Customized reconstruction with the free anterolateral thigh perforator flap

From April of 2003 through September of 2006, 70 free anterolateral thigh (ALT) flaps were transferred for reconstructing soft-tissue defects. The overall success rate was 96%. Among 70 free ALT flaps, 11 were elevated as cutaneous ALT septocutaneous vessel flaps. Fifty-seven were harvested as cutaneous ALT myocutaneous "true" perforator flaps. Two flaps were used as fasciocutaneous perforator flaps based on independent skin vessels. Fifty-four ALT flaps were used for lower extremity reconstruction, 11 flaps were used for upper extremity reconstruction, 3 flaps were used for trunk reconstruction, and 1 flap was used for head and neck reconstruction. Total flap failure occurred in 3 patients (4.28% of the flaps), and partial failure occurred in 5 patients (7.14% of the flaps). The three flaps that failed completely were reconstructed with a free radial forearm flap, a latissimus dorsi flap and skin grafting, respectively. Among the five flaps that failed partially, three were reconstructed with skin grafting, one with a sural flap, and one with primary closure. The free ALT flap has become the workhorse for covering defects in most clinical situations in our center. It is a reliable flap with consistent anatomy and a long, constant pedicle diameter. Its versatility, in which thickness and volume can be adjusted, leads to a perfect match for customized reconstruction of complex defects.     

Free and island flap transfer for soft tissue defects in the hand and forearm

Two hundred twenty patients with soft tissue defects in the hand and forearm were treated with 226 free and island flap transfers. Reconstructed sites involved the thumb in 74 cases, the fingers in 117, the hand in 30, and the forearm in 5. Seventy-nine patients received 82 free flaps, and 141 patients received 144 island flaps. Fifty-six finger reconstruction cases and 73 of 74 thumb reconstruction cases had sensory flap transfers. In the free flap transfer group, 77 flaps survived (93.9%), and 5 failed. In the island flap transfer group, 140 flaps survived (97.2%), and 4 failed. Of the five-failures in the free flap transfers, four were dorsalis pedis flaps, two of which were on patients with an arteriovenous fistula. Of the four failures in the island flap transfers, two were posterior interosseous flaps and two were digital island flaps. All four were reverse-flow island flaps. © 1996 Wiley-Liss, Inc.     

Upper extremity reconstruction using free SCIA/SIEA flap

The most suitable free flap alternative in upper extremity reconstruction has adequate and quality of tissue with consistent vascular pedicle. Free flap must provide convenient tissue texture to reconstruct aesthetic and functional units of upper extremity. Furthermore, minimal donor site morbidity is preferred features in free flap election. In our efforts to obtain the best possible outcome for patients, we chose, as a first priority, the free superficial circumflex inferior artery (SCIA)/superficial inferior epigastric artery (SIEA) flap over other free flap options for the soft‐tissue reconstruction of upper extremities. The authors retrospectively report the results of 20 free SCIA/SIEA flaps for upper extremity reconstruction during the past 3 years. Nineteen of 20 flaps were successful (95%): three required emergent postoperative reexploration of the anastomosis and one failed. Flap thinning (n = 4) was performed during the flap harvest, whereas some flaps were thinned with secondary debulking (n = 4). The functional and aesthetic results were evaluated as acceptable by all patients. Based on our results, a free SCIA/SIEA flap has the following advantages in soft‐tissue reconstruction of the upper extremity: (1) if necessary, flap thinning may be performed safely at the time of flap elevation and (2) flaps are harvested using a lower abdominal incision so that it causes minimal donor site scar. © 2009 Wiley‐Liss, Inc. Microsurgery, 2010.     

The fate of the failed second-attempt free flap.

The superiority of a free flap in many clinical situations is unparalleled and, fortunately, initial failure rates have become almost nonexistent. Nevertheless, failures do occur, and then often an attempt at a second free flap transfer is the only worthy alternative for the same reason. In the author's experience during the past two decades, a second attempt was indicated after the failure of 19 free flaps. There were two distinct groups. Intraoperative failure was recognized for eight flaps and a second free flap was attempted immediately, with a 50% success rate. The rest were redone on a delayed basis, with 63.7% successful-a rate that was not statistically different from the first group. There were eight second failures (42.1%) overall. The need for vein grafts was the only notable factor associated with a higher risk for second flap failure (seven of eight failed second flaps). The ultimate fate of failed flaps was dismal, in that three required limb amputations and two have had unstable wounds for more than 15 years. This morbidity vindicated the difficult decision to undertake a second free flap attempt, which never can be taken lightly. Because successful flaps avoided these problems, an aggressive approach is emphasized, including an immediate second free flap attempt if conditions are favorable.     

