The Role of Pedicled Latissimus Dorsi Flap in Scalp Defect Reconstruction Following Tumour Excision

Scalp is a common site for skin tumors mainly squamous cell carcinoma and basal cell carcinoma. It is always challenging to reconstruct the scalp defect following tumor excision. Conventional methods of skin grafting or rotation flap is not always feasible for large scalp defect. This paper presents the author’s experience in 3 patients of scalp tumors in which conventional methods were not sufficient to reconstruct the defect, hence pedicled latissimus dorsi flap was used considering the flap size to cover the defect and reach needed for the pedicled flap. In all the 3 cases latissimus dorsi myocutaneous was able to reach the defect site and cover the large scalp defect area; thereby serving as an alternative to free flap which is technically more challenging, skill based and less feasible in normal surgical settings.     

带蒂穿支皮瓣在乳房再造术中的应用

与游离穿支皮瓣相比,带蒂穿支皮瓣分离技术更加简单,安全系数更高,而且供区畸形更小。近年来,应用带蒂穿支皮瓣技术已经成为乳房再造手术一种新的选择, 甚至是一些患者的首选方案。常用的带蒂穿支皮瓣有胸背动脉穿支皮瓣、肋间动脉穿支皮瓣(外侧肋间动脉穿支皮瓣、前侧肋间动脉穿支皮瓣)等,其他可用的选择包括前锯肌动脉穿支皮瓣,腹壁上动脉穿支皮瓣,胸外侧动脉穿支皮瓣等。为了提高手术设计的精确性,术前需要评估穿支血管的质量,并对其定位穿支。皮瓣的设计相比游离皮瓣手术而言,显得更加重要。虽然带蒂穿支皮瓣在乳房再造领域的作用尚不能取代游离皮瓣的金标准地位,但随着“损伤最小化”重建概念的日渐推广,带蒂穿支皮瓣将会成为乳房再造领域里的一种新的趋势。     

Choice of flaps for breast reconstruction

The optimal method for breast reconstruction should be safe, reliable, and accessible for every patient, and it should display little or no donor-site morbidity. After comparing mammary implants it has been found that autogenous breast reconstruction can create a ptotic, soft, symmetrical breast mound. The transverse rectus abdominis musculocutaneous flap (TRAM) remains the most popular method for autogenous reconstruction. Modern trends in breast reconstruction using the TRAM flap have promoted adequate blood supply to the flap while minimizing donor-site defects in the anterior abdominal wall. The pedicled TRAM flap remains one of the most frequently used flaps, but the indirect blood supply in this flap has required many modifications and refinements. Such modifications have included the bipedicled TRAM flap, the free TRAM flap, and the supercharged TRAM flap. To avoid donor-site morbidities, the muscle-sparing free TRAM, deep inferior epigastric perforator flap (DIEP), and superficial inferior epigastric artery (SIEA) flap were introduced. The DIEP perforator flap requires meticulous technique but offers proven reliability and a low rate of complications. As surgeons become more comfortable with harvesting DIEP flaps, the frequency of usage seems likely to increase. The latissimus dorsi musculocutaneous flap, gluteus maximus musculocutaneous flap, and others may be selected when these modifications of free TRAM flap are unavailable or unusable.     

Reconstruction of full-thickness cheek defects after cancer surgery

The value of various surgical techniques used to reconstruct full-thickness cheek defects is discussed. Small defects can be repaired with the use of local cervical skin flaps with a random vascular pattern. Axial pattern temporal flap is another choice, either alone or combined with a cervical flap. Whenever local tissues are not suitable (i.e. after irradiation or neck dissection) a transfer of distant myocutaneous island flap based on a pedicle of axial muscle vessels is a valuable alternative. Split skin graft may form a good intra-oral lining of such island flap.     

