Closure of craniofacial defects after cancer resection

Resection of malignancies of the upper face and skull base may result in complex bone and soft tissue defects. To better define the optimal management of these defects, we conducted a retrospective review of 75 consecutive patients who underwent closure of 76 craniofacial defects after malignant tumor excision from 1966 to 1990. Wound complications requiring further surgery occurred in 30% of the defects (23 of 76). Wound complications at anterior, temporal, or combined sites were correlated with each method of reconstruction (scalp flap or split thickness skin graft, pedicled myocutaneous flap, and free flap). The presence of a large combined defect involving both frontal and temporal areas was the only significant risk factor for development of a wound complication requiring secondary surgery. These data suggest that anterior or temporal craniofacial defects may be closed with either scalp flaps and split thickness skin grafts or pedicled myocutaneous flaps with reasonable wound complication rates of 16% to 22%. Large combined defects have high wound complication rates (90%) when local tissue is used; therefore, other methods of closure such as free tissue transfer should be strongly considered in these patients.     

Histomorphometric analysis of intraoral split-thickness skin grafts.

Transposition of split-thickness skin grafts from the anterior thigh to the oral cavity is an ideal method for reconstruction of selected defects following major oncologic ablative surgery. This alternative potentially allows for tongue mobility, deglutition, and articulation superior to that obtained with bulky adynamic myocutaneous flaps. We have examined the adaptive responses of split-thickness skin grafts to the intraoral environment with biopsies from 10 patients 11 to 90 months following oral cavity reconstruction. Histologic examination of intraoral skin grafts shows preservation of the cytoarchitecture of the epidermis, an absence or atrophy of skin appendages, and a statistically significant thinning of the keratin layer. A "junctional zone" between the normal oral cavity mucosa and the skin graft was identified. This zone is characterized by an abrupt transition from keratinized stratified squamous epithelium with a prominent granular layer, to nonkeratinized stratified squamous epithelium lacking a granular layer. This study clearly demonstrates that split-thickness skin, when transposed to the oral cavity, maintains the epidermal phenotype and does not assume the histologic characteristics of mucosa.     

Reconstruction of extensive defects of the cranium using free-tissue transfer

Fourteen patients with large tissue deficits in the calvarium and orbits were reconstructed using microvascular free-tissue transfer (15 flaps). The etiology of these defects was skin neoplasms (seven), osteomyelitis (four), burn (two), and trauma (one). The free flaps used were the latissimus dorsi muscle flap with a split-thickness skin graft (seven), latissimus dorsi myocutaneous flap (two), rectus abdominis myocutaneous flap (three), radial forearm fasciocutaneous flap (two), and split-iliac crest flap (one). There was one postoperative death, one flap failure, two recurrences of neoplasm, and one loss of bone grafts and flap from infection. The free flaps can offer good results in patients undergoing wide resection in the cranium and orbits providing immediate repair with acceptable cosmetic result, minimized morbidity, and short hospitalization. However, immediate reconstruction following tumor resection carries a danger of positive margins discovered on permanent histologic sections or the difficulty in detecting recurrence underneath a bulky free flap.     

Intraoral and oropharyngeal reconstruction using a de-epithelialized forearm flap

We have used free forearm flaps for closure of various intraoral and oropharyngeal defects after radical ablation of tumors. A problem remained, however, in that split-thickness skin grafts required to close the forearm defect had to be obtained from other areas. To avoid this disadvantage, we de-epithelialized forearm flaps and the donor defects were closed with the split-thickness skin obtained from flap de-epithelialization. As a result of this procedure, unnecessary scarring has been avoided and postoperative management has been simplified. Such complications as flap loss, fistulae, or scar contracture have not occurred with greater frequency than is seen in normal circumstances. The de-epithelialized forearm flap procedure is explained. Histological findings concerning the de-epithelialized forearm flap are described, and the advantages of this method stated.     