Penis reconstruction using three different operative methods.

To identify the relative success rates, including aesthetic success, of three penis reconstruction techniques, we reviewed 44 cases of penis reconstruction carried out over the past 12 years. The three operative methods we surveyed involved: lower abdominal pedicled fascia flaps; paraumbilical island flaps; and free forearm flaps. Reconstructions survived in only half of the patients receiving lower abdominal pedicled fascia flaps, but 100% success rates were obtained with paraumbilical island flaps and free forearm flaps. The paraumbilical island flap is safe in terms of its blood supply, and the operative procedure is relatively simple in that it does not require microsurgery. Although, the flap is thicker than the forearm skin flap, its shape is satisfactory in slim patients; furthermore, it can be defatted secondarily. The free forearm skin flap provides the best shape, but skilled microsurgery is necessary to carry out the procedure, and damage is likely to the forearm. In conclusion, the best methods to repair defects in the penis in our experience are the paraumbilical island flap and free forearm flap. Lower abdominal pedicled fascia flaps are unsuitable for penile reconstruction and should be used less often.     

显微外科皮瓣修复[足母]甲瓣供区的临床应用

目的探讨应用显微外科皮瓣对[足母]甲瓣供区进行修复的临床疗效,并对皮瓣选择做出分析。方法应用5种近位足部带蒂皮瓣和2种远位游离皮瓣对57例[足母]甲瓣供区软组织缺损进行修复。其中近位带蒂皮瓣33例:带蒂足跗外侧动脉皮瓣2例,以第1跖背动脉的跖蹼穿支为蒂的足背逆行皮瓣15例,带第1跖背动脉的足背逆行皮瓣3例,顺行足第2趾胫侧皮瓣11例,逆行足底内侧皮瓣2例,足部皮瓣供区行全厚皮片游离植皮。远位游离皮瓣24例:游离腹股沟皮瓣13例,游离股前外侧皮瓣11例。皮瓣供区均直接缝合。结果57例皮瓣中53例成活良好;以第1跖背动脉的跖蹼穿支为蒂的足背逆行皮瓣3例远端部分坏死,经换药治疗后创面愈合;游离腹股沟皮瓣1例术后发生血管危象,经血管探查术后未缓解,Ⅱ期行游离植皮修复[足母]甲瓣供区创面。术后随访2~12个月,行走姿态良好。结论合适的显微皮瓣技术可以良好的修复[足母]甲瓣供区创面,保全肢体的完整性,减少医源性损伤,患者更容易接受[足母]甲瓣移植的手术方式。皮瓣选择不应只关注[足母]趾供区的修复,更应合理运用显微皮瓣技术,重视供、受区的平衡。     

Free tissue transfers at Hutt Hospital

Background: The Wellington Regional Plastic, Maxillofacial & Burns Unit based at Hutt Hospital provides comprehensive reconstructive services to central New Zealand with a population of 1.1 million. Free tissue transfer procedures in the Unit were audited to determine the indications and rate of usage in our population, our success and complication rates, and how these compare with published series. Methods: Prospectively collected data on all free tissue transfer procedures between January 2006 and September 2010 were analysed. Results: Two hundred and seven free flaps including 17 flap types being performed on 186 consecutive patients including 199 primary and 8 salvage flaps. Eighty‐three percent were elective and 17% were acute cases. The majority of the flaps were used for head and neck (48%) and breast (31.5%) reconstruction. Ulnar forearm flap was the most commonly used fasciocutaneous flap. 18.8% of patients had major complications requiring return to theatre. Microsurgical revision was performed in nine (4.3%) flaps of which six were successfully salvaged. Overall, 13 flaps (6.3%) failed completely, giving an overall success rate of 93.7%. Haematoma requiring formal drainage occurred in 12 (5.8%) cases. Discussion: The wide variety of flaps used reflects the very broad range of defects requiring free flap reconstruction. We show a free flap success rate of 93.7% in our medium‐sized regional unit. Our microsurgical revision rate of 4.3% is lower than the revision rate of 10% in reported series with high overall success rates. More consistent early detection of failing flaps is likely to further improve our overall success rate.     

