The role of pedicled flaps in burned nose reconstruction

Burn patients have unique needs for nasal reconstruction. Standard techniques may not be available or appropriate. Alternate methods can be very successful and are described.Correspondence to: B. M. Achauer     

Shoulder reconstruction after tumor resection by pedicled scapular crest graft

The current authors present and evaluate a technique for reconstructing proximal humeral defects that result after resection of malignant bone tumors. Sixteen patients were included in this study with an average followup of 3 years (range, 12-76 months). Twelve patients had intraarticular resections, two had extraarticular resections, and two had intercalary resections. Reconstruction was done at the lateral border of the scapula (based on the circumflex scapular vessels) that was osteotomized and mobilized to bridge the resultant defect. Shoulder arthrodesis was done in 14 patients and the shoulder was spared in the two patients who had intercalary resections. Function was evaluated according to the Musculoskeletal Tumor Society scoring system. The average time for union of the graft proximally and distally was 6 months after which the graft started to hypertrophy. The average functional score was 22.5 points (75%) with a minimum score of 18 points (60%) and a maximum score of 27 points (90%). Nonunion of the distal host-graft junction occurred in two patients; both patients required iliac crest bone grafting and both achieved clinical and radiographic union without additional intervention. In three patients, the proximal fixation became loose but had no effect on function. The authors conclude that this technique is inexpensive, effective, and a durable reconstructive option for proximal humeral defects that are less than 15 cm. It has a predictable functional outcome (60%-90%) that is comparable with other reconstructive options.     

Tibia reconstruction using cross-leg pedicled fibular flaps: report of two cases]

The paper presents the results of treatment of two children with cross-leg pedicle fibular flaps. A boy (10 years old) was operated because of an extensive defect of the proximal tibial shaft (15 cm) and soft tissue deficit due to osteosarcoma. He had been previously operated several times: tumor resection with chemiotherapy, bone reconstruction using allografts and two other procedures because of inflammatory complications. The second case was a 9-year old girl who underwent an extensive excision of congenital pseudoarthrosis of the tibia due to neurofibroma and reconstruction of the further fragment of the tibia. Vascularized fibula was nailed deep into the tibial shaft, beyond the previously implanted metal elements. This allowed to maintain a correct axis of the limb, a firm stabilization of the transplant and probably evoked a quick periosteal reaction of the tibia. Plaster of Paris was used to immobilize the limb. Postoperative course showed no complications. The flap pedicle was cut off after 3-4 weeks. Progressive bone healing followed by bony hypertrophy was observed after 8 weeks. The children were able to fully load the operated extremities and ambulate without crutches (the boys 12 months post-surgery and the girl 6 months post-surgery).     

Stepladder dorsal metacarpal flaps for dorsal finger and hand reconstruction.

The authors demonstrate successful cases of stepladder dorsal metacarpal V-Y advancement and rotation-advancement flaps for reconstructing defects on the dorsum of the finger and hand. One side of the flap is designed in a multilobed shape, and each lobed flap is designed on the dorsum of adjacent fingers. These flaps are supplied by dorsal metacarpal vessels. Consequently, this method has the elements of the stepped incision technique, in combination with the V-Y and rotation-advancement principle. All flaps survived completely. This technique may be a useful option for reconstruction of defects of the dorsum of the finger and hand.     

Tracheotomy scar revision using deepithelialized subcutaneous pedicled flaps

Summary Optimal revision of the typical tracheotomy scar requires release of any tracheal adhesions, elimination of the co-existing central depression, and a redirection of the usual circular scar. All these objectives may simultaneously be achieved by designing a horizontal lenticular excision around the scar that is then deepithelialized to form two subcutaneous-pedicled flaps. These are advanced together over the trachea to provide necessary central tissue bulk while serving as an additional buried layer for the skin closure to glide over, which usually creates an acceptable transverse scar.     

The use of pedicled perforator flaps for reconstruction of lumbosacral defects

Large lumbosacral defects remain a difficult challenge in reconstructive surgery, especially in the nonparaplegic patient. Traditional options for closure include local rotation or transposition flaps and musculocutaneous flaps. These flaps, however, are not an optimal option in previously irradiated or operated areas, or in cases of large defects. Application of the perforator principle to the traditional musculocutaneous flap creates perforator flaps, which are an additional tool in the treatment of these defects in the nonparaplegic patient. A large amount of healthy, well-vascularized tissue can be transferred on one perforator without sacrificing important underlying muscles. The arc of rotation is also larger than in traditional flaps. The authors present an anatomic overview of three types of pedicled perforator flaps: the superior gluteal artery perforator flap, the lumbar artery perforator flap, and the intercostal artery perforator flap. They also report 4 patients in whom a pedicled perforator flap was used to reconstruct a large lumbosacral defect.     

