Z-plasty closure of the donor defect of the radial forearm free flap

The radial forearm is a popular free flap site for reconstruction of head and neck defects, because of its abundant, pliable, skin component and an available, extended, vascular pedicle. In addition, vascularized composite flaps, including a segment of radius, can be designed for skeletal stabilization. The donor-site defect can involve various complications, including loss of skin graft, unsatisfactory appearance, numbness, and radial fracture. Recent advances in reducing donor-site defect problems have included the use of rotation skin flaps, local muscle rotation, and soft-tissue expansion; however, each of these has its own limitations. Two cases are presented in which radial forearm donor site defects, measuring less than 4 cm x6 cm, were primarily closed successfully with z-plasties based on the longitudinal skin incision. Each patient has regained preoperative mobility, and prompt primary healing was achieved without complications.     

15 years experience with microvascular free tissue transfert for repair of head and neck cancer defects

We present the modalities and results obtained with free flap reconstruction of head and neck cancers defects. This retrospective review of 165 free transfers performed between 1984 and 1999 included 89 radial forearm flaps (54%), 38 latissimus dorsi flaps (23%), 28 osteomyocutaneous flaps (17%), 6 omentum flaps (4%), 2 jejunum flaps, and 2 cutaneous scapular flaps. Indications were orobuccopharynx (34%), hypopharynx (24%), mandible (17%), craniofacial (15%) and skin (10%) defects. Flap failure rate was 9%. Reconstruction of a radiated site was a statistically significant indicator of flap failure. Four types of free flaps were preferred for reconstruction of head and neck cancer defects. The radial forearm flap was used as a lap flap for the orobuccopharynx, the tubuled radial forearm flap for reconstruction of the digestive tract after total pharyngolaryngectomy, the osteomyocutaneous free fibular flap for pelvimandibulectomy, especially for the anterior arch, the latissimus dorsi flap to fill craniofacial defects, and the free omentum flap for craniofacial complications after radiotherapy.     

Free anterolateral thigh flap for reconstruction of head and neck defects: preliminary results and a comparison with the radial forearm flap

BACKGROUND: The authors present their personal preliminary experience with the free anterolateral thigh flap in the reconstruction of head and neck defects and compare these first cases with the radial forearm flaps. METHODS: Seventeen patients undergoing free flap reconstruction between December 1998 and September 2001 have been selected for this retrospective study and evaluated. In fourteeen patients reconstruction was performed with a radial forearm flap. In three patients an anterolateral thigh flap was used. Six dissections on cadavers have also been performed in order to study the anatomical variations of the perforators of the lateral circumflex femoral system. RESULTS: All flaps survived, without any major vascular impairment. CONCLUSIONS: Despite a laborious dissection of the pedicle the anterolateral thigh is a versatile flap, with a minimal morbidity of the donor area. Even if the radial forearm is overall accepted as the gold standard for head and neck reconstruction, the anterolateral thigh flap is suggested as a good and safe surgical option, especially when a large flap is requested or in female patients concerned with the cosmetic result in the forearm donor area.     

Full-thickness cheek and lip reconstruction with the radial forearm free flap

The radial forearm free flap has proven versatility in head and neck reconstruction. It is superior to regional alternatives such as the pectoralis flap because it is thin, pliable, and predominantly hairless. A more recent application is the use of the folded forearm flap to replace both the skin and inner lining, simultaneously, in full-thickness cheek and lip defects. Nine such cases are presented in this report. Each patient had a recurrent lesion that had been reconstructed previously with local flaps, and all but one were treated with postoperative radiation therapy. The average size of the external defects after resection was 27 cm2, and of the intraoral defects, 18 cm2. All free flaps survived completely. The folded forearm flap solved the reconstructive problem for each patient in a single-stage procedure, providing good contour and a reasonable color match. The flap is easy to raise, has a long pedicle with large-diameter vessels, and has an acceptable donor site defect not associated with long-term morbidity.     

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.     

吻合血管的股前外侧皮瓣修复头颈肿瘤术后复杂缺损

目的：评价吻合血管的股前外侧皮瓣在头颈肿瘤术后复杂缺损修复中的作用。方法：1990年5月-2001年4月，应用吻合血管的股前外侧皮瓣移植，修复口颊癌、喉癌、面部皮肤癌、上颌窦癌术后大面积软组织复杂缺损21例。结果：19例成功，1例皮瓣部分坏死，1例失败。随诊6个月到10年，9例无瘤生存，外观及功能满意；2例带瘤生存；5例死于局部复发；4例分别死于颈淋巴结转移、脑转移、第二原发癌及脑血管意外；1例失访。结论：吻合血管的股前外侧皮瓣可提供充足的组织量、存活率高、供区隐蔽、不牺牲重要血管，适用于修复头颈肿瘤术后复杂缺损。     

