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Thomas B, Falkner F, Gazyakan E, Harhaus L, Kneser U, Bigdeli AK. [The conjoined latissimus dorsi and parascapular free flap for reconstruction of extensive soft tissue defects]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2023:10.1007/s00064-023-00806-w. [PMID: 37154965 DOI: 10.1007/s00064-023-00806-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 02/08/2021] [Accepted: 02/14/2021] [Indexed: 05/10/2023]
Abstract
OBJECTIVE Durable and resilient soft tissue reconstruction of vast defects of the extremities or the torso. INDICATIONS Reconstruction of disproportionately large defects, particularly in cases of simultaneous bone and joint reconstruction. CONTRAINDICATIONS History of surgery or irradiation of upper back and axilla, impossibility of surgery under lateral positioning; relative contraindications in wheelchair users, hemiplegics, or amputees. SURGICAL TECHNIQUE General anesthesia and lateral positioning. First, the parascapular flap is harvested, with the initial skin incision made medially in order to identify the medial triangular space and the circumflex scapular artery. Flap raising then proceeds from caudal to cranial. Second, the latissimus dorsi is harvested, with the lateral border being dissected free first, before the thoracodorsal vessels are visualized on its undersurface. Flap raising then proceeds from caudal to cranial. Third, the parascapular flap is advanced through the medial triangular space. If the circumflex scapular and thoracodorsal vessels originate separately from the subscapular axis, an in-flap anastomosis is warranted. Subsequent microvascular anastomoses should be performed outside the zone of injury, typically in an end-to-end fashion of the vein and end-to-side fashion of the artery. POSTOPERATIVE MANAGEMENT Postoperative anticoagulation with low-molecular-weight heparin under anti-Xa monitoring (semitherapeutic in normal-risk and therapeutic in high-risk cases). Hourly clinical assessment of flap perfusion for 5 consecutive days, followed by stepwise relaxation of immobilization and commencement of dangling procedures in cases of lower extremity reconstruction. RESULTS Between 2013 and 2018, 74 conjoined latissimus dorsi and parascapular flaps were transplanted to cover vast defects of the lower (n = 66) and upper extremity (n = 8). The mean defect size was 723 ± 482 cm2 and the mean flap size was 635 ± 203 cm2. Eight flaps required in-flap anastomoses for separate vascular origins. There was no case of total flap loss.
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Affiliation(s)
- Benjamin Thomas
- Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie - Schwerbrandverletztenzentrum der Ruprecht-Karls-Universität Heidelberg, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen am Rhein, Deutschland
| | - Florian Falkner
- Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie - Schwerbrandverletztenzentrum der Ruprecht-Karls-Universität Heidelberg, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen am Rhein, Deutschland
| | - Emre Gazyakan
- Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie - Schwerbrandverletztenzentrum der Ruprecht-Karls-Universität Heidelberg, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen am Rhein, Deutschland
| | - Leila Harhaus
- Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie - Schwerbrandverletztenzentrum der Ruprecht-Karls-Universität Heidelberg, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen am Rhein, Deutschland
| | - Ulrich Kneser
- Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie - Schwerbrandverletztenzentrum der Ruprecht-Karls-Universität Heidelberg, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen am Rhein, Deutschland
| | - Amir Khosrow Bigdeli
- Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie - Schwerbrandverletztenzentrum der Ruprecht-Karls-Universität Heidelberg, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen am Rhein, Deutschland.
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Bigdeli AK, Thomas B, Falkner F, Radu CA, Gazyakan E, Kneser U. Microsurgical reconstruction of extensive lower extremity defects with the conjoined parascapular and latissimus dorsi free flap. Microsurgery 2020; 40:639-648. [PMID: 32822085 DOI: 10.1002/micr.30640] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 06/27/2020] [Accepted: 07/28/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND Extensive lower extremity soft-tissue defects pose a reconstructive challenge. We present our experience with the conjoined parascapular and latissimus dorsi (CPLD) free flap. METHODS From October 2008 to October 2017, 69 patients (14 female, 55 male) with a mean age of 50 years (range: 16-79 years) underwent reconstruction of lower extremity defects with the CPLD free flap. Mean defect size was 24 × 36 cm (range: 14 × 20 to 45 × 80 cm). RESULTS Mean latissimus dorsi (LD) flap size was 19 × 28 cm (range: 14 × 20 to 28 × 42 cm) and mean parascapular (PSC) flap size was 8 × 25 cm (range: 5 × 12 to 11 × 33 cm). Six patients (9%) experienced a total of eight microvascular complications: arterial thrombosis (n = 1), venous thrombosis (n = 6), combined arterial and venous thrombosis (n = 1). The re-exploration rate was 13%. Major complications of the donor-site were seen in 9 patients (13%), of the flap in 13 patients (19%), and of both in 6 patients (9%). Fifteen patients experienced partial flap necrosis (22%). Three CPLD and one PSC flap were lost (5%). PSC flap length was a significant predictor of distal flap necrosis (χ2 (1) = 13.2, p = .004, OR = 1.343, 95% CI [1.098-1.642]). PSC flap width was a significant predictor of donor-site revisions (χ2 (1) = 15.9, p = .010, OR = 4.745, 95% CI [1.584-14.213]). Arterio-venous loops (AVLs) tended to increase the risk of microvascular thrombosis (χ2 (1) = 3.7, p = .08, OR = 4.1, 95% CI [0.9-18.7]). CONCLUSIONS The CPLD free flap is an extremely large and highly reliable flap, allowing one-stage reconstruction of extensive lower extremity defects. It may overcome the need for multiple flaps in selected cases.
