Anterograde–retrograde method for harvest of distally based sural fasciocutaneous flap: Report of results from 154 patients

Distally based sural fasciocutaneous flap is traditionally raised by the retrograde method. This article introduces the anterograde–retrograde method for harvest of the flap and describes our experience on altering the flap plan. A total of 159 flaps in 154 patients were elevated by the anterograde–retrograde approach that harvest of the flap began with exploring the peroneal artery perforators nearby the pivot point before the upper and bilateral edges of the flap were incised. Partial necrosis occurred in 16 (10.1%) flaps, and marginal necrosis developed in 10 flaps. Nine flaps were redesigned with adjusted pivot point and skin island. The anterograde–retrograde approach for harvest of the flap can accurately locate the perforator, readily adjust both the pivot point and skin island if necessary, and thus improve reliability of the flap. This approach is particularly applicable for elevation of the flap without preoperative localization of the perforators by means of the Doppler. © 2012 Wiley Periodicals, Inc.     

Bauchwandhernien als Folge von Hebedefekten nach abdominalen Lappenplastiken

The anatomic characteristics of the anterior abdominal wall allow the harvesting of various types of flaps, some of them with considerable volume. These flaps are used mainly for reconstruction of the female breast, thoracic wall, and perineal or ilioinguinal region. Even though general donor site morbidity is low, hernias and "bulging" can occur due to the harvest of muscle and fascia, which leads to a weakening of the abdominal wall. Hernias and bulging appear mostly after harvest of classic flap types, which include removal of the rectus abdominis muscle. Further refinements of these flaps, i.e. microvascular flaps, in particular perforator flaps, lead to a marked reduction in donor site morbidity. In the following overview, the problem of abdominal wall weakening as a result of flap harvest is discussed and possible therapeutic options are elucidated.     

Free-style free flap

SUMMARY: Advancements in microsurgical techniques as applied to perforator flaps have made harvesting flaps in a free-style manner a practical reality. A hand-held Doppler identifies sizable perforators on which flaps can be based. In free-style free flap harvesting, any region of the body can be chosen as a donor site as long as there is an audible pulsatile Doppler signal. The value of the free-style free flap concept lies in its ability to overcome anatomical variations. The clinical application of raising flaps in a free-style manner has been demonstrated in the thigh where flaps have been raised safety and reliably in spite of the many anatomical uncertainties in this area. Flaps can, thus, be designed and raised in any region of the body to suite the unique requirements of individual cases. However, limitations to the clinical application of the free-style free flap should be noted; the course of the perforator may be unpredictable. Small and long perforators may be difficult to harvest and inset. Furthermore, the skin territory and intra-operative flap thinning should more conservative compared with conventional flaps. These shortcomings can however be overcome by clinical experience and improvement in surgical techniques.     

The thigh as a model for free style free flaps

Following a set of principles, free style free flaps may be harvested from any region of the body where a Doppler signal is heard. By using a retrograde dissection technique, the skin vessel is traced through its subfascial course (intramuscular or septocutaneous), until adequate length or vessel size is achieved. If a "free style free flap" is not originally planned, this approach can be usedwhen anatomic variations or unexpected events are encountered. The thigh, a region that is familiar to the surgical team at Chang Gung Memorial Hospital, was chosen as the site to begin exploring this style of flap harvest. Nine flaps were harvested as free style free flaps from the thigh and were used successfully for the reconstruction of complex defects.     

A new experimental flap design: the saphenous artery periosto-fasciocutaneous flap of the rat

Vascularized periosteal graft is a frequently applied flap model for bone prefabrication studies due to its inhabitance of osteoprogenitor cells and osteoinductive potential. Various bones such as rib and fibula are reported as a potential source for the harvest of the periosteal flap in experimental studies on higher species such as dogs and pigs, which necessitates a rather complicated and expensive experimental setting. Therefore a reliable and inexpensive small animal model on vascularized periosteal flaps is necessary for future research. A new saphenous artery based periosto-fasciocutaneous flap model in rats is described here, which is easily dissected and monitorized. In this experimental study, 15 male Sprague Dawley rats were operated and killed following a 3-month-long follow-up period . The histological analysis revealed heterotopic osteoneogenesis in 12 of 15 flaps (80%), whereas 14 flaps (93.3%) exhibited signs of angioneogenesis originating from the periostofasciocutaneous flap. The presented flap model promises to be an appropriate alternative for new studies where bone prefabrication methods are evaluated.     

