Flow‐through omental flap to free anterolateral thigh flap for complex chest wall reconstruction: Case report and review of the literature

Despite the options currently available for chest wall reconstruction, patients with complex composite defects may still pose a significant challenge for the reconstructive surgeon when only using conventional methods. In particular, prior radiotherapy and/or large en bloc resection may leave inadequate regional flaps and recipient vessels for free tissue transfer. Here, we describe a case in which we reconstruct a 14 cm × 18 cm complex chest wall defect, secondary to tumor resection and infected sternum debridement, with a pedicled flow‐through omental flap to a 14 cm × 22 cm free anterolateral thigh flap using the omental gastroepiploic vessels as recipient vessels. Reconstruction was successful with excellent flap viability, and no complications at recipient or donor sites. We review the literature on complex chest wall reconstruction and introduce this valuable option of utilizing a pedicled omental flap as a flow‐through flap to a free flap for patients without viable recipient vessels or local flaps. © 2015 Wiley Periodicals, Inc. Microsurgery 36:70–76, 2016.     

Reconstruction of full‐thickness cheek defect with chimeric facial artery free flap: A case report

Full‐thickness cheek defects represent a difficult challenge for reconstructive surgeons. Multiple techniques have been described, including local, regional, and free flaps. In this report, the reconstruction of a through and through left cheek defect, resulting from a self‐inflicted gunshot injury, with a chimeric facial artery free flap is presented. The patient underwent reconstruction with a chimeric full‐thickness facial artery free flap, with 9 × 3 cm diameter skin paddle and a 6 × 5 cm myomucosal paddle, was harvested on the contralateral cheek with a 7‐cm length of facial pedicle. The flap was transferred via a microsurgical technique and an end‐to‐end microsurgical anastomosis was performed between the donor and the contralateral facial vessels. The flap was transplanted successfully and there were no donor or recipient site complications with a satisfactory esthetic result 5 years after surgery. This technique may be a good reconstructive option for medium size, full‐thickness, cheek defects allowing a “like with like” reconstruction with minimal donor‐site morbidity.     

Use of a 72‐cm‐long extended bilateral deep inferior epigastric artery perforator free flap for reconstruction of a lower leg with no suitable recipient vessel around the injury zone: A case report

In free‐flap reconstruction of the lower extremity, due either to trauma or pre‐existing vascular disease, healthy vessels may not be readily available in the proximity of the defect. A variety of options including a cross‐leg free flap, vein grafts, arteriovenous loops, and “bridging” flaps have been used to address the issue. The purpose of this report is to present a case in which a 72‐cm long extended bilateral deep inferior epigastric artery perforator (DIEP) free flap was used for coverage of a 20 × 25 cm soft tissue defect of the lower leg following a Gustilo grade IIIC fracture in a 29‐year‐old man. Because usable recipient vessels were far from the zone of injury, and to avoid complications accompanying long vein grafts, a long flap was necessary. The exposed tibia required coverage with a free flap, but peripheral portions of the defect with exposed muscles could be covered with a skin graft. Thus, a 72 × 12 cm flap was chosen. The flap was based on both bilateral DIEPs and on the superficial circumflex iliac artery (SCIA). The flap survived completely with no complications. After one debulking surgery, the flap and the donor site showed pleasing cosmesis, and the patient could walk without crutches at 18 months after the first surgery. In cases where no healthy recipient vessels can be found close to the defect, we believe that the use of an extended bilateral DIEP flap may be a feasible option which shortens or precludes vein grafts with no additional flap donor sites.     

Reconstruction of extensive abdominal wall defect using an eccentric perforator‐based pedicled anterolateral thigh flap: A case report

Reconstruction of extensive abdominal wall defects is a challenge for reconstructive surgeons. In this report, a case of reconstruction of a large abdominal wall defect using an eccentric perforator‐based pedicled anterolateral thigh (ALT) flap is presented. A 30‐year‐old man presented with recurrent desmoid‐type fibromatosis in the abdominal wall. The recurrent tumor was radically excised, and the en bloc excision resulted in a full‐thickness, large abdominal wall defect (25 cm × 20 cm). An eccentric perforator‐based pedicled ALT flap, including wide fascial extension, was transferred to the abdominal defect; fascial portions were sutured to the remnant abdominal fascia. Plication of the fascia along the sutured portion was performed to relieve the skin tension between the flap and the marginal skin of the abdominal defect. Eight months after surgery, the reconstructed abdomen had an acceptable esthetic appearance without tumor recurrence or hernia. The use of an eccentric perforator‐based pedicled ALT flap may be an alternative method for the reconstruction of extensive abdominal wall defects. © 2013 Wiley Periodicals, Inc. Microsurgery 33:482–486, 2013.     

