Tissue expansion of free and pedicled flaps after transfer: possibilities and indications

Tissue expansion in combination with flap transfer has been widely reported as preexpansion of flaps, but only once as expansion of a free flap after transfer. Three free flaps and one pedicled flap were expanded after transfer. Indication, timing of expander implantation and explantation, technical aspects, and complications are reviewed. Indications for expander implantation after flap coverage were adjacent scar contracture, a secondary ulcer, or correction of contour deformity. The expander was placed as early as 4.5 months after free flap transfer. Low grade infection and seroma were complications necessitating early expander removal in two cases. The outcome was satisfactory in all four patients. Tissue expansion after flap transfer has been shown to be a reliable reconstructive option in selected cases. Indications are rare and include hypertrophic scar formation, scar contracture, secondary ulceration, or reconstructive procedures. In early free flap expansion, it is critical to avoid mechanical pressure of the pedicle. In musculocutaneous flaps, this can be accomplished by placing the expander subcutaneously. If more than 6 months have passed since transfer of the flap, the randomized blood supply is sufficient to place the expander anywhere under the flap.     

Severe radiation-induced injury after cardiac catheter ablation: a case requiring free anterolateral thigh flap and vastus lateralis muscle flap reconstruction on the upper arm.

Although cases of radiation-induced skin injury after fluoroscopically-guided procedures have been reported since 1996, diagnosis and treatment of such injury remain difficult. We present the case of a patient who complained of two ulcers, one on his right arm and one on his back, and limited motion of the right elbow joint after repeated cardiac radiofrequency catheter ablations. After resection of the skin ulcer on the patient's arm and of degenerated tissue in the distal part of the triceps brachii muscle, a combined free flap incorporating an anterolateral thigh flap and vastus lateralis muscle flap was transplanted. In the present case, this combined flap was very useful for simultaneous reconstruction of the muscle and skin defects under and over the tendon because the muscle flap and skin flap could be arranged separately.     

Lateral arm free flap in oral cavity reconstruction: a functional evaluation

By use of sophisticated techniques now available from the science of Speech Pathology, we can now document, quantify, and critically analyze the surgeon's reconstructive efforts in the oral cavity. Using these methods, we have evaluated the neurotized lateral arm free flap in six patients receiving oral reconstruction. Two of these are reported in detail. This study has provided a protocol that results in the objective analysis of swallowing, articulation, and range of tongue motion and sensation. All of these tests can be routinely performed by a speech pathologist to document both operative performance as well as patient progress in speech and swallowing. It would appear that we have quantified evidence that the neurotized lateral arm free flap may represent a significant step forward in reducing the morbidity of total and subtotal glossectomy by providing a truly functional reconstruction.     

The free lateral arm flap in reconstructive hand surgery

Microsurgical tissue transplantation has provided a great advance in reconstructive surgery, especially regarding upper limb defects. Compared to conventional pedicled flaps, mobilisation can occur earlier, hospital stay is shorter and no additional interventions for pedicle detachment and flap inset are needed. The lateral arm flap is an exceptionally versatile free flap with straightforward dissection and low donor site morbidity. End-to-side anastomosis preserves blood flow through the main arteries to the hand and reduces the risk of vascular compromise of the hand, which is especially important in case of severe hand injuries. Sixteen patients who underwent hand reconstruction using the lateral arm free flap are reviewed. All arterial anastomoses were conducted in end-to-side-technique either to the radial or the ulnar artery. There was no total- or partial-flap failure and only one revisional procedure due to a haematoma under the anastomosis. Eight flaps required secondary defatting, combined with removal of osteosynthesis material or tenolysis. From our point of view the free lateral arm flap is a very reliable and versatile method to resurface small and medium sized hand defects.     

