The use of free prelaminated and sensate osteofasciocutaneous fibular flap in phalloplasty

SUMMARY: The aim of this study was to present our latest modified protocol on neophallus construction that we have applied in 32 female-to-male transsexuals. The applied protocol consisted of neourethra prelamination with split skin thickness grafting at the lateral donor lower leg, and neophallus construction after 6 months with the free, prelaminated, and sensate osteofasciocutaneous fibular flap, followed by urethro-urethral anastomosis. Because of initial difficulties on harvesting and positioning the fibular flap, we had 2 total and 4 partial necrosis. Ten patients had a urethral stricture, and 7 a fistula. In 6 patients a stricture expansion was required and in 5 closure of the fistula was needed. The donor-site morbidity was moderate. In conclusion, in our series this protocol proved to be the method of choice in this very demanding field of genitalia reconstructive surgery, offering an essential improvement of the quality of life of transsexual patients.     

Phalloplasty for female transsexuals with sensate free forearm flap

One of the primary goals of phalloplasty on female to male transsexuals is to void while standing. However, achieving competence of the neourethra, sensation, and rigidity of the neophallus still present a challenge. Over a 5 year period (1988–1993), 56 phalloplasties using sensate free forearm flaps were performed for 56 primary female transsexuals. The urethrocutaneous fistula rate was 38/56 and one flap totally necrosed. However, when the flap was prefabricated with a tubed graft of vaginal mucosa for the 28 cases (the later part of the series), there were less complications and a lower fistula rate within this portion of the neourethra. Although the whole procedure was time consuming, it was worthwhile and patient satisfaction was high. © 1994 Wiley-Liss, Inc.     

Mandibular reconstruction with free osteofasciocutaneous fibula flap: a 10 years experience

SUMMARY: The aim of this study was to evaluate the usefulness of the free osteofasciocutaneous fibular flap in mandible reconstruction in 23 patients. We reviewed their clinical records and asked the subjects to answer a questionnaire, as well as to attend our hospital for a clinical and radiological examination. The mean follow up was 1.3 years. In 15 patients, the flap was used for contemporaneous intraoral mucosal and extraoral cutaneous reconstruction. In seven cases, bilateral mandibular reconstruction was performed. Skin paddle edge necrosis was observed in seven flaps postoperatively, however, no total flap loss resulted. No additional soft-tissue flap was needed since the fibular flap harvested held an extended skin paddle reaching up to 352 cm(2). The donor-site morbidity was moderate and furthermore most of the patients were satisfied with their functional and aesthetic result. The free osteofasciocutaneous fibular flap is the best possible therapy for the demanding reconstruction of the mandible. The fibular bony part is a safe foundation for the placement of osseointegrated implants which further improves the patient's quality of life.     

The anatomical and neurophysiological basis of the sensate free TRAM and DIEP flaps.

Recent developments in autogenous breast reconstruction using the rectus abdominis myocutaneous free flap include attempts to reinnervate the flap tissue. We have carried out anatomical studies to determine the nature of abdominal-wall cutaneous innervation, with particular emphasis on the harvesting of sensate flaps. Dissections were performed on four embalmed and 12 fresh human cadavers (32 sides). The lowest five intercostal nerve trunks were identified and traced to the lateral border of the rectus sheath. A detailed dissection of the intramuscular course of the nerves and associated vasculature was performed. The relationship of the nerves to the vascular perforators used for rectus abdominis myocutaneous flaps was determined visually, and confirmed histologically. In contrast to previous studies, we show that nerves supplying cutaneous sensation can travel with both medial and lateral vascular perforators. In order to confirm clinically useful innervation, the abdominal flap skin of five patients undergoing TRAM flap reconstruction was stimulated electrically, and sensory recordings were made directly from the related intercostal nerve just prior to flap harvest. These studies represent, to our knowledge, the first clinical application of neurophysiological techniques to outline the perforator neurosomes of flaps based on the deep inferior epigastric vascular axis. We provide the first comprehensive study of abdominal-wall innervation with regard to sensate free-flap harvest. Our dissections show complex patterns of abdominal skin innervation that have not been previously described. The implications for sensate free TRAM and DIEP flap reconstructions, as well as the potential for more accurate inclusion of innervated flap skin, are discussed.     

Donor site morbidity after harvest of free osteofasciocutaneous fibular flaps with an extended skin island

Since 1993, a total of 41 free osteofasciocutaneous fibular flaps with an extended skin island (average dimensions, 16.9 cm long [range, 12-22 cm] x 10.7 cm wide [range, -16 cm], or 180.8 cm [range, 112-352 cm ]) have been used in by the authors in various clinical applications. To evaluate donor site morbidity, the 41 patients involved were asked to answer a questionnaire and to present themselves for clinical and radiological examination. The subjective findings reported by these patients, and the examinations, showed that donor site morbidity was moderate. Apart from some occurrence of mild edema and pain, as well as modest motor weakness of the great toe, and deficiency of distal nervous segments, only 7 patients were found to have a slightly positive anterior drawer of the talus (anterior subluxation of the talus), but no instability. In conclusion, donor site morbidity after harvest of osteofasciocutaneous fibular flaps for different clinical indications, where extended skin islands were needed, is moderate.     