Customized reconstruction with the free anterolateral thigh perforator flap

From April of 2003 through September of 2006, 70 free anterolateral thigh (ALT) flaps were transferred for reconstructing soft-tissue defects. The overall success rate was 96%. Among 70 free ALT flaps, 11 were elevated as cutaneous ALT septocutaneous vessel flaps. Fifty-seven were harvested as cutaneous ALT myocutaneous "true" perforator flaps. Two flaps were used as fasciocutaneous perforator flaps based on independent skin vessels. Fifty-four ALT flaps were used for lower extremity reconstruction, 11 flaps were used for upper extremity reconstruction, 3 flaps were used for trunk reconstruction, and 1 flap was used for head and neck reconstruction. Total flap failure occurred in 3 patients (4.28% of the flaps), and partial failure occurred in 5 patients (7.14% of the flaps). The three flaps that failed completely were reconstructed with a free radial forearm flap, a latissimus dorsi flap and skin grafting, respectively. Among the five flaps that failed partially, three were reconstructed with skin grafting, one with a sural flap, and one with primary closure. The free ALT flap has become the workhorse for covering defects in most clinical situations in our center. It is a reliable flap with consistent anatomy and a long, constant pedicle diameter. Its versatility, in which thickness and volume can be adjusted, leads to a perfect match for customized reconstruction of complex defects.     

Oblique radial forearm reverse-flow flap

A modifed design for the distally-based radial forearm flap is presented, in an oblique direction rather than longitudinally, based on the existence of skin laxity in the proximal forearm region. The skin paddle of the flap is designed in an oblique fashion pedicled on one of the proximal-row septocutaneous perforators, and elevated in the usual manner supplied by the distal radial artery. The oblique radial forearm flap thus created was successfully utilized for reconstruction of seven dorsal hand defects. Results showed that all the flaps could easily be transposed to the defect through a wide arc of rotation and all survived totally, with direct closure of the donor site in five cases, and significant reduction in size in the remaining two cases. It was concluded that the oblique design for the skin island of the reverse radial forearm flap could allow creation of a flap that has a smaller donor defect and yet presents a longer pedicle length, with a wider arc of rotation and better adaptation to a dorsal hand defect, than a conventional longitudinal-design radial forearm flap.     

Preservation of lateral thoracic artery to improve vascular supply of distal skin without compromising pedicle length in harvesting pectoralis major myocutaneous flap.

The pectoralis major myocutaneous (PM) flap is supplied by three arterial systems. The lower chest skin of the PM flap is mainly supplied by the branches of lateral thoracic artery and internal mammary artery. The conventional harvesting technique for head and neck reconstruction utilizes single arterial supply from the pectoral branch of thoracoacromial artery. The distal skin island of PM flap is therefore compromised and requires indirect blood supply by communicating vessels. In harvesting the PM flap, the pectoralis minor muscle is divided to preserve the lateral thoracic artery and its blood supply to the lateral distal skin island of PM flap without compromising the pedicle length for head and neck reconstruction. Six PM flaps were harvested for reconstruction of head and neck defects with preservation of both the pectoral artery and lateral thoracic artery. The focal pint of swing of all six flaps was at the same point just below the mid-point of clavicle for both pectoral artery and lateral thoracic artery. The flaps can reach the oral cavity, tonsil or hypopharynx without limitation and there is no flap necrosis. In conclusion, the lateral thoracic artery can be preserved without compromising the pedicle length of PM flap. It is a recommended technique to improve the blood supply to the distal skin of PM flap.     

急诊组织瓣移植(位)修复伴有严重血管损伤的上肢复杂性组织缺损

目的 介绍急诊组织瓣移植或移位一期修复伴有严重血管损伤的上肢复杂性组织缺损的手术疗效.方法 对10例伴有严重血管损伤的上肢复杂性组织缺损的患者,在修复血管重建肢体血运的同时,根据组织缺损需要采用皮瓣、肌皮瓣、骨皮瓣甚至组织瓣组合移植的方法急诊进行一期修复.其中上臂肱动、静脉长段缺损,合并肱二头肌及上臂内侧大面积皮肤缺损,血管修复后背阔肌皮瓣移位覆盖创面并重建屈肘功能3例;肘部血管损伤合并肘关节周围大面积皮肤撕脱缺损,血管修复后移植胸脐皮瓣覆盖创面2例;前臂尺、桡动脉损伤合并皮肤肌肉缺损,血管修复后移植股前外侧皮瓣覆盖创面3例;前臂尺桡动脉损伤并尺桡骨缺损,血管修复后移植腓骨皮瓣重建尺骨缺损,二期再移植腓骨皮瓣重建桡骨缺损1例;前臂尺、桡动脉损伤合并桡骨及大面积皮肤缺损,血管修复后股前外侧皮瓣加髂骨皮瓣组合移植1例.结果 术后10例患肢及移位组织瓣全部存活.术后随访3～6个月,3例上臂损伤患者,肘关节最大屈曲度为105,屈肘肌力为M_3～M_4地,手功能恢复基本正常;肘及前臂损伤的7例患者,肢体及移植皮瓣完全存活,骨皮瓣和腕部已达骨性愈合,并恢复部分手功能.结论 对严重血管损伤且合并有复杂组织缺损的上肢损伤,急诊在施行血管修复重建肢体血运的同时,采用组织瓣单独或组合移植一期有效覆盖创面,可提高复杂性患肢的成活率,并为二期功能重建术提供良好的软组织条件.     