Utility of the lateral arm flap in head and neck reconstruction

Soft-tissue defects of the head and neck are often reconstructed with fasciocutaneous free flaps. The radial forearm flap is used most commonly, however the lateral arm flap may be the flap of choice in certain situations. Advantages include flap elevation with simultaneous tumor ablation, avoidance of intraoperative patient position changes, and primary closure of the donor site. After extirpative procedures of the head and neck region, 4 patients were reconstructed with the lateral arm flap. Flap survival was 100%, a vein graft to supplement the short pedicle length was necessary in 1 patient, all donor sites were closed primarily, and secondary procedures to reduce flap bulk were necessary in 2 patients. The lateral arm flap is an excellent alternative to the radial forearm flap and should be included in the armamentarium of the reconstructive head and neck surgeon.     

Total penile and urethral reconstruction with an expanded sensate lateral arm flap: case report

The use of cutaneous or musculocutaneous flaps for total phalloplasty requires the lack of hairy skin; otherwise urethral strictures most likely will occur. A case of simultaneous total penile and urethral reconstruction using an expanded lateral arm sensory free flap is presented. The use of an expander in a small area of hairless skin on the lateral arm results in a free flap of sufficient size. This procedure proves to be a useful addition to the reconstructive armamentarium in dealing with similar challenging cases of penile reconstruction.     

Analytic review of 2372 free flap transfers for head and neck reconstruction following cancer resection

Microvascular free tissue transfer has gained world-wide acceptance as a means of reconstructing post-oncologic surgical defects in the head and neck region. Since 1977, the authors have introduced this reconstructive procedure to head and neck reconstruction after cancer ablation, and a total of 2372 free flaps were transferred in 2301 patients during a period of over 23 years. The most frequently used flap was the rectus abdominis flap (784 flaps: 33.1 percent), followed by the jejunum (644 flaps: 27.2 percent) and the forearm flap (384 flaps: 16.2 percent). In the reported series, total and partial flap necrosis accounted for 4.2 percent and 2.5 percent of cases, respectively. There was a significant statistical difference ( p < 0.05) in complete flap survival rate between immediate and secondary reconstruction cases. The authors believe that the above-mentioned three flaps have been a major part of the armamentarium for head and neck reconstruction because of a lower rate of flap necrosis, compared to other flaps.     

Reconstruction of complex parotidectomy defects using the lateral arm free tissue transfer.

OBJECTIVES: The study goal was to show that the lateral arm flap is a viable reconstructive option for complex parotidectomy defects.Study design and setting We studied a case series at a tertiary care medical center from March 1997 to March 2002. The lateral arm flap was used to reconstruct parotidectomy defects that included a composite resection of adjacent tissue in 30 patients. There were 19 men and 11 women (mean age, 62 years; mean follow-up, 19 months). The mean flap area was 114 cm(2), and the mean flap volume was 172 cm(3). The posterior cutaneous nerve of the forearm (PCNF) was used as a facial nerve cable graft in 14 patients. Facial disability outcomes were measured using the Facial Clinimetric Evaluation scale. RESULTS: The major and minor complication rates with use of this reconstructive approach were low: 16.7% (5 of 30) and 26.7% (8 of 30), respectively. Donor site morbidity was minimal, with no patient having a major donor site complication and 23.3% (7 of 30) having minor complications. Functional recovery of the facial nerve occurred in 6 of 8 evaluable patients who underwent facial nerve grafting using the PCNF. Controlling for degree of facial nerve paralysis, Facial Clinimetric Evaluation scale scores of our patients were not statistically different than those of a historic population with a facial paralysis and no surgical defect. CONCLUSIONS: The lateral arm free flap effectively restores facial appearance when used for reconstruction of complex parotidectomy defects. The PCNF, a nerve harvested with the lateral arm flap, can be used as a facial nerve cable graft with a high rate of success. SIGNIFICANCE: The lateral arm flap is successful as a single donor site for reconstructing facial contour and the facial nerve after major ablative defects in the parotid region.     