Bilateral pedicle anterolateral thigh (ALT) flap combined with bilateral sartorius muscle flap for reconstruction of extensive perineoscrotal and medial thigh defect because of Fournier's gangrene

Fournier's gangrene is an acute and potentially lethal necrotizing fasciitis that can lead to extensive defects of the perineoscrotal area and lower abdominal wall as well. Such defect poses challenging tasks for both functional and cosmetic reconstruction. Local perforator pedicle flaps and muscle flaps can be employed and combined for such a reconstruction. In this report we present a case of reconstruction of a massive perineoscrotal and upper medial thigh defect because of Fournier's gangrene using a bilateral pedicle anterolateral thigh (ALT) flap and sartorius muscle flap. A 61 year‐old male who suffered from Fournier's gangrene resulted in a perineal, scrotal, and medial thigh defect of 27 × 30 cm² with exposure of the femoral vessels. A bilateral pedicle ALT flap measuring 30 × 9 cm² based on two perforators and a bilateral sartorius muscle flap were harvested for soft tissue defect reconstruction and inguinal vessels coverage, respectively. The flaps survived completely, with no recipient or donor site morbidity. The length of follow‐up was 6 months and was uneventful. A bilateral pedicle ALT flap combined with bilateral sartorius flap may be considered as a valid and safe option for an extensive inguinal and perineoscrotal reconstruction in selected cases. © 2016 Wiley Periodicals, Inc. Microsurgery 37:669–673, 2017.     

Muscle-sparing abdominal free flaps in head and neck reconstruction

BACKGROUND: Our aim in this retrospective case series was to review the indications, results, and complications of abdominal muscle-sparing free flaps in head and neck cancer reconstruction. METHODS: A retrospective review of all head and neck cancer defects reconstructed with abdominal muscle-sparing free tissue transfers from 1999 to 2004 was performed. Data collected included patient demographics, etiology and site of the defect, reconstructive technique, flap size, recipient vessels, complications, reconstructive technique, and clinical follow-up. RESULTS: Sixteen patients underwent reconstruction with the deep inferior epigastric perforator (DIEP) flap (n = 11), the superficial inferior epigastric artery (SIEA) flap (n = 4), or the superficial circumflex iliac artery (SCIA) flap (n = 1). Average age was 61 years (range, 41-77 years). The average hospital stay was 7.6 days (range, 6-14 days). The average defect size was 74.5 cm(2) (range, 30-240 cm(2)). No subsequent abdominal wall hernias or other donor site complications occurred after a mean follow-up of 21 months. CONCLUSIONS: Muscle-sparing abdominal free flaps are attractive options for head and neck cancer reconstruction. The SIEA and SCIA free flaps have the distinct advantage of eliminating abdominal hernias and other morbidity related to the excision of rectus abdominus fascia or muscle. In addition, the incisions are very low on the abdomen and are more cosmetically pleasing to the patient.     

Simultaneous deep inferior epigastric and bilateral anterolateral thigh perforator flap reconstruction of an extended perineoscrotal defect in Fournier's gangrene: A case report

Fournier's gangrene is lethal necrotizing fasciitis that involves the perineum and external genitalia. We describe the case of a 52‐year‐old man with Fournier's gangrene who underwent reconstruction of an extensive perineoscrotal defect using three pedicled perforator flaps. Three debridement procedures resulted in a skin and soft tissue defect of 36 × 18 cm involving the perineum, scrotum, groin, medial thigh, buttocks, and circumferential perianal area and left the perforating arteries originating from these locations unavailable for reconstruction. We repaired the defect using left deep inferior epigastric artery perforator (DIEP) (29 × 8 cm) and bilateral anterolateral thigh perforator (ALT) flaps (35 × 8 cm and 22 × 7 cm). The flaps reached the defect without tension, and the defect was successfully covered without a skin graft. No postoperative complications occurred except for epidermal necrosis involving a tiny part of the DIEP flap tip. Nine months postoperatively, the patient experienced no impairment of bowel function or hip joint movement. There was also no avulsion or ulceration of the reconstructed perineal skin, and the cosmetic appearances of the healed wound and donor site were satisfactory. The combination of these three perforator flaps enabled us to achieve a satisfactory outcome while avoiding skin grafts.     