Scalp reconstruction by microvascular free tissue transfer

We report on a series of patients with scalp defects who have been treated with a variety of free flaps, spanning the era of microvascular free tissue transfer from its incipient stages to the present. Between 1971 and 1987, 18 patients underwent scalp reconstruction with 21 free flaps: 11 latissimus dorsi, 3 scalp transfers between identical twins, 3 groin, one combined latissimus dorsi and serratus anterior, two serratus anterior, and one omentum. These flaps were used to cover scalp defects resulting from burns, trauma, radiation, and tumors in patients ranging from 7 to 79 years of age. Follow-up has ranged from 3 weeks to 7 years. All of our flaps survived and covered complex defects, many of which had failed more conservative attempts at cover. One patient received radiation therapy to his flap without unfavorable sequelae. This experience began with a pioneering omental flap and includes cutaneous and muscle flaps. The latissimus dorsi is our first choice for free flap reconstruction of extensive, complicated scalp wounds because of its large size, predictable blood supply, ease of harvesting, and provision of excellent vascularity to compromised beds.     

ONE-STAGE RECONSTRUCTION OF DEFECTS IN THE HYPOPHARYNGEAL REGION WITH FREE FLAPS

Despite the almost universal poor prognosis, the reconstruction of combined cervical skin and hypopharyngeal defects after extensive resection of tumour should maintain optimal quality of life. From 1992 to 1996 we treated 10 patients with combined skin and hypopharyngeal defects with five fasciocutaneous free flaps, three myocutaneous latissimus dorsi free flaps, one myocutaneous VRAM (vertical rectus abdominis muscle) free flap and one free radial forearm flap. None of our flaps failed. The complications that required revision (one arterial bleeding, one arterial thrombosis, two fistula formations, one superficial wound dehiscence, one haematoma) occurred mainly in those patients having secondary reconstructions. After primary extensive oncological resection of these tumours reconstruction should be done in one stage. The primary reconstruction should provide sufficient pharyngeal lining, a satisfactory covering of cervical soft-tissue, and adequate functional rehabilitation. We have reviewed our experience and conclusions about the advantages, disadvantages, and current indications for different free flaps in the reconstruction of combined hypopharyngeal, cervico-oesophageal, and cervical skin defects.     

One-stage reconstruction of defects in the hypopharyngeal region with free flaps.

Despite the almost universal poor prognosis, the reconstruction of combined cervical skin and hypopharyngeal defects after extensive resection of tumour should maintain optimal quality of life. From 1992 to 1996 we treated 10 patients with combined skin and hypopharyngeal defects with five fasciocutaneous free flaps, three myocutaneous latissimus dorsi free flaps, one myocutaneous VRAM (vertical rectus abdominis muscle) free flap and one free radial forearm flap. None of our flaps failed. The complications that required revision (one arterial bleeding, one arterial thrombosis, two fistula formations, one superficial wound dehiscence, one haematoma) occurred mainly in those patients having secondary reconstructions. After primary extensive oncological resection of these tumours reconstruction should be done in one stage. The primary reconstruction should provide sufficient pharyngeal lining, a satisfactory covering of cervical soft-tissue, and adequate functional rehabilitation. We have reviewed our experience and conclusions about the advantages, disadvantages, and current indications for different free flaps in the reconstruction of combined hypopharyngeal, cervico-oesophageal, and cervical skin defects.     

Use of colour duplex Doppler imaging in the postoperative assessment of buried free flaps

The postoperative assessment of free flaps is essential to identify and act on signs of incipient flap failure. Where the flap is completely buried, this becomes almost impossible unless part of the flap is exteriorised or an overlying skin window is used. Alternatively, complicated and often impractical monitoring devices have been advocated, but these have failed to gain widespread acceptance. A simpler solution to this problem has been evaluated in a series of patients using colour duplex Doppler imaging. This re-appraisal of a previously reported technique has been facilitated by updated technology in diagnostic radiology. Duplex Doppler imaging was confirmed as an accurate, non-invasive, and inexpensive tool for the postoperative measurement of blood flow within the pedicles of five buried free flaps in four patients undergoing surgery in our unit.     