Microvascular free muscle reconstruction of a large plantar defect

Large plantar defects present a difficult problem in reconstructive surgery. Skin grafts are not durable and most distant flaps are too bulky to allow for ambulation in conventional footwear. Free muscle transfer with skin graft may represent a modality to provide a contoured and durable reconstruction for large plantar defects when local tissue is not available. This study presents a case of sole of foot and distal heel reconstruction with a free microvascular latissimus muscle transfer. The transfer was contoured to fit the defect and then covered with a split-thickness skin graft. Three months following surgery, the patient was walking without assistive devices and using conventional footwear. Now, two and one-half years after surgery, he is employed full-time in a job that entails walking, and has never experienced a tissue breakdown.     

腓骨肌腱鞘筋膜瓣与脂肪筋膜瓣联合转移修复足跟后深度组织缺损

目的探索一种新的局部组织瓣修复足跟后深度组织缺损的方法及效果。方法于小腿下段,外踝腓外侧筋膜间隙,设计切取腓骨肌腱鞘筋膜瓣与脂肪筋膜瓣联合转移,最大筋膜瓣6cm×13cm,覆盖跟腱及跟骨裸露缺损,在其上移植全厚皮片或中厚皮片修复。结果2004至2005年11月,修复足跟后组织缺损6例。修复最小缺损3·5cm×4·0cm,最大4cm×6cm。术后转移筋膜瓣,移植皮片完全存活。随访3个月至1年11个月,供受区稳定愈合,功能形态恢复满意。结论腓骨肌腱鞘筋膜瓣与脂肪筋膜瓣联合转移加皮片移植法,就近取材,供区损伤小,筋膜瓣薄,柔韧滑润,血运恒定丰富,手术时间短,为小腿下段足跟后难愈性中、小面积缺损提供了一种新的简便、可靠的修复方法。     

Histologic changes in skin implanted into the larynx and trachea by myocutaneous flap reconstruction

Skin is the tissue most readily available for relining the walls of the reconstructed larynx or trachea. Its use has been condemned in the past because of potential contracture, complications have occurred when free, split-thickness grafts were used. We studied the changes that develop within skin that is transferred into the lumen of the airway as part of a vascularized sternohyoid myocutaneous flap. Twenty-one dogs underwent reconstruction of laryngotracheal defects by a vascularized myocutaneous flap. The closely shaved and chemically depilated skin included in this reconstruction was ultimately found to be well healed to the adjacent mucosa. Flaps as large as 8 cm2 survived with no evidence of scaling, crusting, or contracture. The cutaneous appendages in the flaps were compared with those found in adjacent skin near the donor site. After proper depilation there was involution of cutaneous appendages. Scarring of the dermis appeared to add support to the grafts. Our findings demonstrate that the rotary door sternohyoid myocutaneous flap is a reliable, well-vascularized flap that can have extensive application in laryngotracheal reconstruction.     

Limb-salvage by Femoro-distal Bypass and Free Muscle Flap Transfer

OBJECTIVES: To evaluate the feasibility and long-term outcome of distal arterial reconstruction combined with free muscle flap transfer for patients who would otherwise have undergone major amputation. METHODS: Between 1996 and 2001, 27 reconstructions using autologous vein were performed in 25 patients. Seventeen of these patients had diabetes mellitus. Gracilis, rectus abdominis and latissimus dorsi muscles were used as free flaps, covered with split-thickness skin grafts. RESULTS: Eighty-five percent of patients had a patent graft and viable muscle flap after 1-month. Mean follow-up was 51 months (4-72 months). At the time of follow-up 77% of reconstructions were patent and 70% of patients regained full functional capacity of their lower extremities. CONCLUSION: Limb-salvage by distal arterial reconstruction and free muscle flap transfer, is feasible with low mortality and morbidity and provides excellent long-term results with regard to graft patency and functional status.     

Free latissimus dorsi flap transfer for subtotal scalp and cranium defect reconstruction: report of seven cases

