Reconstruction of Scalp and Cranium Defect Utilizing Latissimus Dorsi Musculocutaneous and Serratus Anterior Muscle Free Flaps with Interpositional Anastomosis of T-Shaped Flap Artery: Case Report

The use of a combination musculocutaneous free flap, consisting of a latissimus dorsi flap and a serratus anterior flap, for reconstruction of a large scalp and cranium defect is described. The recipient artery, the superficial temporal artery (STA), was anastomosed to the flap artery, without sacrificing blood flow, by means of a special technique: forming the end of the flap artery into a T shape and interposing it between the two stumps of the transected STA, because the STA was crucial for tissue adjacent to the defect. The flap vein was anastomosed to the external jugular vein with a vein graft. The extensive defect was immediately closed with sutures, and there were no remarkable complications.     

A radial forearm flap based on an extended dissection of the cephalic vein. The longest venous pedicle? Case report

A radial forearm flap based on the cephalic vein was elevated to resurface a defect in the left auricular region. The cephalic vein was dissected up to the clavicle and the flap was transferred through a subcutaneous tunnel to the defect. The radial artery was anastomosed to the stump of the external carotid artery using a vein graft. The flap pursued an uneventful course and survived completely. This showed that the long venous pedicle (47 cm) could drain the flap safely and sufficiently.     

腓动脉穿支腓肠神经营养血管游离皮瓣修复手足软组织缺损

目的 探讨腓肠神经营养血管皮瓣游离移植的手术方法及临床应用效果.方法 切取由腓动脉发出单一皮穿支腓肠神经营养血管皮瓣,游离移植修复手背及涉及足前部的足踝部皮肤软组织缺损.皮瓣穿支动脉、小隐静脉分别与受区邻近的主干动脉分支及头静脉或大隐静脉吻合建立血液循环;亦可单纯吻合穿支动、静脉供血.皮瓣腓肠神经与受区皮神经吻合.结果 2005年1月至2007年12月,于临床应用12例.皮瓣切取面积12 cm× 7 cm～18 cm×11 cm,皮瓣全部成活.术后随访7～27个月,皮瓣外观、质地优良,两点辨别觉7～12 mm,肢体功能恢复满意.结论 本术式综合了游离皮瓣、穿支皮瓣与皮神经营养血管皮瓣的优点,皮瓣设计灵活,切取方便,惨复位置随意,血供可靠,是修复手足皮肤软组织缺损的较好方法.     

五个组织瓣组合移植修复全手脱套伤伴五指缺损

目的　探讨用双足供区 5个组织瓣的组合移植 ,修复全手脱套伤伴 5指缺损的优缺点。方法　 1999年 7月 ,为 1例患者设计并应用了该新术式。 ( 1)患侧供足 :设计并切取以足背动脉为蒂的携带甲瓣的足背皮瓣 ,修复手背、虎口及重建拇指。足背动静脉与桡动静脉吻合 ,大隐静脉与头静脉吻合。切取以第一、二趾足底总动脉为蒂的第二足趾游离移植再造示指。第二足趾的桡侧趾足底固有动脉通过血管桥接与足背皮瓣的足底深支作串联吻合 ;尺侧趾足底固有动脉与另一组足内侧皮瓣的足底深支作串联吻合 ;趾静脉与足背皮瓣远端及前臂背侧浅静脉吻合。 ( 2 )健侧供足 :设计并切取以足背动脉为蒂的携带第二足趾的足内侧皮瓣 ,修复手掌、虎口及重建中指。足背动静脉与尺动静脉吻合 ,大隐静脉与前臂内侧浅静脉吻合。足背创面用中厚皮片植皮。结果　 5个移植组织瓣全部成活。术后随访 2个多月 ,虎口大小基本同健侧 ,再造拇指对指、掌侧外展功能基本恢复。重建 3指的痛觉开始恢复。足部活动时无不适感。结论　该术式是修复全手脱套伤伴 5指缺损方法中最新最佳的一种方法     