Closure of large orbital-maxillary defects with free latissimus dorsi myocutaneous flaps

The treatment of advanced cancer of the maxillary sinus often requires extensive ablation and orbital exenteration that results in large full-thickness defects of the upper cheek and orbital regions. Reconstruction of such defects with local flaps is usually difficult because of the need for a large flap. Several regional flaps such as the deltopectoral flap, the temporal flap, and the shoulder flap may be used, but these techniques frequently require surgery in stages and result in severe deformity of the donor site. The island pedicled, pectoralis major myocutaneous flap may be rotated up to the orbital region; however, the uncertain blood supply to the skin in the distal area of the pectoralis may cause unexpected marginal necrosis of the flap. Reconstruction of large orbital-maxillary defects can readily be accomplished in one stage using microsurgical free transfer of latissimus dorsi myocutaneous flaps. The thoracodorsal artery and vein that form the nutrient pedicle of the flap approaches 2 mm in external diameter and up to 10 cm in length, allowing greater versatility in head and neck reconstruction. The muscle may be used to fill the orbital and maxillary cavities and will accept a skin graft on its deep surface. The donor defect is closed primarily and the resulting scar is well concealed beneath the arm. If necessary, extremely large flaps may be transferred by harvesting the entire latissimus dorsi muscle and the overlying skin based on the thoracodorsal system.     

The deep inferior epigastric rectus abdominis muscle and myocutaneous free tissue transfer: further applications for head and neck reconstruction.

The rectus abdominis muscle and myocutaneous free tissue transfer is a well-recognized donor site for reconstruction of complex head and neck defects. Four composite deformities were successfully managed using this donor site. The rectus abdominis myocutaneous "sandwich" flap was used for closure of a pharyngocutaneous fistula and to provide intraoral lining and external coverage for a composite mandibular defect. The rectus muscle flap was used to obliterate a compound frontal sinus injury and an orbitomaxillary defect. All flaps were based on the deep inferior epigastric vascular pedicle.     

Venous flow-through flap as an external monitor for buried radial forearm free flap in head and neck reconstruction.

Postoperative monitoring of buried free flaps in head and neck reconstruction can be extremely difficult or impossible. The authors describe a series of 11 cases over a 21-month period, of buried radial forearm free flaps used in head and neck reconstruction. To monitor the main buried flap a small venous flow-through flap is supplied by and attached to the cephalic vein of a radial forearm free flap. This small venous skin flap is inset separately from the main paddle, so that it is visible at the external surface of the neck, furnishing information about the perfusion of the entire flap.     

游离前臂皮瓣舌再造的临床经验

目的 探讨舌癌根治术应用游离前臂皮瓣施行一期舌再造术的临床效果。方法 随访分析近3年来35例舌鳞癌根治术中应用游离前臂皮瓣施行一期舌再造的结果，总结有关处理经验和教训。结果 术后35例口腔和颈部创面均一期愈合，术后出现血管危象6例，5例抢救成功，1例失败，移植成活率97．2％。随访3个月～2年半，再造舌外形大部分较好，语言和吞咽功能恢复良好。结论 游离前臂皮瓣是舌癌根治术后舌缺损修复的良好材料，通过完善的围手术期处理，可以达到较高的成功率，提高患者的生存质量。     

Flow-through flaps: a review of current knowledge and a novel classification system