The purpose of this paper is to review the results of free latissimus dorsi transfer for scalp and cranial reconstruction in the case of large defects with exposed brain tissue, cranial bone without periosteal cover, and dura, which cannot be reconstructed with local flaps or skin grafts. Free latissimus dorsi transfer was carried out in seven patients with subtotal and total scalp defects (two reconstruction after tumor removal, two reconstructions after long-standing osteitis, two tissue breakdown after irradiation, one defect reconstruction after high voltage injury). There were three male and four female patients. The age ranged from 36 to 72 years. Reconstruction was performed with a muscle flap (1) or a myocutaneous flap (6) in combination with a split-thickness skin mesh (1:1.5) graft in a single-stage procedure. In a retrospective clinical study, the following criteria were evaluated: (1) flap healing, (2) aesthetic result, and (3) complications. All flaps healed primarily, and all wounds remained closed without any signs of infection. Complete wound healing was achieved after 4 to 8 weeks, depending on the “take” of the skin grafts. Secondary skin grafting was necessary in two patients, while revision of the donor site was necessary in two patients. From an aesthetic point of view, four patients complained about the appearance of the retroauricular skin island. After removal of the skin island 6 months after the initial operation, all patients judged the result as good or acceptable. Besides the free omentum flap, the free latissimus dorsi transfer is the only option for cover of subtotal or total scalp defects. Compared to the omentum flap, the latissimus dorsi offers more tissue, has less donor site morbidity, and secondary surgery such as cranial bone reconstruction is possible. Contrary to most authors, our preferred donor vessels are maxillary artery and the external jugular vein. To avoid any vascular compression, we use a myocutaneous flap. The skin island must be removed secondarily. In patients where no bone reconstruction is possible or planned, the de-epithelialized skin paddle can be used for correction of a contour defect.This work was presented at the Spring Meeting of the Belgian Society for Plastic, Reconstructive and Aesthetic Surgery, May 8, 2004 in Ghent, Belgium.     

Reconstruction of large intraoral and adjacent cheek defects by free radial forearm flap

Summary Eighteen patients with intraoral and oropharyngeal carcinoma were treated by radical excision for extensive infiltration of tumour into adjacent tissue. Defects were repaired by free radial forearm flaps. Three patients had bony defects in addition to mucosal and skin defects. The free flap can be easily folded to repair skin and mucosa simultaneously. We consider the free forearm flap to be the procedure of choice in selected cases of large intraoral and adjacent cheek defects.     

Free adipofascial flap for scalp reconstruction: case report

The authors describe a case in which a large defect of the scalp was present after tumor excision. It was covered with a free adipofascial flap and a split-thickness skin graft, with satisfactory results. Numerous similar cases of scalp defects reconstructed with other free flaps have been described. But since donor-site morbidity is minimized with free adipofascial flaps, they should be used more often for reconstruction of scalp defects.     

Cross-foot island instep flap: a new use of instep skin flap for management of persistent wounds after complex plantar foot reconstruction

When presented with an extensive soft-tissue defect involving the sole of the foot, reconstruction with free muscle flaps covered by a split-thickness skin graft is the proposed method of treatment. However, persistent graft breakdown and a chronic wound of the weight-bearing flap is a challenging problem during the late postoperative period, as experienced by the authors in their patients with high-energy-induced lower extremity injuries. The authors used the instep flap as an island cross-foot flap to manage persistent graft breakdown that involved skin-grafted muscle flaps transferred previously to the heel in 3 patients and to treat a chronic wound involving an amputation stump in 1 patient. The vascular pathology of the injured extremities indicated a cross-leg procedure instead of a free flap transfer. Pedicles were wrapped with split-thickness skin grafts and flaps were harvested superficial to the plantar fascia. Pedicles were divided during postoperative week 3, and no complications related to the operation or to immobilization have been encountered during the postoperative follow-up. During the 1-year follow-up, durable coverage, free from development of open wounds, has been achieved, and patients have expressed their satisfaction. In the case of complicated, high-velocity foot injuries, the authors suggest that this procedure be kept in mind as an alternative treatment option because it has some advantages over conventional cross-leg procedures.     