吻合血管的游离组织瓣修复进行性单侧面萎缩症

目的用游离的股前外侧筋膜脂肪瓣充填修复进行性单侧面萎缩症。方法设计以旋股外侧动脉降支为血管蒂的游离股前外侧筋膜脂肪瓣或旋肩胛血管为血管蒂的肩胛真皮脂肪瓣，切取筋膜脂肪瓣或真皮脂肪瓣后将其转移至面部萎缩处，然后将旋股外侧动脉降支或旋肩胛血管和面动静脉相吻合。结果临床治疗8例，其中应用股前外侧筋膜脂肪瓣7例，肩胛真皮脂肪瓣1例，组织瓣全部成活，矫正的患侧面部形态与健侧基本对称，外形满意。结论游离组织瓣移植，尤其以旋股外侧动脉降支为血管蒂的股前外侧筋膜脂肪瓣能提供足够的组织量，是修复进行性单侧面萎缩症较好的方法。     

以旋股外侧动脉降支供血的游离组织瓣修复小腿软组织缺损

目的 探讨以旋股外侧动脉降支逆行转位供血的游离组织瓣修复严重的小腿创伤伴软组织缺损的临床效果.方法 对小腿软组织损伤严重且无可携带游离组织瓣的血管,以旋股外侧动脉降支的远端为蒂,将其近端与游离组织瓣的动脉吻接,大隐静脉或小隐静脉与游离组织瓣的动脉伴行静脉吻接,2004年10月至2009年12月,采用该方法修复小腿软组织缺损36例,其中携带背阔肌肌皮瓣15例,股前外侧皮瓣12例,胸脐皮瓣9例.结果 36例游离皮瓣(肌皮瓣)均顺利成活,无一例出现血管危象,随访6个月至2.5年,皮瓣外形及功能恢复均较满意.结论 在小腿无可供吻合的血管时,应用以旋股外侧动脉降支逆行转位供血的游离组织瓣修复小腿软组织缺损,是一种切实有效的手术方法.

Abstract：

Objective To investigate the therapeutic effect of free tissue flap anastomosed with reverse descendant branch of lateral femoral circumflex artery for severe soft tissue defect at leg. Methods The severe soft tissue defect at leg, without any vessels for anastomosis of free tissue flap, was reconstructed with free tissue flap, which was anastomosed with proximal end of descendant branch of lateral femoral circumflex artery and great saphenous vein. From Oct. 2004 to Dec. 2009, 36 cases were treated with 15 cases of latissimus dorsi musculocutaneous flaps, 12 cases of anterolateral femoral flaps,and 9 cases of thoracoumbilicus flaps. Results All the 36 free flaps survived completely. The patients were followed up for 6 months to 2. 5 years with good cosmetic results. Conclusions It is effective and practical to repair the severe soft tissue defects at legs with the reverse descendant branch of lateral femoral circumflex artery to carry the free flaps.     

游离尺动脉腕上皮支皮瓣修复手指创面

目的探讨尺动脉腕上皮支皮瓣修复手指创面的手术方法及效果。方法对11例手指皮肤软组织缺损合并肌腱或骨外露者,采用游离尺动脉腕上皮支皮瓣进行修复。其中8例面积为2．5cm×1．0cm-5．2cm×2．2cm的皮瓣．在腕上皮支下行支轴线上切取：3例面积为5．5cm×3．0cm×6．2cm×3．8cm的皮瓣,在腕上皮支下行支及上行支轴线上切取。皮瓣切取后,8例下行支皮瓣内腕上皮支主干均直接与受区指动脉吻合,3例合并有上行支的皮瓣均移植了前臂静脉与受区的指动脉吻合,皮瓣内的皮下静脉或伴行静脉分别与近端指掌侧或指背侧2-3根静脉吻合,将皮瓣内携带的1条尺神经手背支与指固有神经接合。结果术后11例皮瓣全部成活．并获得4～17个月随访。皮肤弹性、色泽、质地良好,外形满意。两点辨别觉9-12mm。结论游离尺动脉腕上皮支皮瓣供区隐蔽,血管穿支位置恒定,不损伤主干血管,供区损伤小,切取简单。修复手指缺损外观满意,可携带神经恢复皮瓣感觉,是修复手指创面的一种理想选择。     

Microvascular reconstruction of nasal ala using a reversed superficial temporal artery auricular flap.