Hand reconstruction with lobulated combined flaps based on the circumflex scapular pedicle

Repair of multiple soft tissue defects on hand often pose a difficult problem to the reconstructive surgeons with employing a limited number of reliable flaps and recipient vessels. This report is to explore the feasibility and advantage of the treatment of multiple soft tissue defects on hand with combined island flaps based on branches of the circumflex scapular system. From 2002 to 2006, nine patients had transfer of the scapular lobulated combined flaps based on the transverse branch, ascending branch, and descending branch of the circumflex scapular vascular pedicle for coverage of soft-tissue defects over injured hands. Follow-up ranged from 6 months to 24 months with average 12.1 months' all of nine flaps completely survived without complications. Arterial insufficiency was found in one flap because of the pedicle compression in the subcutaneous tunnel. The blood supply to flap was restored after the compression was released. All transferred flaps showed good appearance without significantly swelling and congestion. Two flaps underwent secondary debulking surgery. At 6 months postoperatively, partial protective sensation (S1) was restored in the flaps. The donor sites were directly closed in six cases. Skin grafts were used to cover the donor sites in other three cases. All of donor sites healed without complications. Our report shows that the management of multiple soft tissue defects on hand in complex hand injuries with lobulated flaps of circumflex scapular system can obtain good results for its good appearance and low donor site complications. It is probably the optimal surgical intervention for these injuries.     

应用吻合血管的骨肌皮瓣修复下颌骨放射性骨坏死

目的探讨下颌骨放射性骨坏死所致颌面部组织缺损的修复手段。方法对下颌骨放射性骨坏死行死骨扩大切除术，同期用吻合血管的骨肌(皮)瓣移植修复颌面部组织缺损。共有髂骨肌皮瓣9例、髂骨肌瓣串联前臂皮瓣5例、腓骨肌皮瓣5例以及腓骨肌瓣串联前臂皮瓣1例修复20例下颌骨骨坏死。结果临床随访1～5年，除1例髂骨肌皮瓣坏死外其余均正常成活。吻合血管的骨肌皮瓣移植成功率达95％。结论下颌骨放射性骨坏死应行死骨扩大切除术，同期用吻合血管的骨肌(皮)瓣移植可以有效修复手术所致的颌面部组织缺损。     

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.     

The dorsal metacarpal arteries: anatomical study. Feasibility of pedicled metacarpal bone flaps

The vascular anatomy of the dorsal aspect of the hand is variable. Nevertheless the presence of the first and the second dorsal metacarpal artery (DMA) is constant. DMA3 and 4 are more variable. The anatomical study presented demonstrates the segmental vascularization of the metacarpal bones and the possibility of harvesting metacarpal bone flaps. The reliability of such a flap decreases from the second to the fifth metacarpal bone regarding the frequency of presence of the DMAs. The authors describe six new vascularized bone flaps from the third and the fourth metacarpal bones pedicled on the second or the third dorsal metacarpal artery in an anterograde or retrograde flow mode. This study suggests that the radial and the ulnar side of the third metacarpal bone could be harvested respectively on the DMA2 and DMA3. The radial side of the fourth metacarpal bone could also be a reliable vascularized bone donor site. Flaps can be used proximally or distally based to repair bone defects either on metacarpal and carpal bones or on proximal phalanges.     

Our experience in lower limb reconstruction with perforator flaps

The application of Taylor's concept about body angiosomes, referred to tissue transfers, has meant that the development of the perforator flaps and muscles is no longer needed as a carrier of skin flap vascularity. In this paper, we revise 59 lower limb reconstructions with local and free perforator flaps performed in the last 5 years, and a basic reconstructive algorithm is also suggested to help with the management of the lower limb soft tissue reconstruction with perforator flaps. The advantages of the perforator flaps are (1) muscles and their function are preserved; (2) the main vascular trunks are spared; (3) it is possible to make a more specific reconstruction, replacing "like with like" (even performing compound or chimeric flaps); (4) the donor site can often be closed primarily; (5) the general morbidity is reduced; (6) a better cosmetic result can be achieved.     

Microsurgical reconstruction: experience with free fascia flaps

Microsurgical reconstruction can often benefit from the thin, pliable, and vascular characteristics of free fascia flaps. Investigation to identify donor sites and to maximize reliability of these flaps continues. Microfil injections of the thoracodorsal artery confirm the ability to use the fascia overlying the serratus anterior muscle as a free flap based on this vessel. We have used this flap in distal extremity wounds in 4 patients with one failure (venous thrombosis). Free fascia flaps from other donor sites have been used in 9 patients in a variety of locations (head and neck, hand, and extremity) with excellent results. We conclude that when thin, well-vascularized tissue is required for reconstructive purposes, the skin-grafted free fascial flap provides excellent durable coverage with minimal donor site complications.     

肩胛皮瓣再造阴茎

目的：探索一种新的阴茎再造手术方式。方法：应用肩胛皮瓣游离移植和银丝棒硅胶阴茎假体置入行阴茎再造。结果：自2000年3月起，已在临床应用6例，术后皮瓣全部成活。经随访6－12个月，阴茎形态和功能良好，结论：此手术方法设计合理，术后形态功能良好，供区无明显继发畸形，是一种较好的阴茎再造方法。