The dartos musculocutaneous flap

Six dartos musculocutaneous flaps have been used to resurface proximal penile defects. The vascular anatomy of the flap, surgical technique and complications are described in detail.     

A rat musculocutaneous flap model: the biceps femoris musculocutaneous flap

The purpose of this study was to describe a new musculocutaneous flap model in the rat. A total of 25 Wistar rats weighing 200 to 280 g were used in this experiment. In 15 rats, the vascular anatomy of the biceps femoris muscle and the cutaneous blood supply of its overlying posterior thigh skin were studied by anatomic dissection, dye injection, and microangiography using 5 rats in each group. The anatomic studies revealed that the main axial vessel supplying the biceps femoris muscle was the caudal femoral branch of the popliteal vessels. The posterior thigh skin overlying the biceps femoris muscle received a consistent musculocutaneous perforator at the center of the mid-posterior line of the posterior thigh. Based on the caudal femoral-popliteal vascular pedicle, the biceps femoris musculocutaneous flap was created in the rat, comprised of the whole muscle and its overlying posterior thigh skin. The skin paddle was designed as an ellipse with its longitudinal axis paralleling that of the extremity, generally measuring 4 x 2 cm. Island flaps were raised as described and replaced either in situ (N = 5) or transposed to a sacral defect (N = 5). Results showed that the cutaneous islands of all the flaps survived completely. Tetrazolium blue stain used to indicate muscle survival revealed that the average muscle viability was 86.7+/-3.4%. The authors conclude that the biceps femoris musculocutaneous flap is a reliable and true musculocutaneous flap model for future biological and pharmacological studies. It offers the following advantages: It has a consistent vascular pedicle and a musculocutaneous perforator, it supports a relatively large skin island, and there is no risk of autocannibalization of the flap because the flap is located dorsally.     

The gracilis muscle as musculocutaneous flap. Evaluation of 20 cases]

The use of gracilis as muscular or myocutaneous flap is very well-known. The authors report 20 cases of gracilis flap including 13 reconstructions of the vaginal cavity following extended abdomino-perineal resection. Some technical points concerning the localization of the cutaneous part of the flap and the pedicle dissection are discussed. The use of gracilis flap is still limited in surgical teams following extended abdomino-perineal resection, nevertheless it is a very useful flap because of its low morbidity, the shortening of patient hospitalization and the very satisfying aesthetic result of the neo-vaginal cavity.     

The transverse gracilis musculocutaneous flap.

Through detailed anatomical study and latex injection of 24 cadaver legs, the blood supply to the skin overlying the gracilis muscle was examined. The proximal pedicle entered the gracilis muscle 10 +/- 2 cm below the pubic tubercle. The dissections identified both septocutaneous and musculocutaneous perforators from the proximal gracilis pedicle. These branches had a pronounced tendency to travel in a transverse direction, supplying the cutaneous territory over the adductor longus and sartorius anteriorly and extending for > 5 cm beyond the posterior margin of the gracilis muscle. This information led to a "new" transverse design of the gracilis musculocutaneous flap, such that the vascular perforators are invariably included in the cutaneous portion of the flap. In contrast, the traditional design, because of skin mobility, may allow elevation outside the skin territory of the muscle perforators.     

Flap within a first dorsal metacarpal artery flap for recurrent thumb injury

Thumb pulp defects are commonly due to avulsion injuries. It is important to reconstruct these defects using sensate. A very good option for these defects is the islanded first dorsal metacarpal artery flap (FDMA). We present a patient, a carpenter by occupation, who had initial thumb pulp injury which was reconstructed with islanded first dorsal metacarpal artery flap. At 6-month follow-up, he had near normal sensation and two-point discrimination of 2 mm. The same patient represented after 1 year with similar injury to the same reconstructed thumb. This time, VY advancement flap was designed within the remnant of the previous FDMA flap. Flap within a flap is not a new concept. In the present scenario, it worked as a great indigenous solution as it was a simple alternative. It preserved the sensation and avoided the need of other complex reconstructions. The procedure was performed under local anaesthesia, and patient could return to his normal activities within 2 weeks post-op. This is a rare case report of making use of the concept of flap within a flap for recurrent thumb injury which was reconstructed previously with FDMA flap. VY advancement design aided the necessary movement required to cover the defect yet preserving the regained sensation making it a useful tool before embarking upon complex reconstructions.Level of Evidence: Level V, therapeutic study.     

Vertical trapezius musculocutaneous flap: a retrospective study.

From 1986 to 2001, 17 patients (aged 26-77 years) were treated using the vertical trapezius musculocutaneous flap. A two-stage procedure was used in 7 and a single-stage island flap in 10. The donor site was closed directly in all patients. Mean length of hospital stay was 16 days (range 12-25). There was no operative mortality. Complications were one partial flap necrosis and two seromas of the donor site, complicated by infection. With a minimum follow-up of more than two years, our study confirms the usefulness of the vertical trapezius musculocutaneous flap in head and neck reconstructive surgery. It is a reliable, thin flap of uniform thickness, which carries hairless skin. The length and thickness of its pedicle allows excellent mobility. The main disadvantage of the flap is the complete sacrifice of the muscle necessary for total mobilisation of the flap, and the intraoperative repositioning of the patient.     