Microsurgical technique allows successful transfer of an auricular flap in a one-stage procedure, using the root of the helix. Although a free composite auricular flap with the superficial temporal artery pedicle provides a good solution to repair nasal defects, its vascular pedicle is so limited that a vein graft from other area of the body is usually needed to reach the recipient site, leaving an unpleasant scar on the donor site. The authors present a reversed superficial temporal artery auricular free flap for alar reconstruction by microsurgical transfer. This technique has been performed on four patients with posttraumatic alar defects. In three patients, the reversed superficial temporal vessels of the flap were anastomosed directly with the recipient facial vessels in the nasolabial fold. In one patient, the reversed superficial temporal artery of the flap was anastomosed with the facial artery as above, its accompanying vein to the proximal stem of the superficial temporal vein by a graft taken from the excess length of the reversed superficial temporal artery pedicle because a suitable vein was not found for microvascular anastomosis in the nasolabial area. In these four patients, the size of the flap was 2.5 x 2.0-4.0 x 2.5 cm, the length of the vascular pedicle is 5-8 cm, average 6.5 cm. The reversed superficial temporal artery auricular flap offers a long vascular pedicle of the auricular free flap for microvascular anastomosis in the reconstruction of the ala of nose, delivers a good solution to the problem of the vascular pedicle shortage of the proximal superficial artery auricular flap. There is no need of vein graft from other parts of the body because the superficial temporal vessels on the temple provide not only the flap pedicle but also a source of vessel grafts. This technique may have even wider applications in other facial cutaneous defect.     

Chest wall reconstruction using a free rectus abdominis myocutaneous flap in a case of recurrence after bilateral breast cancer surgery

A 64 years old woman with anterior chest wall recurrence after bilateral mastectomy for breast cancer was treated by the resection of chest wall in full thickness involving the whole sternum and the anterior part of ribs except the first rib. The thoracic cage was reconstructed using a free rectus abdominis myocutaneous flap which was placed over Marlex mesh covering the defect of chest wall. By means of surgical microscope, inferior epigastric artery and vein of the graft were anastomosed with internal thoracic artery and vein at the neck, respectively. Postoperative course was uneventful and the patient is alive and well for one year after the surgery. A free myocutaneous flap method provides enough volume of soft tissue for coverage of a large defect and chest wall stability.     

游离足内侧皮瓣的解剖研究与临床应用

目的 改进和完善以足底内侧动脉深支的内侧支供血的游离足内侧皮瓣的设计和应用技术。方法 基于８只足标本的解剖观测结果,制定独特皮瓣设计方案,应用游离足内侧皮瓣修复手部皮肤缺损４例,改进如下：皮瓣静脉回流选用大隐静脉,缝合皮瓣的隐神经带,利用动脉蒂的伴行静脉与受区动脉吻合,挽救发生动脉危象的皮瓣等。结果 ４例皮瓣均完全存活,效果良好。结论 皮瓣设计例题,将该皮瓣的深静脉动脉化是动脉危象的有效补救措施,     

游离串联皮瓣修复颅骨外露头皮缺损的应用

摘要 目的 探讨合并颅骨外露的大面积头皮缺损的修复方法。方法 应用游离前臂皮瓣及游离股前外侧皮瓣,串联后修复外伤致合并骨外露的头皮缺损7例。将前臂皮瓣血管蒂近端与甲状腺上动脉和颈内静脉吻合,远端与股前外侧皮瓣血管蒂吻合。无骨外露的缺损用游离植皮修复。结果 7例皮瓣存活良好,修复的头皮外观良好,质地柔软。结论 将游离前臂皮瓣和股前外侧皮瓣串联移植,修复大面积头皮缺损临床效果满意。     

吻合血管的骨移植及钛板内固定修复下颌骨缺损

目的 探讨吻合血管的游离髂骨或腓骨移植及钛板坚强内固定在修复下颌骨缺损中的临床应用效果。方法 选择7例以旋髂深动静脉为蒂的游离髂骨肌瓣和2例以腓动静脉为蒂的游离腓骨肌瓣修复9例下颌骨缺损，并用钛板坚强内固定，血管的动静脉蒂分别与颌外动静脉吻合。结果 9例术后2～4周经放射性核素锝亚甲基二磷酸盐(^99mTc MDP)扫描证实血供良好，移植骨成活。经6个月至3年随访，移植骨固位稳定。结论 吻合血管的骨移植及钛板内固定是修复下颌骨缺损的最佳选择之一。     