Coverage of supraumbilical abdominal wall defects: The tunnelled‐pedicled ALT technique

Abdominal wall defects are a challenge for reconstructive surgeons. Although the utility of anterolateral thigh perforator (ALT) flap has been well established for lower abdominal wall reconstruction, pedicled ALT flap is usually not considered for supraumbilical defects in the most recent algorithms. The purpose of this paper is to report the results of a tunneled pedicled ALT flap for reconstruction of supraumbilical defect from a series of patients. From July 2009 to September2014, six patients underwent delayed abdominal wall coverage using pedicled ALT flaps and reinforcement with polypropylene meshes. Defects occurred after surgical complications and abdominal trauma. Flaps were tunneled beneath the rectus femoris and sartorius muscles to increase the pedicle length. The size of the skin islands ranged from 22–29 × 10–14 cm. All flaps survived and the healing of the wounds was successful. Partial dehiscence of donor site occurred in one patient, and small wound dehiscence due to minimal distal necrosis was observed in another patient. No functional problems were reported in donor site, and no complications occurred in 6–68 months of follow‐up. The tunneled pedicled ALT flap may provide a reliable alternative method for abdominal wall reconstruction, including supraumbilical defects. © 2015 Wiley Periodicals, Inc. Microsurgery 37:119–127, 2017.     

The bipedicled free TRAM flap.

Unilateral breast reconstruction with all 4 zones of a free TRAM flap was performed in 2 patients with total or near-total transection of the flap by a vertical midline infraumbilical scar. To permit this, both inferior epigastric pedicles were raised and anastomosed to the thoracodorsal vessels and the serratus collateral. Vein grafts were not required and both flaps perfused in toto. The technique is recommended for reconstruction of the larger breast (i.e. where more than a "hemi-TRAM" flap is required for symmetry) in the presence of extensive midline infraumbilical scarring. Avoidance of epigastric bulge, improved vascularity and vastly reduced abdominal wall donor defect give this technique advantages over the conventional bipedicled TRAM flap.     

Transversely‐inset great toe hemi‐pulp flap transfer for the reconstruction of a thumb‐tip defect

Thumb‐tip defect is a common traumatic disease, and replantation of an amputated thumb‐tip is the first choice of treatment when available. When an amputee is not available, local flaps such as volar advancement flap are used for reconstruction. However, it is difficult to cover whole defect area by a local flap when a defect is relatively large. In this report, we present a case of the use of a free great toe hemi‐pulp flap transfer to reconstruct a thumb‐tip defect. A 69‐year‐old right‐handed male suffered from the right thumb‐tip crush amputation in Tamai Zone 2. The distal phalanx and the nail matrix were preserved, and the defect size was 5 cm × 4 cm. The thumb‐tip was reconstructed with a free great toe hemi‐pulp flap under local anesthesia. The flap included extended subcutaneous adiposal tissue (skin size 4.5 cm × 3 cm; fat size 4.5 cm × 5.5 cm) to reconstruct the nail bed, and was transversely inset at the recipient site to cover the whole area of the defect. The donor site could be primarily closed without skin grafting. At postoperative 6 months, the patient was satisfied with good results of the reconstructed thumb‐tip and the donor site. Transversely‐inset great toe hemi‐pulp flap may be useful to reconstruct a thumb‐tip defect, which allows relatively wide defect reconstruction. © 2014 Wiley Periodicals, Inc. Microsurgery 35:235–238, 2015.     