Suprafascial compared with subfascial harvest of the radial forearm flap: an anatomic study

PURPOSE: Inclusion of the deep fascia within the radial forearm flap is conventionally thought to be essential for flap viability. Angiography and dissection studies were used in this study to elucidate the role of the deep fascia in perfusion of the radial forearm flap. METHODS: Twenty-four radial forearm flaps were harvested from 12 fresh cadavers. Ten paired suprafascial and subfascial flaps were harvested, the radial arteries were cannulated, and methylene blue dye was injected into the radial artery followed by a barium sulfate/gelatin mixture. The flaps were digitally radiographed, and the vascular territory was measured using software. The cutaneous dye staining patterns for paired flaps were recorded photographically. Computed tomography scans were performed for 3 paired flaps to evaluate the vascular pattern within the flap. Two pairs of forearms were subjected to intravascular injection with colored latex through the brachial artery prior to flap harvest, and microdissection of the flap and fascia was performed. RESULTS: No significant difference was found in the vascular territory measured for the flap when harvested using the subfascial or the suprafascial technique. Flap dissection studies confirmed that this is because of the poorly developed subfascial plexus in the forearm, with preservation of the deep fascia not contributing to the mechanism of flap perfusion. CONCLUSIONS: Inclusion of the deep fascia during flap harvest does not contribute to the perfusion of the radial forearm flap and therefore the deep fascia does not need to be included to maintain flap vascularity.     

Microsurgical workhorse flaps in head and neck reconstruction

The aim of reconstruction after resection of head and neck tumors is to achieve acceptable functional and esthetic results with minimal donor site morbidity. Although many flaps have been developed for bone and soft tissue reconstructions, our experience in the past years has identified the anterolateral thigh flap (cutaneous or myocutaneous), the radial forearm flap, and the osteoseptocutaneous fibula flap as the most useful flaps for head and neck reconstruction. These three flaps can be used for reconstruction of almost all kinds of defects, either as a single flap or in combination. The harvest of these flaps is relatively simple and straightforward. All flaps have adequate pedicle vessel length and caliber. Donor site morbidity is negligible. As most reconstructive microsurgeons do not have enough patient volume to master many different kinds of flaps in their professional life, we recommend focusing on these three flaps as workhorse flaps instead of hunting for many other flaps for head and neck reconstruction.     

Endoscopic harvest of temporoparietal fascial free flaps for coverage of hand wounds

The temporoparietal fascial (TPF) flap is a thin, pliable, and well-vascularized flap that is ideal for reconstructing hand defects. Conventionally harvested flaps, however, result in a large scar over the temporal fossa, which may be problematic in patients with male-pattern baldness. We describe an endoscopic technique for harvesting the TPF flap through a 4-cm preauricular incision to reduce donor site morbidity. Five TPF flaps were used to cover hand wounds. Three of the flaps were successful and there were no injuries to the frontal branch of the facial nerve in this series. Endoscopic harvest of the TPF flap is an ideal solution for covering medium-sized hand defects without potentially prominent scars in the temporal area.     

Free tensor fascia lata perforator flap as a backup procedure for head and neck reconstruction

Free tissue transfer is an essential part of the head and neck reconstruction. Despite several flap options, free perforator flaps have become very popular for head and neck. Anterolateral thigh perforator flap has multiple advantages among other options and is preferred by most of the reconstructive microsurgeons. Besides its advantages, sometimes it is impossible to harvest an anterolateral thigh perforator flap, and the surgeon has to shift to another option. Between January 2002 and June 2005, 5 tensor fascia lata perforator flaps were used for head and neck reconstruction because anterolateral thigh perforator flap could not be elevated due to absence or insufficient musculocutaneous perforators. Only 1 flap was reexplored and salvaged by redoing the venous anastomosis. All flaps survived without any other problem. Donor sites were covered by split-thickness skin grafts in 4 patients and closed directly in 1 of them. Doppler examination is important in planning of anterolateral thigh perforator; if the signals of the perforators are absent or very weak, the surgeon can shift to another flap. This decision may also be made during the operation when insufficient perforators are seen. Based on our experience, tensor fascia lata perforator flap is a safe alternative when anterolateral thigh perforator harvest is not possible. Tensor fascia lata perforator flap can be harvested from the same anatomic region with almost same morbidity.     

Nonendoscopic harvest of the gastrocnemius muscle flap through a small incision

Traditional gastrocnemius flap harvest requires a long skin incision, starting from the popliteal fossa to the mid leg. The authors designed three instruments to facilitate harvest of this flap through a small incision without the help of an endoscope in 10 patients. All 10 gastrocnemius muscle flaps survived with a 100% success rate.     