Reconstruction of foot dorsiflexion using lateral arm free flap with vascularized triceps tendon

A lateral arm free flap including vascularized triceps tendon was transferred to reconstruct the tibialis anterior tendon and skin defects over the anterior distal third of the left cruris of a patient who was injured by gunshot. Four months after surgery, the patient walked and ran well, and dorsiflexed his ankle joint actively to 10°. Considering cosmetic appearance, it was obvious that the flap suited the recipient area perfectly.     

Use of anterolateral thigh and lateral arm fasciocutaneous free flaps in lateral skull base reconstruction

Lateral skull base defects following tumor ablation are ideally reconstructed with microvascular free tissue transfer. Although the rectus abdominis free flap is the workhorse in skull base reconstruction, it has a number of drawbacks. Anecdotal reports have indicated that fasciocutaneous free flaps may be useful alternatives in selected cases. Patients undergoing lateral arm (4 cases) or anterolateral thigh (8 cases) fasciocutaneous free flap reconstruction of lateral skull base defects between 1999 and 2005 were therefore reviewed. Twelve consecutive patients (4 males, 8 females) with a mean age of 63 years (range, 39 to 74) underwent such reconstruction following resection of lateral (11 cases) and anterolateral (1 case) skull base lesions. Eight patients had squamous cell carcinoma, 3 had infection or osteoradionecrosis, and 1 had adenoid cystic carcinoma. The duration of surgery (from induction of anesthesia to exit from the operating room) averaged 14.5 hours (range, 10 to 19.5 hours). All donor sites were closed directly. All the flap transfers were successful, with minimal reconstructive and donor site morbidity. During the follow-up period (average, 18 months; range, 2-48 months), 2 patients died of metastatic disease, and another 2 died of other unrelated causes. The remaining 8 patients are alive and disease free. It is concluded that lateral arm and anterolateral thigh fasciocutaneous free flaps should be considered as viable reconstructive options for lateral skull base ablative defects.     

Microsurgical repair after excision of large cancers. Apropos of 14 cases]

The specialty which has benefited the most from the rapid development of reconstructive microsurgery over the last decade, has been plastic surgery. In particular, the authors refer to reconstructive microsurgery after malignant tumor resection. Resections which used to cause serious psychological problems or which required multiple reconstructive procedures, can now be performed as a single stage procedure with good oncological, functional and aesthetic results. This experience concerns the treatment of 14 primary or recurrent malignant tumors of the skin and soft tissues using microsurgical techniques. The free latissimus dorsi musculocutaneous flap was the flap most commonly used. The authors also used the groin flap, the scapular flap, the tensor fasciae latae flap, the dorsalis pedis flap and finally the jejunum combined with the second metatarsus to reconstruct the mandible and the floor of the mouth. Complications consisted of complete necrosis of a dorsalis pedis flap and two revisions were performed for venous thrombosis. With a minimum follow-up of 5 years, one patient has developed a local recurrence and another has developed regional lymph node metastases. The functional and aesthetic results were quite satisfactory. The authors believe that microsurgery is a very valuable technique to treat difficult reconstructive problems.     

Microvascular Free Flaps in Early Reconstruction of Burns in the Hand and Forearm: Case Reports

In the reconstructive plastic surgery a free flap provides a one-stage method to achieve an optimal functional and aesthetic result. We report five acute burns or early contractions of the hand and forearm with free-flap reconstruction. In each case an attempt was made to design the flap to restore missing tissue components. We used three different musculocutaneous free flaps and two free skin flaps: a latissimus dorsi, a rectus abdominis and a rectus femoris renervated musculocutaneous flap, as well as a dorsalis pedis and a horizontal fasciocutaneous upper arm flap. In all five cases, the hand and wrist showed early restoration of function.     

