injections and dissections to study the vascular anatomy of the periolecranon region in search of a suitable local flap for coverage of periolecranon defects. This report details our experience in 31 patients with a one-stage technique for elbow coverage employing a proximally based forearm fasciocutaneous flap. Surgical techniques and clinical applications are discussed; a satisfactory long-term outcome is documented in 30 of 31 patients. The advantages of using this model fasciocutaneous flap include enhanced vascularity, sensibility, and ease of elevation.     

Cadaveric study and clinical application of turnover fascial flap for lower-limb defects

Moderately sized defects of various etiologies are encountered frequently in the lower limb. Several reconstructive modalities are available. Majority of them do not meet all the desirable criterion of recipient and donor site. In a search for an optimal procedure, the fascial flap emerged. We found the fascial flap to be suitable and advantageous for many defects. This paper describes the anatomical basis, planning, technique, and application of the fascial flap. To establish the technique, we divided the study in to two parts (a) cadaveric dissection and (b) clinical application. Dissection in 12 fresh cadaver limbs confirmed the location of the perforators of the posterior tibial and peroneal vessels. It also visualised the rich vascular network associated on either side of the deep fascia. The findings also suggested the safe dimension of a retrograde flap which is the key to success. Convinced and encouraged with the above findings, fascial flaps were successfully used for moderately sized defects at various non-weight-bearing areas of lower limb in 20 patients. Out of these, eight were random flaps and 12 were pre-Dopplered perforator flaps. Out of 20, 16 flaps healed uneventfully. In four cases one had complete necrosis while another had partial necrosis. Two cases had complete graft loss although the flap survived. These cases were followed up from 6 months to 2.5 years with an average of 1.5 years. Fascial flaps provide gratifying results in the majority of moderately sized lower-limb defects in non-weight-bearing areas. It meets most of the requirements of reconstruction in a single stage. Therefore, wherever feasible this simple method is justified.     

Use of a free gracilis flap for coverage of medium size defects over the ankle and foot

We report the use of a free gracilis flap in six cases of medium size tissue loss over the ankle and foot. All the procedures were done under spinal or epidural block. A muscle flap was used twice and a musculocutaneous flap four times. The skin paddle was reliable in three cases for evaluation of the vascularity of the musculocutaneous flaps, but in one case there was necrosis of 70% of the surface. In three cases the fatty skin paddle was removed at two weeks and the entire muscle surface was mesh skin grafted. The advantages of the use of a gracilis flap are easy dissection and low donor site morbidity. This flat and thin muscle is well-suited for medium size defects from 8-15 cm. The length of the pedicle could be extended to 8 cm by dissecting it as far as the profunda femoris vessels.     

The bilobed arterialized venous free flap for simultaneous coverage of 2 separate defects of a digit

We report a case of a 17-year-old patient who sustained multiple finger contusions on the left hand. After thorough debridement, the volar and dorsal defects of the middle finger were covered simultaneously with bilobed arterialized venous free flap from the left forearm. The flap was composed of 2 paddles, which were connected by a subcutaneous bridge containing a subcutaneous venous network. The subdermal plexus in the bridge was interrupted with no impairment of blood supply to the second cutaneous paddle. The flap survived completely with only temporary mild venous congestion. Excellent functional and cosmetic result was reached. We consider bilobed arterialized venous free flap as a useful option for coverage of concomitant volar and dorsal digital defects.     

A palmar cross-finger flap for coverage of thumb defects

We have devised a method of covering tissue defects of the distal thumb using a flap elevated between the two flexion creases on the palmar skin over the proximal phalanx of the long finger. The advantages of this method over the usual dorsally based, distal, cross-finger flap include improved appearance of the donor finger, comfortable positioning, and avoidance of joint contractures. Although sensitivity of the palmar scar, contractures, or other disadvantages of this approach were sought during follow-up, none were found.     

