Free flaps for coverage of the foot and ankle

Coverage of complex soft tissue injuries to the foot and ankle is difficult and often can be achieved only by the use of free flaps. Selection of the appropriate flap must be patient-oriented. Indications for composite tissue transfer are presented. In addition, the vascular anatomy and characteristics of commonly used flaps--the groin flap, the scapular flap, and the latissimus dorsi, tensor fascia lata, and gracilis flaps are presented along with case histories illustrating their utilization.     

Free flaps for soft tissue coverage in the hand and fingers

With mastery of conventional methods, free flaps are indicated in selected cases for coverage of the hand and fingers. Careful preoperative planning, delicate intraoperative management, and postoperative physiotherapy are the mainstays for success in functional recovery and aesthetic result. Thin flaps of good vascularity are favored for coverage of the hand and finger. For hand surgeons, the lateral arm fasciocutaneous or fascia flap, toe flaps, and the latissimus dorsi flap seem to be the easiest and most useful free flaps applicable to most situations.     

Modified dorsalis pedis flap for coverage of a pretibial pressure sore after hip rotationplasty.

Rotationplasty is a well-established procedure after total femur resection, especially in children. Rehabilitation is superior to disarticulation of the hip or hemipelvectomy because patients regain hip and knee function.(1) A tight fit of the prosthetic shaft is essential. The pretibial area has a low physiological resistance to pressure and shear forces, and is thus at increased risk of developing pressure-related complications.Skin defects with exposure of skeletal elements require flap coverage. The dorsalis pedis flap is one of the surgical options available for skin coverage of the proximal anterior leg. It can be rotated to cover almost any site on the anterior aspect of the leg if the pedicle is mobilised up to the anterior tibial artery.(2)Since donor site complications are common, this flap has few indications.(3) Copyright 2001 The British Association of Plastic Surgeons.     

Perforator-based fasciocutaneous flap for pressure sore reconstruction

Abstract

Pressure sore reconstruction is always a challenge for plastic surgeons due to its high recurrence rate. In addition to the myocutaneous flap, the perforator-based fasciocutaneous flap has become a new entity used for pressure sore reconstruction. This study presents a series of 26 perforator-based fasciocutaneous flaps for pressure sore reconstruction, with good outcomes in 21 patients from July 2008 to April 2011. The flaps were advanced, transposed, or rotated to obliterate the defects. Twenty of 26 flaps healed uneventfully without complication. One patient had a flap that totally necrosed, one had partial flap necrosis (flap rotated 180° in the above two cases), one had infection and healed by a secondary flap, one had minor wound dehiscence, one died of pneumonia 1 week postoperatively, and recurrence developed in one patient. The perforator-based fasciocutaneous flap is a reliable method and produced good results in this series. These flaps are well vascularised, have enough soft tissue bulk, and have a high degree of mobilisation freedom.     

The role of medial gastrocnemius free flap in coverage of ischial pressure sore in paraplegic patients

Pressure sores, and especially ischial pressure sores, are a serious concern in the life of paraplegic patients. The treatment of this pathology is obviously surgery, and several local flaps can be used for coverage. However, recurrent pressure sores in an active patient can be frustrating if all local flaps have been used. Free flaps are therefore the next option. In our experience, the free medial gastrocnemius musculocutaneous flap is the best option. This paper reports the closure of ischial pressure sores with a free medial gastrocnemius flap, the patient selection criteria used, and the postoperative care provided.     

V-Y advancement flaps. Reusable flaps for pressure ulcer repair

V-Y advancement modification of skin paddle design for the biceps femoris, tensor fascia lata, transverse lumbar, and gracilis flaps permits readvancement of each of these flaps for recurrent pressure ulcers. Our use of this refinement of these flaps over the past twelve years shows that up to two readvancements of each of these flaps can be done, thus preserving reconstructive options in a patient population prone to pressure ulcer recurrence.     

Free flaps versus conventional surgery

On the basis of about 60 cases, we discuss the clinical use of groin, latissimus dorsi, dorsalis pedis, scapular, parascapular, and forearm free flaps. These flaps are evaluated in relation to some alternate reconstructive procedures in various regions of the body, with photographic documentation.     