Salvage of the lower leg using a reversed long free fibular flap

The advantages of end-to-side anastomoses have been well documented in microvascular surgery. The vessels of the fibular flap do not usually permit end-to-side anastomosis to recipient vessels in the proximal part of the lower leg because the pedicle length of the free fibular flap is usually too short. Therefore, vein grafts are used to elongate the vessels. If a harvested long free fibular flap that is used to bridge a massive defect of the tibia is reversed and placed into the medullary cavity of the tibia, the flap vessels can be anastomosed, using the end-to-side technique, to the recipient vessels without vein grafts in the distal part of the lower leg. Thus, the flap artery (the peroneal artery) fills in a retrograde fashion. The patient reported was reconstructed with a reversed long free fibular flap. The postoperative period was uneventful. The patient can stand and walk with a protective shoe 2 years postoperatively.     

Intraoral anastomosis of a prelaminated radial forearm flap in reconstruction of a large persistent cleft palate

In this report, we present a case of a prelaminated radial forearm flap in reconstruction of a large persistent cleft palate with transoral single arterial and three venous anastomoses. A 17‐years‐old female patient presented a large cleft palate defect and complete dentition, dysmelia of both arms and bilateral thumb aplasia. A radial flap was prelaminated using oral mucosa 5 days prior to transplantation. Five days after flap prelamination, the facial artery and vein, submandibular vein, and a venous branch to the masseter muscle behind the buccinator muscle fibers were exposed through an intraoral incision lateral to the inferior right mucogingival junction. The radial artery, its bilateral accompanying veins, and the cephalic vein of transplanted flap were anastomosed transorally to the facial vessels, submandibular vein, and masseter branch. The vessel pedicle ran through the palatoglossal arch dorsal to the second upper molar. Good flow and flap perfusion were evinced, and further‐on successful healing was achieved. The case encourages similar treatment in comparable situations avoiding facial nerve hazard and extraoral scars. © 2013 Wiley Periodicals, Inc. Microsurgery 34:229–232, 2014.     

Reconstruction of large scalp and calvarium defects by using the semi-free latissimus dorsi flap associated with methylmethacrylate implant for cranioplasty

The semi free latissimus dorsi flap is characterized by a temporary vascular anastomosis on a pedicle not belonging to the loco-regional anatomy of the skin defect; after a period of autonomy, the section of the flap pedicle is obligatory. Its advantage compared to the classic free flap is the great microsurgical security avoiding complex, and stressful supervision in the postoperative period. From June 1998 to January 2001, 7 patients ranging from 18 to 65 years old and suffering from large scalp defects going between 20 x 13 cm and 27 x 18 cm have benefited from this surgical method. The etiology of these defects was: in 4 cases dermatofibrosarcoma protuberans involving the periost, in 1 case destruction of the near entirety of the scalp and calvarium by electrical burn, in 1 case an instable scar of burn with osteomyelitis and in the last case an osteomyelitis on a frontal cranioplasty. Three stages have been used:--The thoraco-dorsal artery was anastomosed on the wrist to the radial artery in a termino-lateral way and the thoraco-dorsal vein to the superficiel radial vein in a termino-terminal way;--The flap was fixed to the forearm for 2 weeks, then, the debridement which has always exposed the dura was done; The flap was sutured to the defect after reconstruction of calvarial defect with the méthylmétacrylate implant;--After 3 weeks the pedicle was sectioned and the flap tailored exactly to the defect. No postoperative complications were reported. With a mean follow-up of 18 months, the scalp coverage was very satisfactory.     

The Pruitt-Inahara carotid shunt as an assisting tool to anastomose the arterial free flap pedicle to the internal carotid artery in the vessel-depleted neck

Microvascular free tissue transfer in head and neck reconstruction requires suitable recipient vessels which are frequently compromised by prior surgery or radiotherapy to the neck. This article details a new technique of arterial free flap pedicle anastomosis to the internal carotid artery in a vessel-depleted neck. A 63-year-old female was referred because of recurrence of squamous cell carcinoma of the tongue, which involved the left-sided tongue base and pharynx with circumferential involvement of the homolateral external carotid artery. This artery and its branches were excluded as potential recipients. To close the defect after tumor excision, a free vertical rectus abdominis muscle arterial flap pedicle was anastomosed to the homolateral internal carotid artery with the help of a Pruitt-Inahara outlying carotid shunt. The venous anastomosis was performed to the internal jugular vein. The VRAM flap survived without complications. This procedure is to be considered an alternative rescue technique for salvage reconstruction in vessel depleted necks.     