Island flap perineoplasty for coverage of perineal skin defects after repair of cloacal deformity

Background : Traumatic cloacal defect is an injury sustained during childbirth in which the anovaginal septum is completely disrupted and the anus and vagina open as a common channel. Such injuries result in complete faecal incontinence and are difficult to repair both in terms of improving function and obtaining skin closure. Methods : Four cases of traumatic cloacal defect with a delayed presentation are illustrated here. All were treated with an overlapping anterior sphincter repair in combination with island flap perineoplasty to achieve skin closure. Anorectal function before and after surgery and the success of achieving primary wound healing were evaluated. Results : In all four cases profound incontinence was found preoperatively; all patients returned to normal or near normal continence following overlapping anterior sphincter repair. Island flap perineoplasty was successful in achieving primary healing in all cases and no flaps were lost to necrosis. Conclusions : Island flap perineoplasty is an effective method of achieving skin closure after anterior sphincter repair of traumatic cloacal defects.     

Simultaneous coverage of two separate dorsal digital defects with a syndactylizing venous free flap

We report a case of a 58-year-old patient who sustained multiple finger injuries on the right hand. After thorough debridement, two dorsal defects of the middle and ring fingers were covered simultaneously with a single arterialized venous free flap from the right forearm. The flap was used to create a dorsally syndactylized digit which survived completely and was subsequently divided longitudinally. With early flap division, excellent functional and cosmetic result was achieved. We consider the syndactylized venous free flap with early division as a useful option for simultaneous coverage of separate dorsal digital defects.     

Risk factors and complications in free TRAM flap breast reconstruction

METHODS: The authors retrospectively reviewed 500 free TRAM flaps performed between 1992 and 2003. This cohort was subdivided based on smoking history, obesity, preoperative chemotherapy, preoperative radiation therapy, peripheral vascular disease, chronic obstructive pulmonary disease (COPD), and hypertension, and compared surgical complication rates. Measured complications included fat necrosis, mastectomy flap necrosis, abdominal flap necrosis, partial TRAM flap loss, wound infection, hematoma, seroma, vessel thrombosis, and abdominal hernia. Chi2 analysis and Fisher exact test were performed to determine differences between groups, and linear regression models were used to predict the risk factors of surgical complications. RESULTS: Smokers were more likely to have a higher incidence of wound infection (P = 0.01), mastectomy flap necrosis (P = 0.015), abdominal flap necrosis (P = 0.033), and fat necrosis (P = 0.01). Obese patients were more likely to have higher rates of mastectomy flap necrosis (P = 0.01) and hematoma (P = 0.01). Patients with peripheral vascular disease were more likely to have a higher incidence of wound infection (P = 0.031), and patients with preoperative radiation therapy were more likely to have a higher incidence of seroma (P = 0.043). Logistic regression showed that smoking was found to be a risk factor for fat necrosis (P = 0.006), wound infection (P = 0.002), mastectomy flap necrosis (P = 0.039), and abdominal flap necrosis (P = 0.042). Obesity was a risk factor for mastectomy flap necrosis (P = 0.002). Peripheral vascular disease was a risk factor for wound infection (P = 0.032). CONCLUSION: Awareness of risk factors and associated complications will lead to modification and individualization of surgical techniques in an attempt to limit these complications and continually improve outcomes.     

全麻下血管化游离皮瓣修复术后患者谵妄的危险因素

Objective To investigate the risk factors for postoperative delirium in patients after vascular free flap reconstruction performed under general anesthesia.Methods Two hundred and sixteen ASA Ⅰ-Ⅲ patients aged 18-80 yr undergoing vascular free flap reconstruction surgery were enrolled in this study.Patient characteristics before and during operation were recorded.The patients were followed up for 5 days after operation.Their level of consciousness,severity of pain and sleep quality were evaluated daily.The patients were divided into 2 groups according to the occurrence of delirium during the 5 days after operation:delirium group and non-delirium group.The method of CAM-ICU was reed in the diagnosis of postoperative delirium.Multivariate logistic regression was used to analyze the risk factors for postoperative delirium.Results logistic regression analysis showed that old age,history of alcohol abuse and sleep diacrder after operation were risk factors for delirium developed after free flap surgery.Conclusion Old age,history of alcohol abuse and sleep disorder after operation were the risk factors for postoperative delirium in patients after vascular free flap reconstruction performed under general anesthesia.     