The role of fabricated chimeric free flaps in reconstruction of devastating hand and forearm injuries

Devastating hand and forearm injuries almost exclusively need free flap transfer if reconstruction is attempted. Early active and passive motion is only possible with aggressive, early, and comprehensive reconstruction. Despite recent advances in compound flaps, in selected cases it might be wise to harvest several smaller flaps and microsurgically combine them to one "chain-linked" flap "system." Four microsurgically fabricated chimeric free flaps were used in four patients for complex hand and forearm injuries. The combinations were sensate anterolateral thigh (ALT) flap plus sensate extended lateral arm flap (2x), ALT plus free fibula, and ALT plus functional musculocutaneous gracilis muscle. All flaps survived completely. Functional rehabilitation was possible immediately after flap transfer. There were no donor-site complications except two widened scars. The microsurgical fabrication of chimeric free flaps, as well established in head and neck reconstruction, can be successfully adapted to massive hand injuries as well. Individual placement of selected tissue components, early comprehensive reconstruction, and reduction of the number of operations are beneficial in cases that need more than one free flap.     

Soft Tissue Coverage at the Resource-challenged Facility

Covering soft tissue defects remains challenging for orthopaedic surgeons, especially those in resource-challenged facilities. Covering tissue defects follow a plan from simple to complex: primary closure, local flap, area flap, pedicle flap, and free flap. I will limit my discussion to the role of latter two. At the district-level hospital in Vietnam, pedicle flaps are generally more useful, so I will discuss free flaps only briefly. The choices of pedicle flaps include: kite flap, posterior interosseous flap, radial flap (Chinese flap), neurocutaneous flap, anterolateral thigh fasciocutaneous flap, gastrocnemius flap, sural flap, posterior leg flaps; we typically use a free flap with the latissimus dorsi. Soft tissue coverage with pedicle flaps has many advantages: reliability, relatively easy harvest, and good blood supply. Free flaps with microanastomosis have an important place in covering difficult medium- or large-sized soft tissue defects but also require more instruments and more highly trained surgeons. The author certifies that he/she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. The author certifies that his/her institution does not require approval for the human protocol for this investigation and that the investigation was conducted in conformity with ethical principles of research.     

Endoscopic harvest of four muscle flaps: safe and effective techniques

The recent explosion of endoscopic techniques in plastic surgery has led to the successful harvest of a number of useful muscle flaps. The gracilis, rectus femoris, external oblique, and gastrocnemius muscles can all be harvested safely and reproducibly using endoscopic techniques. The aim of this study was to identify a safe and effective technique for endoscopic muscle flap harvest. Harvesting the gracilis muscle as a free flap and the gastrocnemius as a pedicle flap lends themselves best to the use of endoscopic techniques.     

An anatomical study and clinical cases of 'super-thin flaps' with transverse cervical perforator.

We present a microangiogram study and clinical cases of super-thin flaps based on a transverse cervical perforator. This flap is the first to use the perforator of the superficial branch of the transverse cervical artery. This flap is more useful for providing colour and texture matches than a skin graft, and it is easier to harvest the flap than a free flap because it is a kind of skin flap.     

Reverse posterior interosseous flap in childhood: a reliable alternative for complex hand defects

Restoration of complex hand defects in children is still problematic because of the limited choices of treatment. The reverse posterior interosseous flap is a versatile flap, with successful results shown in adults. The purpose of this study was to highlight the utility and versatility of the flap and to simplify the technique for ease of harvest in the pediatric age group. Complex hand defects were repaired using this flap in 10 children. Ages of the patients averaged 9.1 years. Fasciocutaneous and osteofasciocutaneous flaps were used in 7 and 3 children, respectively. All flaps survived completely. The average time of bone union was 3 months. This flap can be used with safety and versatility in coverage of children's upper limb. The diameter of the vessels is not a handicap in the flap dissection. Harvest of the flap is easy and rapid, and the operation time is short, as in adult patients.     

Endoscopic harvest of the rectus abdominis muscle

The rectus abdominis muscle is a versatile muscle with many applications. The use of this muscle is often limited by its considerable donor site morbidity. This study reports a minimally invasive technique to harvest the rectus abdominis muscle. The described technique has been used successfully in 5 patients who required a superiorly based flap for reconstruction of a sternal defect. All patients have had long-term flap survival and resolution of their sternal osteomyelitis. Although initially lengthy, harvest times have been less than 1 hour for the last 3 patients. Patients report minimal discomfort at their operative site. To date there have been no hernias or other complications. The rectus abdominis muscle can be harvested successfully endoscopically. With no other modification other than port site placement, this technique could be used to harvest free flaps or harvest inferiorly based rectus flaps. This technique is learned easily, is safe, and should reduce substantially the donor site morbidity associated with more traditional harvesting techniques.     