A novel technique for cheek mucosa defect reconstruction using a pedicled buccal fat pad and buccinator myomucosal island flap

Reconstruction of cheek mucosa defects following tumor resections can be approached with several techniques, depending on size of the defect. Fasciocutaneous and perforators free flaps are widely employed today for such reconstructions. However, small defects or general health of the patient may limit their indications. Furthermore, approaching moderate size defects, some techniques, like temporalis muscle or fascia pedicled flaps, lead to contracture with limitation of mouth opening or trisma, and others, like intraoral local flaps, do not provide enough tissue for the reconstructions. In this work the authors propose, for reconstructing these kind of defects, the use of a buccinator myomucosal island flap and a buccal fat pad pedicled flap association. A case is reported and the surgical technique is explained. This new reconstructive technique can easily be used for reconstructing moderate-sized cheek defects, achieving optimal results: the internal mucosal lining is restored in few weeks without any retraction, contracture, of scars on the face limiting the aesthetic outcome and mouth opening.     

One stage reconstruction of the floor of the mouth with a subcutaneous pedicled nasolabial flap

BackgroundNasolabial flaps have been recognised as versatile flaps for a variety of defects in the face, nose, lip and the oral cavity. Random pattern inferiorly based nasolabial flaps (NLF) have been utilised for covering small defects on the anterior floor of the mouth, but usually require a second stage procedure to divide the flap base. A subcutaneous pedicled inferiorly based nasolabial flap can provide a one stage repair of moderate sized defects of the floor of the mouth after de epithelialisation of the base of the flap.AimTo evaluate the feasibility of a single stage reconstruction of intermediate sized defects in the oral cavity with an inferiorly based pedicled NLF. The study includes the indications of use of the flap, flap design, technique, and the complications rate. The incidence of secondary procedures and the final functional and the aesthetic results will also be evaluated.Materials and methodsA group of 20 patients presented with (T1–2) squamous cell carcinoma of the oral cavity have been treated at the Department of Surgery, National Cancer Institute, Cairo; in the period between January 2008 and September 2010. The pathology was confirmed with an incision biopsy and all metastatic work were carried out confirming that all patients were free from distant metastasis at presentation. Preoperative assessment also included assessment of the stage of the disease, the flap design and patient fitness for general anaesthesia. All patients underwent surgical excision combined with reconstruction of the defect with a subcutaneous inferiorly based pedicled NLF. The proximal part of the flap was routinely de epithelialised before it has been tunnelled through the cheek so a one stage procedure could only be required.ResultsThe mean age of the patients was 62.3 ± 6 years, range (52–69 years). All patients were diagnosed with squamous cell carcinoma. The anterior floor of the mouth constituted 40% of the defects, the lateral floor of the mouth 20% and the inner surface of the cheek 40%. There was no reported major complication; and only one patient suffered a reactionary haemorrhage that required re-exploration to secure the bleeder. A single procedure was adequate in most patients (80%), only 20% of patients required revision of the scar at the donor site or release of the tongue. The overall aesthetic results were either very satisfactory or satisfactory in the majority of patients (90%). Two patients were not satisfied with the final aesthetic results, one suffered from ectropion and the other had a donor site wound healing problem. The functional results (deglutition, speech) were satisfactory in most patients (70%), all were edentulous.ConclusionAn inferiorly based pedicled NLF is a reliable flap for the reconstruction of small and medium sized defects in the oral cavity. The flap can be best utilised for old edentulous and high risk patients where it can be used as a single stage procedure which is particularly useful in those types of patients. The flap can be safely combined with neck dissection even when the facial artery was ligated.     

肿瘤致颅顶部穿通性组织缺损的修复

目的:探讨肿瘤致颅顶部穿通性组织缺损的外科修复方法和临床效果。方法:回顾性分析我院30例颅顶部肿瘤切除后造成的穿通性组织缺损修复方法。头皮软组织层修复:局部头皮瓣或/和供区游离皮片移植术修复23例;带血管蒂肌皮瓣5例;吻合血管的前臂游离皮瓣2例。颅骨修复:一期钛板修复10例,二期钛板修复2例,其余18例未修复。硬脑膜修复:30例均行硬脑膜修补,除3例用人工脑膜补片外,其余全部用自体材料包括颅骨骨膜、颞肌筋膜、帽状腱膜、阔筋膜。术后16例行放射治疗,剂量50Gy~75Gy,4例行化学治疗。结果:主要并发症有皮瓣部分坏死4例、脑脊液漏2例、颅内感染1例、癫痫2例、轻偏瘫2例、下极面瘫1例、昏迷7天后苏醒1例。结论:肿瘤致颅顶部穿通性组织缺损可以成功修复,关闭颅腔,术后行综合治疗,患者生存率和生存质量得到改善。     