应用腹壁下动脉穿支皮瓣再造乳房

目的对应用腹壁下动脉穿支(deepinferiorepigastricperforator,DIEP)皮瓣进行乳房再造进结。方法2000年3月~2005年3月,收治18例患者,其中因乳腺癌导致乳房缺损17例,术前行放射治疗者7例放射治疗者10例;先天性Poland’s综合征1例。胸壁缺损范围12cm×8cm~25cm×20cm。应用DIEP皮瓣游离进行乳房再造,皮瓣切取范围12cm×8cm~35cm×22cm。15例乳房再造患者使用的受区血管是胸廓内血管,其中腹壁下动、静脉分别与切断后的胸廓内动、静脉近、远心端行吻合者13例;仅切取一侧腹壁下血管,与胸廓内动、静心端行吻合者2例。3例行即刻乳房再造者使用的受区血管分别是胸背动、静脉和胸背动、静脉加旋肩胛动、静脉。18例患者中16例术后皮瓣全部成活,2例术后出现皮瓣坏死。其中行放射治疗1例,未行放射治疗1例。Poland合征患者术后皮瓣远端约1/3面积坏死。术后半年行乳头再造和乳房修整者2例。2例术后2周出现腹部供瓣区正口部分裂开,行创面清创后,分别应用直接缝合和植皮的方法进行修复。结论DIEP皮瓣在保留了传统下腹部横直肌皮瓣乳房再造所具有的优点同时,可最大限度保留腹直肌的功能,从而避免术后出现腹壁薄弱、腹壁疝等并发目前较理想的乳房再造方式。     

Sliding free transverse rectus abdominis myocutaneous flap for closure of a massive abdominal wall defect: A case report

Despite considerable advances in reconstructive surgery, massive abdominal wall defects continue to pose a significant surgical challenge. We report the case of a 72‐year‐old morbidly obese female patient with Clostridium septicum‐related gas gangrene of the abdominal wall. After multidisciplinary treatment and multiple extensive debridements, a massive full‐thickness defect (40 cm × 35 cm) of the right abdominal wall was present. The abdominal contents were covered with a resorbable mesh to prevent evisceration. Finally, the composite defect was successfully reconstructed through a contralateral extended free transverse rectus abdominis myocutaneus (TRAM) flap (50 cm × 38 cm). An arterio‐venous loop to the superficial femoral vessels using the great saphenous vein was necessary to allow the flap to reach the defect. Postoperatively, a minor wound healing disorder of the flap was successfully treated with split skin grafting. Six month after surgery, the patient presented with a completely healed flap coverage area and a small abdominal hernia without the need of further surgical revision. This case illustrates the use of a sliding free TRAM flap for closure of a massive abdominal wall defect.     

腹壁下动脉穿支皮瓣游离移植修复四肢软组织缺损

目的：报告腹壁下动脉穿支皮瓣游离移植修复四肢组织缺损临床应用结果。方法：自2006年1月至2012年1月,应用腹壁下动脉穿支皮瓣带蒂移植修复小腿（7例）和前臂（6例）软组织缺损13例,其中男9例,女4例;年龄21-45岁,平均33岁。软组织缺损范围7 cm×17 cm-8 cm×26 cm。外侧支和内侧支穿支皮瓣分别是7例和6例。供区直接缝合。结果：1例皮瓣发生小的皮缘裂开,术后1个月自然愈合,皮瓣全部成活。术后随访1.8-4.0年,平均2.8年,受区外形较好。结论：腹壁下动脉穿支皮瓣游离移植很适宜修复四肢软组织缺损,这种技术安全、可靠,可降低对供区的损伤。     

Turbocharged bilateral pedicled DIEP flap for reconstruction of thigh defect without recipient vessels: A case report

Reconstruction of thigh defects is usually straightforward, but in cases of poor soft tissue quality, free flap reconstruction is not possible due to the absence of recipient vessels. The turbocharge technique may increase the viable, vascularized area of a flap. In this report we present a case of the use of a turbocharged bilateral pedicled DIEP flap for reconstruction of thigh defect without recipient vessels. A 29‐year‐old woman who underwent neoadjuvant chemotherapy plus radiation therapy for a leiomyosarcoma on the left thigh. Six weeks later, complete tumor excision and a femoropopliteal bypass with contralateral saphenous vein was performed. In the following days the wound had dehiscence, infection, necrosis of the surrounding muscles and exposure of femoropopliteal bypass. No recipient vessels were available for free flap and critical limb ischemia due to bypass thrombosis was detected. The reconstruction of a large thigh defect (30 × 12 cm) and the coverage of a femoropopliteal bypass with a turbocharged bilateral pedicled DIEP flap was performed. A flap including the entire infraumbilical tissue was designed and the anastomosis of the proximal stump of the right inferior epigastric vessels with the distal ends of the inferior left epigastric vessels was performed to increase the viable area. The flap survived without any complications during the postoperative period. At 12‐month follow up, coverage was stable with no tumor recurrence. Our result suggests that a turbocharged bilateral pedicled DIEP flap may be an option for reconstructing large tissue defects when no recipient vessels are available for free flap.     