A modification of technique to cover a large posterior thigh defect using an anterolateral thigh flap

Anterolateral thigh (ALT) flap is one of the popular flaps for soft-tissue reconstruction. It is a versatile flap which commonly used to resurface external skin defect and internal mucosal lining. In addition if raised as musculocutaneous flap, the muscle portion provides bulk to fill up any potential space. With increase knowledge on the vascular anatomy of this flap, it is possible to harvest 2 skin paddles base on more than one branches of the supplying vessel. This technique is commonly employed to provide coverage of more than one epithelial surfaces such as the complex facial defect after maxillectomy where both the cheek skin and oral mucosa reconstruction are required. Using similar concept, we report a case in which a large external skin defect was successfully covered with an ALT flap and the donor site could be closed primarily without skin grafting.     

血管变异型前臂背侧皮瓣修复手部皮肤软组织缺损

目的 探讨骨间后动脉血管变异时前臂背侧皮瓣的切取方法.方法 以骨间后动脉为蒂逆行岛状皮瓣转移修复手部皮肤软组织缺损时,遇到血管变异共9例,采取以骨间后动脉桡侧支为蒂切取逆行岛状前臂背侧皮瓣、以骨间后动脉近端为蒂切取游离骨间后动脉皮瓣、以骨间后动脉穿支为蒂切取游离前臂背侧穿支皮瓣等方法,进行皮瓣转移或移植修复手部创面.结果 9例皮瓣中有8例顺利存活;1例术后2 d皮瓣远端出现肿胀、青紫、小水泡,及时对症处理,5 d后部分皮缘形成干痂,皮瓣颜色恢复正常,脱痂后存活.9例随访3个月至2年,皮瓣质地柔软,弹性好,外形满意.结论 以桡骨间后动脉侧支为蒂的前臂背侧皮瓣逆行转移,以骨间后动脉近端或骨间后动脉穿支为蒂的前臂背侧皮瓣游离移植修复手部创面,是解决骨间后动脉血管变异较理想的方法.     

血管变异型前臂背侧皮瓣修复手部皮肤软组织缺损

目的 探讨骨间后动脉血管变异时前臂背侧皮瓣的切取方法.方法 以骨间后动脉为蒂逆行岛状皮瓣转移修复手部皮肤软组织缺损时,遇到血管变异共9例,采取以骨间后动脉桡侧支为蒂切取逆行岛状前臂背侧皮瓣、以骨间后动脉近端为蒂切取游离骨间后动脉皮瓣、以骨间后动脉穿支为蒂切取游离前臂背侧穿支皮瓣等方法,进行皮瓣转移或移植修复手部创面.结果 9例皮瓣中有8例顺利存活;1例术后2 d皮瓣远端出现肿胀、青紫、小水泡,及时对症处理,5 d后部分皮缘形成干痂,皮瓣颜色恢复正常,脱痂后存活.9例随访3个月至2年,皮瓣质地柔软,弹性好,外形满意.结论 以桡骨间后动脉侧支为蒂的前臂背侧皮瓣逆行转移,以骨间后动脉近端或骨间后动脉穿支为蒂的前臂背侧皮瓣游离移植修复手部创面,是解决骨间后动脉血管变异较理想的方法.     

血管变异型前臂背侧皮瓣修复手部皮肤软组织缺损

目的 探讨骨间后动脉血管变异时前臂背侧皮瓣的切取方法.方法 以骨间后动脉为蒂逆行岛状皮瓣转移修复手部皮肤软组织缺损时,遇到血管变异共9例,采取以骨间后动脉桡侧支为蒂切取逆行岛状前臂背侧皮瓣、以骨间后动脉近端为蒂切取游离骨间后动脉皮瓣、以骨间后动脉穿支为蒂切取游离前臂背侧穿支皮瓣等方法,进行皮瓣转移或移植修复手部创面.结果 9例皮瓣中有8例顺利存活;1例术后2 d皮瓣远端出现肿胀、青紫、小水泡,及时对症处理,5 d后部分皮缘形成干痂,皮瓣颜色恢复正常,脱痂后存活.9例随访3个月至2年,皮瓣质地柔软,弹性好,外形满意.结论 以桡骨间后动脉侧支为蒂的前臂背侧皮瓣逆行转移,以骨间后动脉近端或骨间后动脉穿支为蒂的前臂背侧皮瓣游离移植修复手部创面,是解决骨间后动脉血管变异较理想的方法.