自体组织移植进展

目的综述骨科领域较常见的自体组织移植,如皮瓣、肌瓣、骨(膜)瓣等移植在修复重建外科应用的现状及对未来的发展进行展望.方法回顾近几年国内外有关自体组织移植发展的文献,进行分析整理,总结其应用进展,并根据多年的临床经验,指出今后的发展方向.结果目前临床选用较多的几个游离皮瓣供区是股前外侧皮瓣、背阔肌皮瓣、上臂外侧皮瓣、肩胛皮瓣、颞顶筋膜瓣以及各种穿支皮瓣等.其中穿支皮瓣具有受区修复好和供区损失小的优点.由于肌肉皮瓣游离移植的优点较多,因此替代了单纯肌肉游离移植.较常用的肌皮瓣为背阔肌肌皮瓣,可急诊移植血管桥接修复,也可保留胸背神经移植修复,或应用桥式游离肌皮瓣移植修复等.骨缺损、骨不连是骨科的一大难题.常用的带血供骨移植供骨部位有肋骨、髂骨、腓骨及肩胛骨等,可应用治疗大块骨缺损、骨不连、骨缺损、股骨头缺血性坏死及骨肿瘤切除后植骨等.结论利用自体组织移植来修复组织缺损已成为修复重建外科手术方式之一.     

Reconstructive potential of the lateral arm flap after tumor resection

The reconstruction of extended tumor-related defects in different anatomic regions requires a versatile and reliable flap. For many surgeons, the lateral arm flap has become the technique of choice in the reconstruction of small- to medium-sized defects. The aim of this study was to analyze the reconstructive potential of the lateral arm flap after cancer ablation in various indications. Between 1998 and 2006, 14 patients underwent reconstruction with differently composed and designed lateral arm flaps at our institution. Complete coverage of all defects was achieved with a single surgical procedure. With a flap survival rate of 100% in our series, excellent long term results and high patient satisfaction combined with low donor site morbidity, we can recommend the use of the lateral arm flap in tumor patients.     

Reconstruction of large defect of foot with extensive bone loss exclusively using a latissimus dorsi muscle free flap: a potential new indication for this flap

In cases of extensive damage to the foot, with significant bone loss, it is generally accepted that reconstruction must include bone flaps or grafts either in the emergency setting or subsequently. In this report, we describe the case of an 18-year-old student with an avulsion injury of the dorsum of his right foot. Consequently, he lost most of the soft tissue over the dorsum of the foot and the cuboid, navicular, and cuneiform bones. A latissimus dorsi free flap was used to reconstruct the defect. A functional pseudoarthrosis developed between the remaining bones of the foot, and the patient experienced satisfactory foot function after rehabilitation. For this reason, no additional reconstructive procedure was undertaken. This case suggests that it might be adequate to use the latissimus dorsi muscle flap more liberally than previously reported in the reconstruction of extensive defects of the dorsum of the foot, including cases with significant bone loss. This option could avoid the morbidity and inconvenience of a second surgery and the need to harvest a bone flap or graft.     

Skin expansion before breast reconstruction with the superior gluteal artery perforator flap improves aesthetic outcome

To improve the aesthetic outcome in the reconstructed breast and in the flap donor area, the technique of skin expansion in the mastectomy site was used in eight patients who subsequently underwent breast reconstruction using the superior gluteal artery perforator (SGAP) flap. The authors think that skin expansion before final reconstructive surgery provides adequate ptosis and better positioning of the flap on the chest, leading to a more natural appearance and symmetry of the reconstructed breast. Furthermore, the skin expansion reduces the amount of free flap skin required for breast reconstruction, resulting in less donor site scarring and morbidity. They present their surgical refinements to improve the aesthetic appearance of the breast reconstructed using the SGAP flap.     

Free flap donor site refinement using tissue expansion

Posttransfer tissue expansion has been used to negate concern for the aesthetic donor site deformity following 15 free tissue transfers involving donor sites of the scalp, trunk, and extremities. There appears to be no contraindication to placing these implants immediately, as was done in 87% of cases, although it is recommended that expansion be delayed until adequate wound healing has occurred at any skin graft interface. This technique has had major positive benefits for refining the radial forearm flap and hair-bearing temporoparietal fasciocutaneous flap defects, which may have heretofore been avoided secondary to aesthetic concerns. Tissue expansion techniques should be considered as an important adjunct for any microsurgical reconstructive effort.