乳腺癌改良根治术后即刻乳房再造不同方法的临床应用

目的：探讨乳腺癌改良根治术后即刻乳房再造不同方法的适应证、手术方法及优缺点。方法：本组37例乳腺癌患者,分别采用横形腹直肌肌皮瓣带蒂转移、腹壁下动脉穿支皮瓣吻合血管游离移植、背阔肌肌皮瓣带蒂转移、单纯乳房假体置入以及不同方法相结合进行术后即刻乳房再造。结果：除2例单纯TRAM皮瓣患者近腋窝皮瓣局部坏死,1例TRAM＋DIEP联合皮瓣患者下腹正中局部皮瓣脂肪液化外,余34例皮瓣全部成活,形态满意。随访5个月-10年,无腹部薄弱或腹壁疝等并发症,患者生活质量均得到提高。结论：乳腺癌术后即刻再造安全可行,不同的方法各有优缺点,应根据患者具体情况选择适合患者本人的方法进行乳房再造。     

Deep inferior epigastric artery perforator free flaps in head and neck reconstruction

The advantage of free perforator flaps versus free musculocutaneous flaps is the reduced morbidity of the donor site with preservation of nerves, muscles and deep fascia. In this study, we evaluated the reconstruction results of deep inferior epigastric artery perforator (DIEAP) free flaps in the head and neck. A retrospective review was performed of 12 patients with head and neck tumor ablation defects that were reconstructed with the deep inferior epigastric artery perforator (DIEAP) free flaps between January 2004 and December 2006. Reconstruction outcomes and complications were measured. Recipient sites were subdivided into defects of total or subtotal glossectomy (N=6), three-dimensional defects of midface (N=3), through and through defects of the cheek (N=2), and anterior skull base resection with an external skin component defect (N=1).The overall free flap success rate was 92% (11/12). One DIEAP free flap was lost because the draining jugular vein thrombosed. No complications were observed in the donor site, including abdominal bulge or hernia. Due to the advantage of minimum donor site morbidity, the DIEAP free flap is a new and reliable reconstruction choice for head and neck surgical defects.     

Reconstruction of maxillectomy and midfacial defects with free tissue transfer

The maxillary bones are part of the midfacial skeleton and are closely related to the eyeglobe, nasal airway, and oral cavity. Together with the overlying soft tissues, the two maxillae are responsible to a large extent for facial contour. Maxillectomy defects become more complex when critical structures such as the orbit, globe, and cranial base are resected, and reconstruction with distant tissues become essential. In this article, we describe a classification system and algorithm for reconstruction of these complex defects using various pedicled and free flaps. Most defects that involve resection of the maxilla and adjacent soft tissues may be classified into one of the following four types: Type I defects, Limited maxillectomy; Type II defects, Subtotal maxillectomy; Type III defects, Total maxillectomy; and Type IV defects, Orbitomaxillectomy. Using this classification, reconstruction of maxillectomy and midfacial defects may be approached considering the relationship between volume and surface area requirements, that is, addressing the bony defect first, followed by assessment of the associated soft tissue, skin, palate, and cheek-lining deficits. In our experience, most complex maxillectomy defects are best reconstructed using free tissue transfer. The rectus abdominis and radial forearm free flap in combination with immediate bone grafting or as an osteocutaneous flap reliably provide the best aesthetic and functional results. A temporalis muscle pedicled flap is used for reconstruction of maxillectomy defects only in those patients who are not candidates for a microsurgical procedure.     