Assessment of donor site morbidity for free radial forearm osteocutaneous flaps

Purpose: Assessment of donor site morbidity and recipient site complications following free radial forearm osteocutaneous flap (FRFOCF) harvest and evaluation of patient perceived upper limb disability for free radial forearm osteocutaneous versus fasciocutaneous flaps (FRFF). Methods: First a case series was undertaken of 218 patients who underwent an FRFOCF at two tertiary referral centers between February 1998 and November 2010. Outcomes included forearm donor site morbidity and recipient site complications. Second, the disability of the arm, shoulder, and hand (DASH) questionnaire assessing patient perceived arm disability was administered by phone to 60 consecutive patients who underwent an FRFOCF or FRFF. Results: Mean patient age was 63 years with male predominance (62.8%). Median bone length harvested was 8 cm (range, 3–12 cm) with prophylactic plating of the radius following harvest. Donor site morbidity included fracture (1 patient, 0.5%) and sensory neuropathy (5 patients, 2.3%). Mean DASH scores were comparative between groups and to established normative values. Mandibular malunion rate was 3.2% and hardware extrusion at the recipient site occurred in 15.6%. Conclusion: Reluctance to perform FRFOCF by surgeons usually centers on concerns regarding potential donor site morbidity and adequacy of available bone stock; however, we identified minimal objective or patient perceived donor site morbidity or recipient site complications following harvest of FRFOCFs. Mild wrist weakness and stiffness are common but do not impede ability to perform activities of daily living. Data from this and other reports suggest this flap is particularly useful for midfacial and short segment mandibular reconstruction. © 2012 Wiley Periodicals, Inc. Microsurgery, 2012.     

Autocannibalization of sensate and denervated rat groin flaps

The extent to which rats self-mutilate was studied in 30 Sprague-Dawley rats. The experiment tested unilateral and bilateral sensate and denervated groin flaps, with statistically significant results obtained between the bilateral groups.     

Double-barrel free fibula flap for treatment of infected nonunion of both forearm bones

Free vascularized bone transfer is a viable treatment option for extensive bony defects greater than 6 to 8 cm involving scarred, poorly vascularized, or infected recipient beds, such as in chronically infected nonunion of the radius and ulna treated with a double-barrel free fibula flap. Both patients reported here experienced bony union with significant resolution of their symptoms. Although range of motion improved following an aggressive physical therapy regimen, pronation was adversely affected. Chronic infected nonunions or nonunions from radionecrosis involving large segmental defects of both forearm bones are a truly unique challenge and must be treated aggressively to ensure any useful long term function of the injured limb.     

Clinical and instrumental evaluation of implant stability after free fibula flaps for jaw reconstruction

Osseointegration is a direct union between bone and an allograft with no soft tissue interposition. It represents the morphological basis of secondary stability. Introduction of Resonance Frequency Analysis (RFA) as a commercially available technique has made it possible to measure implant stability as an Implant Stability Quotient (ISQ) unit at any time during the course of implant treatment and loading. The study aims to clinically and objectively analyze the stability of implants loaded upon revascularized free fibula flaps on patients who underwent maxilla or mandible reconstruction following trauma, oncological resection or class V–VI Cawood's atrophy treatment. Of the 105 patients that underwent jaw bone reconstruction with free fibula flaps in our division between 1993 and 2003, 37 were eligible for implant-supported dental rehabilitation. Of these, the last 12 were selected and included in the study. Primary and secondary implant stability assessments involved a clinical evaluation, radiograms and RFA measurements using the Osstell (Integration Diagnostics, Savedalen, Sweden) at the time of implant insertion, at 6 months and at 1 year of functional loading. 76 implants were loaded in 12 patients. All of them were clinically stable at each evaluation. Radiograms showed modest bone resorption after 1 year of functional load in 16 implants (21%). Implant stability levels ranged from 48 to 74 ISQ (mean 59.9±7.8 ISQ) at 6 months. At 1 year, the mean ISQ level was higher (62.6±7.2) but still coherent according to the radiographic evidence. Implant-supported dental rehabilitation of the reconstructed jawbone is not always possible. Free fibula flap represents a good substrate for implant osseointegration being a bicortical bone capable of structural remodelling after masticatory load enhancement. When possible, instrumental evaluation of implant stability with RFA and supported by radiograms represent the best objective way to assess osseointegration as a clinical evidence alone is unable to offer a definitive assessment.Presented at the 16th Annual Meeting of the European Association of Plastic Surgeons (EURAPS), May 26–28, 2005, Marseille, France.     