全麻下血管化游离皮瓣修复术后患者谵妄的危险因素

目的 筛选全麻下血管化游离皮瓣修复术后患者谵妄的危险因素.方法 择期行血管化游离皮瓣修复手术的患者216例,年龄18～80岁,根据术后5d内是否发生谵妄分为术后谵妄组和非术后谵妄组.可能的危险因素进行组间比较后,将差异有统计学意义的因素进行logistic回归分析,筛选发生术后谵妄的危险因素.结果 logistic回归分析结果显示,酗酒、术后睡眠紊乱和高龄是术后谵妄的独立危险因素(P<0.05),相对危险度依次为17.066,5.647和1.047.结论 高龄、酗酒史和术后睡眠紊乱是全麻下血管化游离皮瓣修复术后患者谵妄的危险因素.     

Use of a free gracilis flap for coverage of medium size defects over the ankle and foot.

We report the use of a free gracilis flap in six cases of medium size tissue loss over the ankle and foot. All the procedures were done under spinal or epidural block. A muscle flap was used twice and a musculocutaneous flap four times. The skin paddle was reliable in three cases for evaluation of the vascularity of the musculocutaneous flaps, but in one case there was necrosis of 70% of the surface. In three cases the fatty skin paddle was removed at two weeks and the entire muscle surface was mesh skin grafted. The advantages of the use of a gracilis flap are easy dissection and low donor site morbidity. This flat and thin muscle is well-suited for medium size defects from 8-15 cm. The length of the pedicle could be extended to 8 cm by dissecting it as far as the profunda femoris vessels.     

全麻下血管化游离皮瓣修复术后患者谵妄的危险因素

Objective To investigate the risk factors for postoperative delirium in patients after vascular free flap reconstruction performed under general anesthesia.Methods Two hundred and sixteen ASA Ⅰ-Ⅲ patients aged 18-80 yr undergoing vascular free flap reconstruction surgery were enrolled in this study.Patient characteristics before and during operation were recorded.The patients were followed up for 5 days after operation.Their level of consciousness,severity of pain and sleep quality were evaluated daily.The patients were divided into 2 groups according to the occurrence of delirium during the 5 days after operation:delirium group and non-delirium group.The method of CAM-ICU was reed in the diagnosis of postoperative delirium.Multivariate logistic regression was used to analyze the risk factors for postoperative delirium.Results logistic regression analysis showed that old age,history of alcohol abuse and sleep diacrder after operation were risk factors for delirium developed after free flap surgery.Conclusion Old age,history of alcohol abuse and sleep disorder after operation were the risk factors for postoperative delirium in patients after vascular free flap reconstruction performed under general anesthesia.     

Designing the latissimus dorsi free flap for knee coverage

Several techniques have been described for coverage of the exposed knee joint using local soft tissue and muscle. Occasionally, because of multiple previous procedures or the extent of the defect, local tissue is inadequate. In these situations the latissimus dorsi free flap is useful. The most acceptable recipient vessels comprise the superficial femoral system, but they are at a significant distance from the knee. This distance is bridged by designing the flap as a paddle with a narrow strip of proximal muscle in continuity with the thoracodorsal vessels. Placing the skin island eccentrically allows the muscle to be folded on itself and packed into the bony defect.     

The adipofascial turn-over flap for the coverage of finger defects

Summary This procedure was used to resurface finger defects in seven cases. The flaps survived completely, except one which had a 20% loss. The clinical results and pertinent literature are described and discussed.