多指背侧皮肤和指骨复合缺损的修复与功能重建

目的探讨多指外伤近端背侧皮肤和指骨复合缺损的修复方法与疗效。方法1996年6月～2005年3月收治6例多指近端背侧皮肤和指骨复合缺损患者,累及2指者3例,3指者2例,4指者1例。一期采用游离髂骨移植分别重建各指骨缺损,然后行游离皮瓣移植修复,其中采用足背皮瓣4例,上臂外侧皮瓣1例,胸外侧皮瓣1例。二期行分指术同时做皮瓣部分修薄整形,3例患者另行伸指功能重建术。结果6例患者术后获6个月～9年(平均2年8个月)随访,移植皮瓣全部成活,经二期皮瓣修薄整形后指背修复、外形美观,随访手部X线片示游离髂骨移植成活良好、具有正常指骨形态特征。3例患者肌腱移植重建指伸肌腱功能后远节指间关节仲直功能恢复。结论髂骨移植修复多指指骨缺损和游离皮瓣移植覆盖是修复多指外伤背侧皮肤和指骨复合缺损的有效方法,后期皮瓣整形能他伤指恢复美观,伸指功能重建有助于恢复远节指间关节的功能。     

小腿内侧游离皮瓣修复舌根癌切除后缺损

目的 探讨小腿内侧游离皮瓣在舌根癌术后缺损修复中的应用.方法 应用小腿内侧游离皮瓣,对4例舌根癌切除术后缺损进行修复,对该皮瓣的应用解剖,制作技术及其优缺点进行了阐述.结果 4侧小腿内侧皮瓣均获得成功.口内外伤口均愈合良好.移植于小腿内侧供区皮肤缺损区的皮片全部成活.结论 小腿内侧皮瓣适用于舌根及口咽部组织缺损的修复,对于口腔颌面部肿瘤术后的软组织缺损,可利用携带部分比目鱼肌的小腿内侧肌皮瓣修复并填充软组织缺损.小腿内侧游离皮瓣的皮下脂肪薄,皮瓣较柔软且远离术区,术后供区隐蔽,损伤小.     

Defektdeckung durch freie Lappenplastiken am Fußrücken

Background

Large complex soft-tissue defects on the dorsum of the foot, with exposed tendons, joints, bones, nerves and vessels, have to be reconstructed by transplantation of free tissue grafts with good blood flow.

Patients and methods

Evaluation of 19 patients with an average age of 38 years who underwent closure of defects on the dorsum of the foot with free muscle flaps (with split-thickness skin grafts) in 14 cases and with free fasciocutaneous flaps in 5 is presented. In 10 patients a gracilis muscle flap was used, in 4 patients a latissimus dorsi flap, and in 2 patients a groin flap, while in 1 patient each an anterolateral thigh flap, an anteromedial thigh flap and a lateral arm flap was used. The aesthetic outcome was evaluated with reference to skin texture, pigmentation, thickness of the free flap and scar formation. The Stanmore system was used to determine the postoperative functional results.

Results

On average, patients were followed up for 29 months. We had no flap loss. A flap debulking procedure was performed in 6 patients. Better aesthetic results were obtained with muscle flaps plus skin graft than with fasciocutaneous flaps. Functional results were excellent in 6 patients, good in 5 and poor in 8 patients.

Conclusion

Free muscle flaps with skin grafts, particularly the free gracilis muscle flap, are superior to fasciocutaneous flaps and perforating flaps in aesthetic outcome and donor site morbidity.     

Immediate full-thickness facial defects reconstruction using the radial forearm free flap

Summary The restoration of composite tissue defects of the oral cavity involving skin and mucosa remains a difficult problem for reconstructive surgeons. A method for immediate one-stage reconstruction of combined intraoral and facial defects with the radial forearm free flap is described. Four patients operated on between July and December of 1991 for advanced squamous cell carcinoma of oral cavity involving oral mucosa, skin and in two cases the mandible were reconstructed with a radial forearm flap to obtain reconstruction of facial and intraoral mucosa. The area of the fold is deepithelialized to be sutured to adjacent tissue.     

Limb salvage of infected diabetic foot ulcers with microsurgical free-muscle transfer

This study was comprised of 9 diabetic patients with 10 infected foot ulcers, including osteomyelitis in 4 limbs and gangrene in 3 limbs. Adequate debridement of these complicated wounds inevitably resulted in exposure of bones or tendons. All defects were successfully reconstructed with free gracilis muscle flaps covered with split-thickness skin grafts. No recurrence of ulcer or infection was noted in the muscle-transplanted area during the follow-up period. Laser Doppler perfusion monitor measurement showed that the perfusion unit of the denervated free muscle flap increased to a peak at the second week after transplantation; the neovascularization of the grafted skin, the progressive decrease of the muscle swelling, and the decreased interstitial pressure may be the main contributing factors. The perfusion unit of the muscle flap reached equilibrium with the surrounding tissue at about 8 weeks after microsurgical transfer. Lower extremity amputation is a major health problem in the diabetic population. The microvascular free-muscle transfer was proved to play an effective and important role in limb salvage in diabetic patients with infected foot ulcers. The gracilis muscle flap was recommended due to its lack of bulkiness and minimal donor site deformity.     