Anterolateral thigh flap pedicle for interposition artery and vein grafts in head and neck reconstruction: a case report

The selection of receiving vessels is one of the most critical steps in ensuring a successful outcome in microvascular surgery. The use of interposition grafts in microsurgery offers the surgeon valuable options when the free flaps vascular pedicles are too short to be anastomosed directly to the recipient vessels. Here, we present a case in which artery and vein grafts were used in microsurgical reconstruction of an anterior maxillary defect with an iliac free flap. As donor vessels, we used the descending branch of the lateral circumflex femoral artery and one of the two venae commitantes. The flap survived without major or minor complications. The anterolateral thigh flap pedicle allowed us to harvest safe, reliable grafts easily, with a suitable vessel length and diameter.     

The free TRAM procedure in breast reconstruction: choice of vascular receptor site

In this study, 70 consecutive cases of breast reconstruction with the use of a free Transverse Rectus Abdominal Myocutaneous (TRAM) flap were reviewed with respect to the type of recipient vessels. We describe our evolution of choice of the receptor vessels. The deep inferior epigastric artery was anastomosed to the thoracodorsal artery in 15 cases. In 55 cases the internal mammary artery (IMA) was used as a recipient vessel. The deep inferior epigastric vein was anastomosed to the thoracodorsal vein in 15 cases, to the cephalic vein in eight cases, the external jugular vein in 16 cases and to the internal mammary vein (IMV) in 31 cases. Total flap necrosis occurred in four cases. In an additional four cases there was partial necrosis requiring minor operative correction. In six cases venous outflow problems were the cause of flap necrosis. The external jugular vein (n = 3) and cephalic vein (n = 2) were relatively frequently involved in cases of venous outflow problems. One flap was rescued 5 days after surgery following venous thrombosis by inserting a vein graft. The IMA and vein proved to be reliable and easy to access as recipient vessels for anastomosing the vessels of the free TRAM.     

代偿性应用股前内侧皮瓣修复四肢软组织缺损

目的探讨在行股前外侧皮瓣修复四肢软组织缺损时因血管变异临时变更原设计,代偿性应用股前内侧皮瓣补充替代的临床疗效。方法2005年3月-2013年3月,在行股前外侧皮瓣修复四肢软组织缺损时因血管变异临时改制股前内侧皮瓣修复5例,其中手背创面3例,足背创面2例;缺损面积5cm×8cm×11cm×19cm：本组3例与受区桡动脉、头静脉吻合,2例与足背动脉、伴行静脉吻合;供区直接缝合3例,部分植皮2例。结果本组5例皮瓣全部成活,未出现血管危象,其中1例因切取面积过大,出现皮瓣远端部分坏死．经换药后愈合。随访1～24个月,临床效果满意。结论股前内侧皮瓣可作为股前外侧皮瓣的补充替代,应用股前内侧皮瓣游离移植修复四肢软组织缺损,临床效果满意,值得推广虚丽、     

应用游离前锯肌瓣矫治半侧颜面萎缩的初步临床研究

目的探讨应用游离前锯肌瓣矫治半侧颜面萎缩的可行性,并讨论前锯肌瓣的解剖、制作及手术中注意的问题。方法2001年9月~2004年7月,对3例严重半侧颜面萎缩患者采用游离前锯肌瓣移植术,其前锯肌瓣以胸背动、静脉为蒂,与颞浅动、静脉,颌外动、静脉,舌动、静脉等吻合;术中同时解剖胸长神经,并与面神经上颊支吻合。游离肌瓣大小12 cm×8 cm~16 cm×12 cm。结果3例患者术后前锯肌瓣游离移植颜面部凹陷区后色泽血运均良好,肌瓣完全成活,面颊部丰满圆润,无明显突起或不平,颌面部切口愈合好,瘢痕不明显,肩部运动良好,无“翼状肩”。随访1~3年,患者外形恢复满意。结论应用游离前锯肌瓣矫治严重半侧颜面萎缩安全可靠,术后有利于改善患者外形。远期疗效尚待进一步观察。