An effective pharyngoesophageal reconstruction with free radial forearm flaps

Summary Treatment of cancer of the cervical aerodigestive tract is challenging due in part to the difficulty in reestablishment of pharyngoesophageal continuity after resection of the involved tract. From May 1989 to August 1990, six patients underwent immediate reconstruction utilizing microvascular transfer of free radial forearm flaps following resection of pharyngoesophageal neoplasms. A small island flap connected to the radial vascular pedicle by fasciocutaneous branch was used to monitor the vascular condition of the hidden fabricated free forearm flap. Stricture is the most troublesome complication of esophageal reconstruction using a conventional free forearm flap. Two small triangular flaps were designed and inserted bilaterally in the distal anastomosis of both lateral esophageal walls to prevent circular contracture. The outer layer sutures were anchored to surrounding rigid structures to withstand shrinkage and circular contraction. The problem of stricture was solved by these procedures. This one-stage, easily monitored operation for pharyngoesophageal reconstruction is considered to be as useful as a free jejunal transfer.     

Analysis of radial forearm free flaps in 37 consecutive cases

Thirty-seven radial forearm free flap transfers have been performed in a three year period. The results obtained have proven that the radial forearm free flap, a pioneer in free flaps, is going to keep its useful position in reconstructive procedures. Out of 37 cases there was only one total flap loss (2.7%). Other complications experienced arose from the donor site; two partial skin graft losses and one transient radial nerve injury. Preparation of a better recipient bed for split skin grafting and application of silicone sheeting also reduced the morbidity of donor defect. Received: 21 October 1996 / Accepted: 29 January 1997     

Functional total and subtotal heel reconstruction with free composite osteofasciocutaneous groin flaps of the deep circumflex iliac vessels

Functional and esthetic reconstruction of the bony and tendinous structures with a stable, sensate soft tissue integument after complex posttraumatic defects of the heel is demanding. Cases are rare in the literature and hardly comparable due to their heterogeneity. The reconstructive approach has to consider both patient profile and the reconstructive tree, with free microvascular flaps playing a primary role. The goals are the reconstruction of both osteotendinous structures and slender soft tissue lining for proper shoe fitting for ambulation and mechanical and thermal protection. The flap should be sensate in weightbearing areas to optimize gait and to prevent long-term complications by ulcers. The osteofasciocutaneous deep inferior circumflex artery (DCIA) flap is especially suitable for complex heel defects with subtotal or total loss of the calcaneal bone as all components (iliac bone, groin skin, and fascia lata) can have a wide range of size and shape. We operated on 2 cases with this variable composite flap. One patient had a complete heel defect by war shrapnel. The complete calcaneus, soft heel, and Achilles tendon were reconstructed. The second patient had an empty os calcis after a comminuted fracture and a lateral crush-induced soft tissue defect. In both patients, a stable wound closure, osseous integration, and weightbearing ambulation could be achieved.     

Reinnervated radial forearm free flaps in head and neck reconstruction.

The radial forearm flap has proved to be a reliable free flap for intraoral reconstruction after major head and neck ablative surgery for cancer. In contrast to the myocutaneous flap, it is thin and flexible, and as a result, it is better suited to conforming to the irregular surface which remains over an intact or restored mandible. A criticism of both techniques however, is that while the flap effectively fills the defect, it serves as an insensate reservoir in which food and saliva can collect. A modification of the reinnervated radial forearm free flap is presented, with discussion of its use in three patients, following extensive resection of the floor of the mouth and tongue.     

游离髂骨皮瓣在前臂复杂性外伤中的应用

我们自1999年以来，急症采用以旋髂深动脉为蒂的髂骨皮瓣修复此类创伤9例，取得良好效果，现介绍如下。     

Usefulness in combined free anterolateral thigh and vastus lateralis muscle flaps

Background

The anterolateral thigh flap has been a popular flap in reconstructive surgery. However, the details concerning the anterolateral thigh flap combined with the vastus lateralis muscle flap have not been reported. We described the surgical procedures, complication of the donor site, and advantages and disadvantages of this combined flap.

Methods

We analyzed 29 patients who underwent reconstruction with an anterolateral thigh flap–vastus lateralis muscle flap.

Results

The recipient sites were in the head and neck area (n?=?25), extremities (n?=?3), and trunk (n?=?1). The vastus lateralis was used as a muscle flap in 28 cases. The rectus femoris was harvested in one case because the vastus lateralis could not be harvested with a skin flap. Four cases required two vastus lateralis muscle flaps with a skin flap. Partial ischemia of the muscle flap occurred in one case. Additional donor-site surgery was required in two cases. No donor-site dysfunction was observed in our series.

Conclusion

This combined flap is advantageous in that the volume and number of muscle flaps can be adjusted and the skin and muscle flaps can be placed in separate positions. Although harvesting this flap is safe and not difficult, attention should be paid to anatomical variations of the vascular pedicle supplying the skin and muscle flap and to the circulation of the muscle flap. Level of Evidence: level IV, therapeutic study.