The correction of postburn deformation of the neck using a musculocutaneous flap from the major pectoral muscle

In 15 patients with the postburn neck deformation, the plasty with a musculocutaneous flap of the musculus pectoralis major was employed. Use of the technique permits to avoid prolonged immobilization of a neck. A good functional and cosmetic result has been noted.     

The nasalis musculocutaneous flap; a report of three cases

In three cases a nasalis musculocutaneous flap, using the dog-ear, has been used to help close the secondary defect after transfer of a superiorly based nasolabial flap to the nose. In one case part of the nasalis flap was used to close a defect in the nasal lining.     

The tensor fascia lata musculocutaneous flap.

The tensor fascia lata (TFL) muscle, together with the overlying skin of the anterolateral thigh, makes a reliable musculocutaneous unit. It can be lengthened safely by taking the fascia lata and the skin of the anterolateral mid and lower thigh to within 8 cm of the knee. The skin of the longer flap is supplied by large perforating musculocutaneous arteries, the terminal branches of the vascular pedicle of the muscle. The shorter flap can easily be transposed over the trochanteric area, while the larger flap will cover not only the trochanter but also the ischial and sacral areas. The flap serves equally well as a transposition, island, or free flap. The anatomical and vascular basis of the flap is presented, together with its application in 21 patients. Possible further applications of the flap, including anterior rotation, are discussed.     

Free anterolateral thigh flap raised on musculocutaneous perforators of rectus femoris muscle

The anterolateral thigh flap (ALTF) has been in wide clinical use for the last two decades, its major disadvantage has been its variable anatomy. We are presenting a case in which no substantial perforators were found to be arising from either the lateral septum of thigh or Vastus Laterlis muscle. In this case, instead of raising another flap, we used the same skin paddle raised on the musculocutaneous perforators of rectus femoris muscle.     

The versatile anterolateral thigh flap: a musculocutaneous flap in disguise in head and neck reconstruction.

In search of an alternative soft tissue free flap donor site to radial forearm flap and rectus abdominis flap in head and neck reconstruction, we used the anterolateral thigh flap for reconstruction of various defects in the head and neck in 59 patients. The aim was to demonstrate the versatility of this donor site and propose a new approach to achieve a safer flap dissection. With the exception of three cases, all defects resulted from excision of malignant tumours. The defects were categorised as full thickness defects of the mandible (33.9%), full thickness defects of the cheek (52.5%) and others (13.6%). During the flap dissection a direct septocutaneous pedicle was observed in 12% of the cases. In the remaining cases there were only musculocutaneous perforators and the flaps were raised either as a split vastus lateralis musculocutaneous flap (72%) or as a perforator flap (16%), depending on the required thickness. Total flap survival was 96.7% with one total and one partial failure and two re-explorations (3.3%). The mean follow-up time was 7.1 months (range: 1-12 months). In conclusion, the anterolateral thigh flap is a versatile and dependable flap that can be adapted to any type of defect by modifying the flap design and composition. It should be considered to be a musculocutaneous flap of the vastus lateralis muscle that can also be raised as a perforator flap. When harvested and used in this context, the flap dissection becomes very safe and consistent, nullifying the only major disadvantage associated with this donor site.     

Pectoralis major musculocutaneous flap: a new flap in head and neck reconstruction.

The pectoralis major musculocutaneous flap described by Ariyan has great potential in single stage reconstructions of the head and neck. The advantages of the flap are greater length, improved vascularity, bulk, and one-stage reconstruction of oropharyngeal defects. The flap was used successfully in eight patients to reconstruct large defects in the head and neck area. Experience to date indicates that this flap has greater versatility than the deltopectoral flap in one-stage head and neck reconstructions.     

The deep inferior epigastric artery local musculocutaneous flap: a method of preserving sensation

We present a case in which an island extended inferior epigastric artery musculocutaneous flap, used to resurface an amputation stump, retained sensation. The reasons for this are discussed.     

The dartos musculocutaneous island flap in urethral reconstruction

Reconstruction of the burned penile urethra has received scant attention in the surgical literature. Techniques used in repairing congenital hypospadias may not be applicable in this situation. We describe a dartos musculocutaneous island flap used to reconstruct the distal burned penile urethra in a 13-year-old boy who sustained burns to 85% of his total body surface area. Reconstruction was completed in one surgical procedure, and at two-year follow-up good results were demonstrated.     