Flaps have long been recognized as an essential tool for soft-tissue reconstruction. Flaps range in complexity from local to free and perforator flaps and can include a variety of composite tissues. The concept of a flow-through flap, in which both the proximal and the distal ends of the vascular pedicle of a free flap are anastamosed to provide blood flow to distal tissues, was first described by Soutar et al. in 1983. An uninterrupted arterial flow was established by Soutar et al. between the external carotid and distal facial artery via a radial forearm flap for head and neck reconstruction (Soutar et al., Br J Plast Surg 1983;36:1-8). Shortly thereafter, Foucher et al. were the first to report the reconstruction of an extremity with a simultaneous vascular defect by utilizing a radial forearm flow-through flap (Foucher et al., Br J Plast Surg 1984;37:139-148). The utility of the flow-through flap is now well established, and its indications for use continue to grow. The principle advantage of this flap is that it provides the opportunity for a single stage composite reconstruction of both soft tissue and vascular defects, making it particularly useful in the reconstruction of ischemic extremities and defects from oncologic ablations. Improvements in microsurgical equipment and techniques are making early difficulties with these flaps irrelevant, giving plastic surgeons opportunities to become more creative in the choices and uses of flow-through flaps. The literature consists mostly of case reports and series. The nomenclature used to describe the types of flow-through flaps is confusing and inconsistent. The purpose of this article is to provide an organized review of flow-through flaps and to classify these flaps based on their inflow, outflow, and the nature of their vascular conduit. Additionally, we have included a discussion on the physiology of these flaps, reviewed the current literature, and summarized the various types of flow-through flaps in a reference guide that can aid in flap selection.     

改良桡动脉穿支皮瓣在修复额面部组织缺损中的应用

目的 探讨改良桡动脉穿支皮瓣在修复额面部中小面积缺损中的临床应用.方法 以桡动脉腕上皮支动脉和桡动脉伴行静脉为蒂.通过筋膜蒂营养的前臂近端桡侧皮瓣(最大面积10 cm×5 cm),游离移植修复额面部肿瘤切除后的组织缺损10例.结果 修复额部缺损6例,面颊都缺损4例,术后皮瓣全部存活,经随访6～12个月后行皮瓣修薄整形术.10例病例经8～18个月随访,平均随访11.3个月,其中7例于术后6～9个月进行二次整形.所有病例皮瓣柔软,瘢痕不明显,皮色与面颊部基本接近,皮瓣两点分辨率在20～40mm.结论 改良的前臂桡动脉穿支皮瓣是修复额面部中小面积缺损的主要方法之一.     

Mandibular-facial reconstruction with segmentally split serratus anterior composite flaps

Oncologic or traumatic head and neck defects with missing mandible, facial skin, and oral mucosa are especially well suited to reconstruction with a composite tissue unit, based on the subscapular-thoracodorsal vessels, that carries any combination of skin, bone, and muscle to restore vascularized skeletal structures, oral lining, and skin cover. The subscapular-thoracodorsal vascular pedicles supply segmentally split units of the lower serratus muscle and ribs on which it originates. Also, one or two skin paddles for cover and lining flaps are carried either by the cutaneous scapular and parascapular branches of the circumflex scapular vessels or by surgically split segments of the latissimus dorsi musculocutaneous flap. The composite flap can be designed in a variety of combinations to meet recipient defect needs and allow retained innervated segments of the component muscles in situ for preservation of donor motor function. The common subscapular-thoracodorsal vascular pedicle can be transferred either as a microvascular free flap or by pedicle transposition through a subpectoral-subplatysmal tunnel to the mandibular-facial defect. This versatile reconstructive unit illustrates many of the refinements of contemporary flap reconstructions.     

A new flap design for monitoring the circulation of a buried free radial forearm flap in pharyngoesophageal reconstruction

The viability of a free radial forearm flap which is used in pharyngoesophageal reconstruction is difficult to monitor because it is hidden by skin. As the most reliable method for monitoring, exteriorization of a small island flap has been reported. The authors used a skin paddle which is placed ulnar to the radial forearm reconstruction flap at the ulnar side of the distal part of the forearm as a monitor flap in one patient. Flap viability was assessed by observing tissue color, turgor, capillary refill, and bleeding of the monitor flap. This monitor flap is easy to elevate. The perfusion of the flap is good because it has a wide pedicle. It permits a long vascular pedicle for the radial forearm reconstruction flap and does not reduce available forearm skin for pharyngoesophageal reconstruction.     

Head and neck reconstruction with the deep inferior epigastric perforator flap: A report of two cases

Rectus abdominis musculocutaneous (RAMC) free flaps are preferred for head and neck reconstruction because of the abundant blood supply to the rectus abdominis musculocutaneous. In contrast, the indications for deep inferior epigastric perforator (DIEP) free flaps in head and neck reconstruction are limited. In this report, two cases of oral cavity reconstruction with DIEP free flaps are described. In both cases, the defect was reconstructed with a DIEP free flap because it could avoid functional damage to the donor site. Successful reconstruction with a two skin‐island method was performed in both patients. Furthermore, donor site morbidity was minimal in both patients. When a DIEP free flap is used for head and neck reconstruction, elimination of dead space is the most difficult problem, because a DIEP free flap does not contain well‐vascularized muscle tissue. We compensate for this disadvantage with a flap designed to include a de‐epithelialized skin flap. Although this technique is not always the first choice for head and neck reconstruction, it is suitable for patients who wish to avoid donor site morbidity. © 2009 Wiley‐Liss, Inc. Microsurgery, 2009.