IMMEDIATE BREAST RECONSTRUCTION WITH LATISSIMUS DORSI MUSCULOCUTANEOUS FLAP： A SUITABLE OPTION FOR CHINESE WOMEN AFTER MASTECTOMY

Objective： To discuss the suitable immediate breast reconstruction modalities for Chinese patients by comparing the pedicled transverse rectus abdominis myocytaneous flap （TRAM） reconstruction with latissimus dorsi myocytaneous flap （LTD） reconstruction plus implants or not after mastectomy due to breast cancer. Methods： From Jan. 2000 to Jul. 2005, 74 staged 0-II patients （mean age 39） were performed immediate breast reconstruction with autologous tissue either using LTD flaps or pedicled TRAM flaps with supplemental implants when necessary after mastectomy due to breast cancer and the charts were reviewed. Results： The age, marriage and menses status did not affect the selection of modalities and the need of implants. In 74 patients, 62 cases （83.8%） were performed LTD reconstruction with 13 implants and 12 cases received TRAM with 1 implant. The difference in need of implants or not between the two modalities had no statistical significance （P=0.442, Fisher＇ exact test）. Aesthetic results judged as good or fair were in 88% patients and the cosmetic effects between LTD and TRAM groups or implant and non-implant groups had no differences. All reconstructions were successful, with 4.1% cumulative locoregional recurrence and 100% overall survival by following up to 66 months （median 9 months）. The DFS and RFS between the two modalities had no significant differences by log rank test. Conclusion： Immediate autologous tissue reconstruction makes it possible to regain the natural and symmetric contour of breast without increased local recurrence. The LTD flap reconstruction is a suitable option for most Chinese women as well as the pedicled TRAM flap.     

改良带蒂胸大肌皮瓣修复头颈部晚期恶性肿瘤术后复杂缺损的临床应用

背景与目的：带蒂胸大肌皮瓣因为具有多种优点一直是头颈部组织缺损修复应用的经典组织瓣。当今,随着显微技术普及和提高,游离组织瓣逐步取代了带蒂组织瓣。然而,临床上并非所有病例均适宜接受游离组织瓣修复手术,邻近带蒂组织瓣更安全可靠。拟通过改进胸大肌皮瓣的制备及修复方法,探讨改良带蒂胸大肌皮瓣在修复头颈部晚期恶性肿瘤术后复杂缺损时的应用。方法：在皮瓣设计方案及制备方法等多方面改进胸大肌皮瓣,修复头颈部晚期恶性肿瘤术后复杂缺损患者51例。结果：51例改良胸大肌皮瓣全部存活,缺损区修复后外形和供区外形情况满意,缺损区功能得到良好的恢复,供区术后功能损伤最小化。结论：胸大肌皮瓣在设计及制备方法等多方面的改良,提高了对头颈部恶性肿瘤术后复杂缺损修复的范围及修复的距离,减少皮瓣坏死的概率,术后供区和受区外形、功能效果满意,目前仍然是头颈部恶性肿瘤术后缺损的重要修复手段之一。     

双侧旋转皮瓣一期修复头皮巨大肿物切除后继发创面

目的：为头皮巨大肿物切除后形成的近似圆形缺损，寻求一种较简便安个、损伤小的一期修复方法方法，方法：在直径5cm-10cm的头皮缺损区周围，选择、设计双侧旋转皮瓣，剥离后将皮瓣旋转移他修复创面，供区拉拢缝合。结果：术后皮瓣全部成活，伤口均Ⅰ期愈合。其中49例获随访1年～6年，病变无复发。修复区头发生长良好，瘢痕不显露。结论：双侧旋转皮瓣一期修复中等大小的头皮缺损，可充分利用邻近的头皮组织，设计灵活，操作简单，创伤相对较小，术后不遗留秃发，瘢痕不显露。     

带蒂胸大肌肌皮瓣移植在头颈癌放疗后手术中的运用

目的:探讨头颈癌放疗后因肿瘤复发进行挽救性手术,带蒂胸大肌肌皮瓣修复手术切除后软组织缺损的可行性和价值。方法:7例头颈部恶性肿瘤进行了根治性放疗后局部复发或颈淋巴结转移,通过手术切除病灶,颈淋巴结清扫,同侧带蒂胸大肌肌皮瓣移植修复软组织缺损创面。结果:7例移植的带蒂胸大肌肌皮瓣全部成活,有2例出现切口裂开,愈合困难。结论:在头颈癌放疗后手术中,带蒂胸大肌肌皮瓣移植是修复手术切除后软组织缺损的有效方法。     