Total phalloplasty using a musculocutaneous latissimus dorsi flap

OBJECTIVE: To present total phalloplasty in children and adults using a musculocutaneous latissimus dorsi (MLD) free flap to create a large neophallus, that allows easy urethroplasty and implantation of a prosthesis. PATIENTS AND METHODS: From April 1999 to January 2006, 16 patients (mean age 24 years, range 10-34) had a total phalloplasty; the indications were congenital anomalies of the penis in 12, iatrogenic in two and accidental penile trauma in two. The MLD flap is mobilized on a subscapular artery and vein, and a thoracodorsal nerve. The neophallus is created on-site and after dividing the neurovascular pedicle, transferred to the pubic region, where it is anastomosed with the femoral artery, saphenous vein and ilio-inguinal nerve. The donor site was closed directly in 15 patients while in one a split-thickness skin graft was used to cover the defect. In the following stages, two- or three-stage buccal mucosa urethroplasty was used in 11 patients; a penile prosthesis was implanted in seven. RESULTS: The mean (range) follow-up was 31 (12-74) months; the penis was 14-18 cm long and 11-15 cm in circumference. There was no partial or total flap necrosis; the donor site healed satisfactorily in 13 patients while in the remaining three there was moderate scarring. The patency of the urethra was good in all patients. Two urethrocutaneous fistulae developed; one closed spontaneously and the other was successfully treated with minor surgery. The function of the implanted penile prostheses was satisfactory in all patients. CONCLUSIONS: The MLD flap allows the creation of a neophallus of good size and with a good aesthetic appearance; it allows urethroplasty and safe implantation of a penile prosthesis, and it can also be used in children.     

The clavicular head of pectoralis major musculocutaneous free flap

A new free flap is described based on the deltoid vessels of the acromiothoracic axis. The flap is comprised of the clavicular head of pectoralis major muscle with overlying skin. It is also possible to harvest vascularised clavicular bone with the flap. The vascular anatomy is reviewed and the technique of raising the flap described. Its clinical application is illustrated with five cases. Four of these were intra-oral reconstructions and the fifth a composite osteo-musculocutaneous flap to a lower limb following trauma.     

Vertical trapezius musculocutaneous flap: A retrospective study

From 1986 to 2001, 17 patients (aged 26–77 years) were treated using the vertical trapezius musculocutaneous flap. A two-stage procedure was used in 7 and a single-stage island flap in 10. The donor site was closed directly in all patients. Mean length of hospital stay was 16 days (range 12–25). There was no operative mortality. Complications were one partial flap necrosis and two seromas of the donor site, complicated by infection. With a minimum follow-up of more than two years, our study confirms the usefulness of the vertical trapezius musculocutaneous flap in head and neck reconstructive surgery. It is a reliable, thin flap of uniform thickness, which carries hairless skin. The length and thickness of its pedicle allows excellent mobility. The main disadvantage of the flap is the complete sacrifice of the muscle necessary for total mobilisation of the flap, and the intraoperative repositioning of the patient.     

Sensory reinnervation of a musculocutaneous flap: an experimental rabbit study.

Sensory neurotisation of a muscle (sensory nerve transfer to the motor nerve of a muscle) produces muscle sensibility, but not skin sensibility. How to achieve sensation of a musculocutaneous flap remains a challenge to reconstructive microsurgeons. The purpose of our study was to determine if multiple nerve grafts which were placed vertically between the neuromuscular entrance zone of a muscle and a target area of dermis on the overlying skin could improve sensation. Thirty-six gracilis musculocutaneous flaps (18 rabbits) were raised and divided into three groups: group 1 consisted of 12 sensory neurotised gracilis musculocutaneous flaps with five nerve grafts each; group 2 consisted of another 12 sensory neurotised gracilis flaps with 10 nerve grafts each; and the control group consisted of 12 sensory neurotised gracilis musculocutaneous flaps without any nerve grafts. All nerve grafts spanned the distance between the neuromuscular entrance zone of the gracilis muscle and a specified 3 cm diameter area of the skin island. The saphenous nerve (sensory) was coapted to the obturator nerve (motor nerve of the gracilis) in an effort to achieve improved sensation of the skin island in the musculocutaneous flaps. After 6 months, the flaps were individually evaluated using cortical somatosensory evoked potentials (CSSEP) using normal, painful, cold and hot stimuli. One unoperated rabbit was studied as the baseline CSEEP for comparison. Retrograde horseradish peroxidase (HRP) labelling was then performed to evaluate the possibility of newly established neural pathways. Results of the CSSEP testing revealed that flaps possessing 10 nerve grafts (group 2) demonstrated better sensation when compared to flaps possessing five nerve grafts (group 1) or no nerve grafts (control group). Furthermore, retrograde HRP labelling proved that a new neural pathway had been established from the skin island to the dorsal root ganglia of S1 and S2 via the interposed nerve grafts and the sensory neurotised gracilis muscle in groups 1 and 2 rabbits. The control group did not display any sensory regeneration.     

Lateral musculocutaneous flap of the trapezius muscle. Anatomic study of the venous drainage

A right and left comparative study of the venous drainage of the lateral trapezius muscle musculocutaneous flap was performed on 16 cadavers. The variability of this drainage explains the precautions required in the use of this flap.