Reconstruction of Complicated Skull Base Defects Utilizing Free Tissue Transfer

We managed five patients with large skull base defects complicated by complex infections with microvascular free tissue transfer. The first patient developed an infection, cerebrospinal fluid (CSF) leak, and meningitis after undergoing a translabyrinthine resection of an acoustic neuroma. The second patient had a history of a gunshot wound to the temporal bone, with a large defect and an infected cholesteatoma that caused several episodes of meningitis. The third through the fifth patients had persistent CSF leakage and infection refractory to conventional therapy. In all cases prior attempts of closure with fat grafts or regional flaps had failed. Rectus abdominis myofascial free flap, radial forearm free flap or a gracilis muscle free flap was used after debridement of the infected cavities. The CSF leaks, local infections, and meningitis were controlled within a week. In our experience, microvascular free tissue provides the necessary bulk of viable, well-vascularized tissue, which not only assures a mechanical seal but also helps clear the local infection.     

Management of complicated wounds of the extremities with scapular fascial free flaps

Management of complicated open wounds of the extremities represents a reconstructive challenge. The goal of reconstruction is to provide coverage of exposed vital structures with well-vascularized tissues for optimal restoration of its form and function. We present our experience with the use of scapular fascial free flaps in the reconstruction of complicated open wounds of the extremities. During the period 2001 to 2009, a total of 12 reconstructions utilizing scapular fascial free flaps were performed: nine for upper extremity wounds and three for lower extremity wounds. Two flaps failed: in one case due to intractable vasospasm, in the other case due to lack of adequate recipient vessels. In the ten successful cases, good functional and aesthetic outcomes were achieved. Based on our experience, we conclude that the scapular fascial free flap, although technically demanding, could be considered as the flap of choice for reconstruction of complicated open wounds of the extremities; it provides ample thin and well vascularized soft tissue coverage with restoration of function and a natural contour of the extremity.     

Free flaps in the reconstruction of hand and distal forearm injuries.

We report a series of 32 free flap reconstructions following acute hand and forearm trauma. The series consists of two dorsalis pedis flaps, four scapular flaps and 26 lateral arm flaps. One flap became infected and failed completely, and a partial necrosis occurred in another flap. The transfers covered large skin defects, exposed tendons, tendon grafts, bone, bone grafts, joints, nerves and nerve grafts. The donor site morbidity was negligible. Our study shows that free microvascular flaps are a safe and convenient alternative to conventional flaps in hand surgery. The lateral arm flap seems very suitable for small and medium size defects.     

Changes in the blood biochemistry following experimental flap ischaemia

The purpose of this study was to elucidate tissue changes occurring within an ischaemic flap by monitoring the blood biochemistry, and to evaluate these changes in relation to ultimate flap viability. A rabbit epigastric free flap was made ischaemic for 4 days at 6 degrees C, then revascularized by anastomosis of its femoral artery and vein. An identical free flap immediately revascularized in another group of rabbits served as a control. The viability of the free flap, as well as various biochemical parameters studied by drawing blood from a catheter in the ear vein, were observed daily. Immediately after the revascularization of ischaemic flaps, there was a 16-fold increase in the plasma levels of creatine kinase (CK) and a smaller but significant 1.5-fold to 2.0-fold increase in lactate dehydrogenase (LDH) and aspartate aminotransferase (AST). In flaps which ultimately failed by 7 days post-ischaemia, the plasma levels of CK, LDH and AST peaked at day 2 post-ischaemia at 68, 13 and 8 times normal respectively, whereas in flaps which survived, the levels of these enzymes recovered to normal by day 3 post-ischaemia. These enzymic changes are probably due to a combination of ischaemic changes in the flap vasculature, ischaemic changes in the flap muscle, and inflammatory changes in the surrounding abdominal tissue. The plasma levels of CK at any time post-ischaemia, and particularly in the first 24 h, were significantly higher in ischaemic flaps which failed compared with those which survived. This parameter is therefore proposed as a possible means of predicting potential flap failure after ischaemic insult, in time to make appropriate surgical intervention.     

Thrombolytic therapy: what is its role in free flap salvage?