Versatility of rectus abdominis free flap for reconstruction of soft-tissue defects in extremities

Rectus abdominis flaps, whose blood supply is mainly provided by superior and deep inferior epigastric vessels, are suitable not only for local transfer but also as free flaps. Based on abundant anastomoses of deep inferior epigastric vessels with other vessels such as superior epigastric vessels, lower intercostal vessels, subcostal vessels, lumbar vessels, superficial epigastric vessels, and superficial and deep iliac circumflex vessels, the rectus abdominis flap may be designed as a vertical flap, transverse flap, or oblique flap. From September 1995-October 2002, 42 free rectus abdominis flaps were transferred to reconstruct a variety of soft-tissue defects. The size of rectus abdominis flaps ranged from 6-25 cm in length and 5-12 cm in width. The overall success rate was 100% (42 of 42). The donor area was closed directly in 8-10-cm-wide flaps, leaving an inconspicuous scar. Larger flaps required skin grafting. After a mean 7-month (range, 3 weeks-18 months) follow-up, all flaps have healed uneventfully, and donor abdominal morbidity is minimal.     

A reappraisal of the free groin flap in aesthetic craniofacial reconstruction

Craniofacial defects are often associated with 3-dimensional volumetric contour deficiencies. The free groin flap was historically popular though technical limitations subsequently caused its use to fall from favor. We sought to determine if a role remained for the free groin flap in aesthetic craniofacial reconstruction. From May 2005 to July 2010, 15 patients had 18 consecutive free groin flaps performed by the senior surgeon at the R Adams Cowley Shock Trauma Center and the Johns Hopkins Medical Institute. Data collected included age, sex, operative date, etiology, defect size, recipient vessels, complications, donor-site closure, and follow-up time. Eighteen groin flaps were used for the patient cohort consisting of 10 males and 5 females (mean age, 26 years; range, 18-40 years) who underwent reconstruction necessitated by various oncologic, traumatic, infectious, and congenital etiologies. The average defect size was 7.3 × 6.3 cm (range, 3-10 × 1-10 cm). Seventeen flaps were based on the superficial circumflex iliac vessels and 1 on the superficial inferior epigastric vessels. Seventeen flaps used the superficial temporal artery and vein as the recipient vessels, and the remaining flap used the superior thyroid artery and retromandibular vein. Of the 18 flaps, 17 survived (94% survival rate). All donor sites were closed primarily. Follow-up time ranged from 6 to 60 months. The free groin flap is generally underused in the reconstruction of complex craniofacial facial defects. Its unique characteristics and minimal donor-site morbidity should prompt the reconstructive surgeon to retain the free groin flap in his or her armamentarium.     

Intraoperative flap design using ICG monitoring of a conjoined fabricated anterolateral thigh/tensor fasciae latae perforator flap in a case of extensive soft tissue reconstruction at the lower extremity

In this report, we present a case of the use of a conjoined fabricated free anterolateral thigh (ALT)/tensor fascia latae (TFL) perforator flap for reconstruction of the lower extremity with intraoperative flap design using intraoperative indocyanine green (ICG) monitoring. The flap was used for reconstruction of a 16 cm × 28 cm sized defect of the lower leg in a 24‐year‐old man. The defect was caused by a third degree open fracture to the tibia. Upon dissection of the ALT perforators, ICG monitoring showed that both dominant ALT perforators did not yield a sufficient perforasome (～16 cm × 17 cm) for the larger flap needed. An adjacent TFL perforator also supplied a large perforasome (～15 cm × 11 cm), so a conjoined fabricated flap was harvested and transplanted to cover an extensive lower leg defect. The artery of the TFL perforator pedicle was being in‐flap anastomosed to a side branch of the ALT pedicle. Postoperative course was uneventful and there were no complications. Length of follow‐up was 6 months, aesthetic and functional outcome was good. The patient was very satisfied with the aesthetic outcome. Both legs were fully mobile after intensive physiotherapy for the reconstructed leg. The leg where the flap had been harvested showed full strength in knee joint flexion. This case could show that identification of the supplying vessels may be possible by ICG monitoring. © 2015 Wiley Periodicals, Inc. Microsurgery 36:684–688, 2016.     