Free flaps in burn reconstruction

In this paper, we present our experience of free flap reconstructions in burned patients. It allows the preservation of otherwise unsalvageable deep burn injuries and secondary correction of contracted burn scars. We analyse the indications of different free flaps, according to different anatomic regions and defects: depth and width of the loss of tissue, different colour skin, texture and thickness of the receptor area, weight-bearing or not weight-bearing surface. Free flap reconstructions were successful in 50 of 53 cases (94%). They provide good aesthetic and functional results with low morbidity both in acute deep burn injuries as in delayed reconstructions.     

Free posterior tibial perforator-based flaps

Free posterior tibial perforator-based flaps, fed by a perforator from the posterior tibial artery, were applied in 2 patients. The advantages of this flap are that they are reliable, relatively large and thin flaps, making it possible to use an innervated flap without sacrificing the posterior tibial artery. This flap provides great advantages for the reconstruction of skin defects at the extremities.     

Free vascularized bone and muscle flaps for osteomyelitis

Chronic, post-traumatic osteomyelitis remains an unsolved problem for orthopedists. With improved knowledge of skin and muscle flap circulation, surgeons are now capable of covering wide defects left by debridement. Early clinical experience with muscle and skin flaps to improve vascularity and achieve a stable, closed wound have been encouraging. Management of wounds with infected bone is primarily aimed at resection of infected or nonviable tissue. Antibiotics are of value, however are of secondary importance to a thorough debridement. It is uncertain as to whether osteomyelitis is a curable entity. However, free tissue transfer affords the surgeon the opportunity to perform a thorough debridement and achieve a stable closed wound.     

带蒂皮瓣移植修复手部创面

目的总结带蒂皮瓣移植修复手部软组织缺损的临床效果。方法自1997年1月—2005年10月,采用带蒂皮瓣移植修复手部软组织缺损1277例1398块皮瓣。其中带蒂腹部皮瓣655例726块,腹部埋藏皮瓣115例,皮管180例,带蒂小皮瓣327例377块,皮瓣切取面积为2．0 cm×2．0 cm～15．0cm×20．0cm。修复急诊创面954例,择期手术瘢痕松解后创面323例。结果1398块皮瓣中,术后47块(47/1 398,占3．4%)发生感染；51块(51/1398,占3．6%)发生坏死,其中腹部皮瓣坏死31块(31/726,占4．3%),皮管坏死20块(20/180,占11．1%)。67块(67/726,占9．2%)腹部皮瓣、48块(48/115,占41．7%)腹部埋藏皮瓣和34块(34/180,占18．9%)腹部皮管术后,因皮瓣臃肿需再次手术修整。6块腹部皮管再造拇指者出现皮瓣破溃,需二次手术扩创缝合。1例交臂皮瓣术后撕脱。所有带蒂小皮瓣均成活,患者对修复后的手部外形满意,暂时性的指间关节僵直经过一段时间的功能练习后,均能完全恢复正常。结论带蒂皮瓣手术操作简单,并发症少。如果适应证选择适当,仍不失为覆盖手部创面的一种理想选择。     

Bipedicled fasciocutaneous flaps for coverage of defects of the knee

We presented three cases in which two bipedicled fasciocutaneous flaps were used for coverage defects of the knee. These bipedicled flaps can be harvested to cover long and narrow sized defects on the anteromedial aspect of the knee region. This procedure is easy, quick and versatile without compromising the principal vessels and muscles of the leg.     

Local fasciocutaneous flaps for cutaneous coverage of lower extremity wounds

Severe lower extremity trauma frequently results in a soft-tissue deficit that mandates wound coverage using some form of vascularized flap. The recent rediscovery of inclusion of the deep fascia during elevation of random skin flaps has enhanced the viability of large local flaps as a reconstructive option in the lower leg. In selected cases of relatively uncontaminated, moderate-sized defects, the choice of this maneuver has permitted closure of many defects which previously might have required a complex microsurgical tissue transfer. This series of 41 random-based local fasciocutaneous flaps in the lower leg in 38 patients has in all cases except two been successful in achieving preferred wound healing. Flap necrosis occurred only in these two cases presumably due to peripheral vascular insufficiency necessitating limb amputation in one patient. Eight (19%) had some form of complication, most occurring in the subset of flaps used for distal third lower leg wounds. The fasciocutaneous flap is conceptually simple, rapidly elevated and inset, and minimizes the region of surgical insult for many multitrauma patients who otherwise might have to forego any attempt for limb salvage.