Reconstruction of burned lower extremities by free flaps

Summary Three latissimus dorsi muscle flaps with skin grafts, one latissimus dorsi myocutaneous flap, and one scapular flap were used in reconstruction of deep burns of the heels and calf caused by various agents. The follow-up period was 11 to 46 months. Of the five patients treated, two sustained electrical injuries, two had contact burns and one suffered a degloving injury with a contact burn resulting from a car accident. The latissimus dorsi muscle flaps with skin grafts gave excellent results in reconstruction of the calf and ankle areas due to their large caliber vessels and versatility. The latissimus dorsi myocutaneous flap was indicated in a case with extensive soft tissue loss on the sole of the foot with stiffness of the ankle joint in plantar flexion. A non-sensory scapular flap was satisfactory for reconstruction of the medial half of the heel since the remaining lateral half of the heel provided adequate sensation for weight-bearing and protection. Early reconstruction of the burned lower part of the leg with free flaps shortens hospitalization and prevents further extension of the injury. Reconstruction of a burned distal lower extremity provides a challenge for the reconstructive surgeon due to limited availability of local tissue; there is durable soft tissue in the weight-bearing area and a relatively poor blood supply compared to other areas of the body. The basic requirement in the treatment of a full thickness burn is early debridement and immediate coverage of the defect with a skin graft or a well vascularized flap. Even though multiple local flaps, such as axial [7, 17], muscle [1], musculocutaneous [5], fasciocutaneous [11], and island flaps [4], have been described. These flaps are useful in relatively small wounds with undamaged sourrounding tissues. Electrical injuries are manifested in a variety of clinical and pathologic ways with early, as well as delayed, tissue damage complicating reconstruction. With the advent and refinement of microvascular techniques, it has become possible to reconstruct extensive defects of the distal lower extremity with either free muscle flaps with skin grafts [8], myocutaneous free flaps [10], or axial free flaps [18]. This paper relates our experience in reconstruction of extensive defects of the lower extremities caused by various burning agents.     

Foot reconstruction using free microvascular muscle flaps with skin grafts

Free muscle flap transfer with skin graft coverage for extensive foot defects can be a successful form of foot reconstruction in well-selected patients who have overall normal foot innervation and deep pressure sensibility. Cutaneous sensibility does not appear to be necessary to maintain a functional or well-healed foot. The major reconstructive goal in plantar foot reconstruction is the restoration of weight-bearing during normal ambulation using regular foot apparel. Based on this reconstructive goal, the authors present their current approach in the reconstruction of extensive defects of the foot using free microvascular muscle flaps with skin grafts.     

游离肩胛区骨皮瓣在舌和口底及下颌骨联合缺损修复中的应用

目的：介绍游离肩胛区骨皮瓣在舌、口底和下颌骨缺损修复中的临床实践。方法：应用肩胛区骨皮瓣游离移植修复因舌癌行扩大根治切除术后的舌、口底、下颌骨联合缺损病人2例,术中根据下颌骨、牙槽、口底和舌缺损的大小设计肩胛区骨皮瓣;术中顺向或逆向寻找血管蒂,掀起肩胛区骨皮瓣,游离移植于口内,吻合血管,固定肩胛骨瓣于颌骨缺损内,将皮瓣与口内缺损创缘缝合,覆盖牙槽、口底、再造舌。结果：骨皮瓣全部成活。患侧颌面形态和舌外形恢复满意。其中1例患者术后5天死亡,死因疑为消化道大出血。结论：肩胛区骨皮瓣具有血管恒定、切口隐蔽、对供区功能影响小、可供组织种类和组织量多、修复范围广等特点,是修复头颈部复合缺损的一种比较满意的方法。