带蒂肌皮瓣在肢体软组织肉瘤术中皮肤缺损修复中的临床应用

目的：探讨带蒂肌皮瓣在肢体软组织肉瘤术中皮肤和肌肉创面缺损修复中的临床应用。方法回顾性分析32例肢体软组织肉瘤切除术中皮肤及肌肉创面缺损行带蒂肌皮瓣修复的临床资料、手术方式和预后。结果术后病理切缘阴性率100豫。术后获得随访26例,随访时间8（2~11）个月,Ⅱ、Ⅲ期肉瘤局部控制率为82豫、76豫,皮瓣修复成活率为95豫。结论规范化的肢体软组织肉瘤手术可降低肿瘤局部复发率,但常致术中皮肤及肌肉创面缺损无法直接缝合,而带蒂肌皮瓣是常用的重要创面缺损修复手段,成功的创面修复可明显提高患者术后的生活质量。     

Surgical therapy of vulvar cancer: how to choose the correct reconstruction?

ObjectiveTo create a comprehensive algorithmic approach to reconstruction after vulvar cancer ablative surgery, which includes both traditional and perforator flaps, evaluating anatomical subunits and shape of the defect.MethodsWe retrospectively reviewed 80 cases of reconstruction after vulvar cancer ablative surgery, performed between June 2006 and January 2016, transferring 101 flaps. We registered the possibility to achieve the complete wound closure, even in presence of very complex defects, and the postoperative complications. On the basis of these experience, analyzing the choices made and considering the complications, we developed an algorithm to help with the selection of the flap in vulvoperineal reconstruction after oncologic ablative surgery for vulvar cancer.ResultsWe employed eight types of different flaps, including 54 traditional fasciocutaneous V-Y flaps, 23 rectus abdominis myocutaneous flaps, 11 anterolateral thigh flaps, three V-Y gracilis myocutaneous flaps, three free style perforators V-Y flaps from the inner thigh, two Limberg flaps, two lotus flaps, two deep inferior epigastric artery perforator flap, and one superficial circumflex iliac artery perforator flap. The structures most frequently involved in resection were vulva, perineum, mons pubis, groins, vagina, urethra and, more rarely, rectum, bladder, and lower abdominal wall.ConclusionThe algorithm we implemented can be a useful tool to help flap selection. The key points in the decision-making process are: anatomical subunits to be covered, overall shape and symmetry of the defect and some patient features such as skin laxity or previous radiotherapy. Perforator flaps, when feasible, must be considered standard in vulvoperineal reconstruction, although in some cases traditional flaps remain the best choice.     

Vertical rectus abdominis myocutaneous flap cover for lower abdomen, chest wall, groin and thigh defects following resection of malignant tumours

Vertical rectus abdominis mycutaneous (VRAM) flap provides a reliable flap cover for large soft tissue defects of chest wall, torso, groin, perineum and thigh. It has been mainly used in trauma and benign conditions. Between January 1994 through January 1999, eight patients with locally advanced malignant tumors underwent radical resection and reconstruction using pedicled VRAM flap. Inferiorly based VRAM flap was used in five patients and superiorly based VRAM flap in three patients. Defect size ranged from 144 to 900 CM2. (mean 386 cm2). Average blood loss for combined resection and reconstruction was 600ml. (range 400-800 ml.) Primary closure of both donor and recipient sites achieved in all patients. There was no wound infection, flap necrosis or abdominal hernia. There patients received postoperative radiotherapy and chemotherapy and two patients received radiotherapy only. All the the patients are alive and free of local recurrence at mean follow up 32 months. Results of our study shows that VRAM flap is versatile and sturdy flap with a wide are of rotation and it can reach diverse anatomical sites like torso, chestwall, thigh and perineum to cover large defects following radical resection for tumors.     