Total aesthetic subunit reconstruction of the burned anterior abdomen using pre‐expanded pedicled anterolateral thigh flap—A case report

Combination of tissue expansion and perforator flaps broadened the reconstructive options in burn cases with wide scar contractures. We report a case of total aesthetic subunit reconstruction of the anterior abdominal skin using a pre‐expanded pedicled anterolateral thigh (ALT) perforator flap in a patient with postburn contractures. Seventeen‐year‐old girl had a history of scalding burn to the anterior abdomen, resulting in tight contractures inhibiting her mobility. After an expansion period of 6 months, the flap of 27 × 30 cm was elevated at the suprafascial plane and tunneled to the anterior abdomen. The flap was used to resurface the defect from xyphoid process down to the mons pubis and bilaterally at linea semilunaris. Postoperative course was uneventful. A good quality aesthetic and functional reconstruction was achieved at the 10‐year follow‐up. Pre‐expanded pedicled ALT flaps may be considered as an option in extensive scarring requiring large amounts of tissue.     

Propeller flap reconstruction of abdominal defects: Review of the literature and case report

The abdominal wall is perfused anteriorly by the superior and deep epigastric vessels with a smaller contribution from the superficial system. The lateral abdominal wall is perfused predominantly from perforators arising from the intercostal vessels. Reconstruction of soft tissue defects involving the abdomen presents a difficult challenge for reconstructive surgeons. Pedicle perforator propeller flaps can be used to reconstruct defects of the abdomen, and here we present a thorough review of the literature as well as a case illustrating the perforasome propeller flap concept. A patient underwent resection for dermatofibrosarcoma protuberans resulting in a large defect of the epigastric soft tissue. A propeller flap was designed based on a perforator arising from the superior deep epigastric vessels and was rotated 90° into the defect allowing primary closure of the donor site. The patient healed uneventfully and was without recurrent disease 37 months following reconstruction. Perforator propeller flaps can be used successfully in reconstruction of abdominal defects and should be incorporated into the armamentarium of reconstructive microsurgeons already facile with perforator dissections. © 2014 Wiley Periodicals, Inc. Microsurgery 35:72–78, 2015.     

Robotic‐assisted deep inferior epigastric artery perforator flap abdominal harvest for breast reconstruction: A case report

The deep inferior epigastric perforator (DIEP) flap is a mainstay of autologous breast reconstruction. The da Vinci robot has recently been adapted for an increasing number of reconstructive surgeries. The literature has yet to describe its use for the intra‐abdominal harvest of the deep inferior epigastric vessels (DIEV) during DIEP flap breast reconstruction. We show the use of the da Vinci robotic surgical system for the intra‐abdominal dissection of DIEV during delayed breast reconstruction with a DIEP flap in a 51‐year‐old female who had undergone a right modified radical mastectomy. After dissecting the flap from the anterior abdominal wall leaving only the targeted perforating vessels intact, a 1.5 cm fascial incision was made adjacent to the perforator and the vessels were dissected to below the level of the fascia. The intra‐abdominal robotic‐assisted dissection of the DIEV up to the perforator was then completed. The DIEV were divided at their origin using the robot and the flap removed from the abdomen for subsequent reconstruction. This technique enabled improved precision of flap harvest while also decreasing the donor‐site morbidity by minimizing the incision length of the anterior rectus sheath. The patient had an uneventful postoperative course and, at 9‐month follow‐up, exhibited no evidence of flap or donor‐site complications, specifically hernia or bulge. This novel approach for the harvest of a DIEP flap introduces an alternative technique to the conventional DIEP flap procedure in the appropriate patient population. Risks inherent to this technique as well as additional costs must be considered.