Thrombolytic agents have been demonstrated to improve free flap salvage in animal models. However, clinical evidence regarding their efficacy has been scant. The authors reviewed their experience with flap salvage using thrombolytic therapy in 1,733 free flaps from February 1990 to July 1998. Patients with intraoperative pedicle thrombosis were excluded from this review. Forty-one of the 55 free flaps that were reexplored emergently were identified as having pedicle thrombosis. Of these 41 flaps, 28 free flaps were salvaged (flap salvage group, 68%) and 13 free flaps failed (flap failure group, 32%). Thrombolytic therapy (urokinase in 7 patients, tissue plasminogen activator in 1 patient) was used in six flaps in the flap salvage group and two flaps in the flap failure group. Statistical analysis demonstrated no difference between the two groups with regard to thrombolytic therapy. There was also no difference between the two groups with regard to use of systemic heparin (100-500 U per hour) at the time of pedicle thrombosis or with regard to whether Fogarty catheters were used. Smoking, preoperative radiotherapy, and the use of interpositional vein grafts during initial flap reconstruction had no impact on the outcome of flap salvage. The flap salvage group was reexplored at a mean of 1.5 days compared with the flap failure group, which was reexplored at a mean of 4.2 days (p = 0.007). Early detection of pedicle thrombosis remains the most important factor in the salvage of free flaps. Although these numbers are small and definitive statements cannot be made, the role of thrombolytic agents in free flap salvage requires further clinical evaluation.     

Venous flaps in digital revascularization and replantation

This is a report on 15 patients who underwent replantation/revascularization of a single digit with a substantial dorsal soft tissue defect. The dorsal defect was covered with a venous flap, a free flap that has only venous inflow and outflow. Postoperatively, the venous flaps were warm, pink, and appeared to exhibit a blanch and refill phenomenon, clinically resembling capillary filling. The flaps from the dorsal aspect of an uninjured digit had a survival rate of 100 percent, with no partial necrosis, while the flaps from a forearm or dorsal foot donor site failed. The advantages of using venous free flaps are twofold. Not only does this technique provide for venous drainage, but it also provides flap coverage and avoids complications, such as vessel occlusion or hematoma formation, associated with skin grafting over a venous anastomosis, with subsequent loss of the skin graft.     

Clinical uses of lower abdominal cutaneous and myocutaneous flaps. Report of 19 cases

Since 1985, 19 cases of tissue defects were repaired with the lower abdominal cutaneous and myocutaneous flaps. Among them, 16 were free cutaneous and myocutaneous flaps and 3 island flaps. The sizes of these flaps ranged from 6 x 7 cm to 30 x 14 cm. Of them, 1 failed, 1 partially and 17 completely survived with satisfactory results. The blood supply of the lower abdominal flap differed from groin flap and seemed to have a constant vascular anatomy with a long pedicle and large diameter, so that dissection of the flap could be accomplished easily. The flap was suitable for repair of large defect of soft tissue. In this paper, improvement of operative technique and two representative cases were presented.     

Reconstruction of the mandible with autogenous bone following treatment for squamous carcinoma

In a series of 24 patients treated for squamous carcinoma of the oral cavity and oropharynx, 26 mandibular reconstructions using 27 grafts or flaps were performed. Reconstruction was immediate in 23 cases and delayed in three. There were five 'simple' bone grafts, 10 pedicled compound myocutaneous flaps, and 12 vascularized free compound flaps. Operative mortality was 12% and complication rate 65%, but 70% of the grafts survived till death or follow-up of the patients. Three 'simple' bone grafts failed and were removed. Three of five compound pectoralis major flaps failed along with one of five pedicled compound latissimus dorsi flaps. Only one vascularized free compound flap was lost. The major cause of graft failure was intra-oral suture line dehiscence exposing the bone to saliva. Under these circumstances, bone graft necrosis occurred when blood supply to the bone was poor--viz. 'simple' grafts and compound pectoralis major flaps. The vascularized free compound flaps were most reliable but the need for jaw preservation where possible and better patient selection are recognized.     

A study of the use of the supraclavicular artery flap for resurfacing of head, neck, and upper torso defects

The head and neck region is an aesthetically demanding area to resurface because of its high visibility. Tissue defects in this area often require distant flaps or free flaps to achieve an aesthetically acceptable result. The use of the Supraclavicular artery flap represents an extremely versatile and useful option for the resurfacing of head, neck and upper torso defects. Furthermore, islanding the flap gives it a wide arc of rotation and the color and texture match is superior to that of free flaps harvested from distant sites. In our study, we used the flap (both unexpanded and expanded) predominantly for resurfacing neck defects resulting from the release of post-burn contractures. However, its applicability in other indications would also be similar. Except one, all our flaps survived almost completely and the post-operative morbidity was very low. We conclude that the supraclavicular artery flap not only provides a reasonably good color and texture match but also maintains the multi-directional activity in the neck region.