各种皮瓣在足底负重区恶性黑色素瘤术后缺损修复中的应用

目的：探讨足底内侧皮瓣、局部逆行岛状皮辫、外踝上穿支皮瓣、内踝上穿支皮瓣和游离股前外侧皮瓣修复足底负重区恶性黑色素瘤广泛切除术后缺损的优缺点。方法：浙江省肿瘤医院骨和软组织肿瘤外科2010-01-13-2013-12～25收治的23例足底负重区皮肤恶性黑色素瘤患者,进行原发灶广泛切除后分别采用足底内侧皮瓣、局部逆行岛状皮瓣、外踝上穿支皮瓣、内踝上穿支皮瓣及游离股前外侧皮瓣进行修复,对其临床资料和随访结果进行分析。结果：术后缺损面积为4cm×4cm～11cm×9cm,切取皮瓣面积5cmX5cm～12cm×10cm。14倒足底内侧皮瓣全部成活,其中皮瓣最大切取面积为7cm×7cm。1例局部逆行岛状皮瓣出现小部分坏死,二期愈合,4例外踝上及内踝上穿支皮瓣全部成活,其中皮瓣最大切取面积为12cm×10cm。4例游离股前外侧皮瓣中,3例成活,1例皮瓣出现远端部分浅表性坏死,经换药后愈合。所有患者无继发性渍疡出现,患足均可无痛行走。2例行足底内侧皮瓣修复术后出现局部复发。结论：各种皮瓣修复足底黑色素瘤术后缺损均可获得较好疗效,对较小足根部的缺损（直径〈8cm）首选足底内侧皮瓣,较大的缺损可采用内外踝上穿支皮瓣,有显微外科条件的可考虑游离股前外侧皮瓣修复局部皮瓣不能覆盖的缺损。     

Selective reconstructive options for the anterior skull base

Carcinomas of the ethmoid, frontal, or maxillary sinuses sometimes invade the anterior skull base. It is necessary to perform en-bloc resection for this invasive carcinoma according to the concepts of surgical treatment for head and neck cancer. The anterior skull base consists of two parts, the orbital roof as the lateral portion and the roofs of the frontal sinus, ethmoid sinus, and/or sphenoid sinus as the central portion. Selective reconstructive options for the anterior skull base depend on the size of the defect of the skull base. A dural defect is repaired by a fascia lata or a pericranial flap. After the dura has been tacked up, reconstruction of the anterior skull base is performed simultaneously with augmentation of the defect of extracranial structures. Larger defects that consist of both central and lateral portions with orbitomaxillary structures are reconstructed by a bulky musculocutaneous flap such as a rectus abdominis or latissimus dorsi flap. The bony reconstruction of supraorbital structures is also to be considered esthetically. On the other hand, intraorbital tissues are basically preserved in cases of central defects of the anterior skull base. These defects are reconstructed by a free forearm flap or a local flap such as a de-epithelialized midline forehead flap or a pericranial flap. We have selected and applied these flaps in 37 patients as reconstructive options for the anterior skull base since 1989. Eleven of the 37 patients had larger defects and 26 had central defects. De-epithelialized midline forehead flaps were used in 20 patients and were recognized to be a very useful and reliable reconstructive option for central defects of the anterior skull base.     

Modification of the infra hyoid musculo-cutaneous flap.

BACKGROUND: In 1986, Wang described the infra hyoid musculo-cutaneous flap. Here, we report technical adaptations and improvements to this flap. METHODS: From 1994 to 1996, we performed 61 infrahyoid flaps using the classical procedure. After 5 years of technical evolution, we studied a new series of 91 flaps from January 2000 to June 2002. We reviewed our experience with the infra hyoid flap and described the surgical procedure, its evolution and the impact on the viability of the flap. RESULTS: In the two series, the main arterial pedicle was usually the superior thyroid artery. Venous drainage was more variable; consequently we always performed a modified neck dissection with preservation of the internal jugular vein. In the first series, the surgical results were good with only seven local complications essentially skin necrosis. The functional and aesthetic results seemed acceptable. In the second series, the results, after technical evolution with better venous drainage and cervical closure, were improved (only one necrosis) and the indications were extended. CONCLUSION: With experience, the infra hyoid myocutaneous flaps is reliable and appears as a particularly useful flap for oral cavity, oral pharynx and pharyngeolaryngeal reconstruction.