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Affiliation(s)
- Amir K Bigdeli
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Benjamin Thomas
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Florian Falkner
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Christian A Radu
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Emre Gazyakan
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
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Ayyala HS, Mohamed OM, Therattil PJ, Lee ES, Keith JD. The forearm fillet flap: 'spare parts' reconstruction for forequarter amputations. CASE REPORTS IN PLASTIC SURGERY AND HAND SURGERY 2019; 6:95-98. [PMID: 31595221 PMCID: PMC6764346 DOI: 10.1080/23320885.2019.1666718] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 09/08/2019] [Indexed: 11/24/2022]
Abstract
Radical forequarter amputation is often performed for recurrent proximal extremity tumors. A free forearm fillet flap is used to provide excellent coverage of the resultant defect without donor site morbidity. Use of a free flap from the distal portion of the extremity with proximal tumor burden is safe and effective.
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Affiliation(s)
- Haripriya S Ayyala
- Division of Plastic Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Omar M Mohamed
- Division of Plastic Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Paul J Therattil
- Division of Plastic Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Edward S Lee
- Division of Plastic Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Jonathan D Keith
- Division of Plastic Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
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Bigdeli AK, Thomas B, Schmidt VJ, Kotsougiani D, Hernekamp FJ, Hirche C, Kneser U, Gazyakan E. The conjoined parascapular and latissimus dorsi free flap for reconstruction of extensive knee defects. Microsurgery 2018; 38:867-875. [DOI: 10.1002/micr.30361] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Revised: 05/02/2018] [Accepted: 06/20/2018] [Indexed: 01/26/2023]
Affiliation(s)
- Amir K. Bigdeli
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen; Hand and Plastic Surgery, University of Heidelberg; Ludwigshafen Germany
| | - Benjamin Thomas
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen; Hand and Plastic Surgery, University of Heidelberg; Ludwigshafen Germany
| | - Volker J. Schmidt
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen; Hand and Plastic Surgery, University of Heidelberg; Ludwigshafen Germany
| | - Dimitra Kotsougiani
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen; Hand and Plastic Surgery, University of Heidelberg; Ludwigshafen Germany
| | - Frederick J. Hernekamp
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen; Hand and Plastic Surgery, University of Heidelberg; Ludwigshafen Germany
| | - Christoph Hirche
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen; Hand and Plastic Surgery, University of Heidelberg; Ludwigshafen Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen; Hand and Plastic Surgery, University of Heidelberg; Ludwigshafen Germany
| | - Emre Gazyakan
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen; Hand and Plastic Surgery, University of Heidelberg; Ludwigshafen Germany
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The Chimeric Versatility of the Subscapular System Revisited: Backup Options, Coverage for Bone Transplants and Vascularized Lymph Nodes. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2018; 6:e1765. [PMID: 29922554 PMCID: PMC5999433 DOI: 10.1097/gox.0000000000001765] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 03/01/2018] [Indexed: 11/26/2022]
Abstract
Traumatic soft tissue and bone defects are demanding challenges for the reconstructive microsurgeons. Common and safe workhorses for these reconstructions are free microvascular flaps based on the subscapular system. In this article, we want to demonstrate the versatility of the serratus anterior muscle combined with other components of the subscapular system for reconstruction of complex lower extremity defects. Three patients with traumatic soft tissue and bone defects of the lower extremity were planned for reconstruction. The defects varied in size and could be covered by 1 or 2 slips of the serratus muscle or split muscle combined with latissimus dorsi muscle flap. In 1 case, the thoracodorsal lymph node package was included for addressing severe posttraumatic lymphedema after burn injury. In another case, the serratus slips served as coverage for a free scapula bone transplant. The chimeric flaps healed without complications; no further operations were needed for reconstruction. By the use of only 1 or 2 slips of the serratus muscle, we could prevent functional impairments for the patients and reduced further scarring compared with classic latissimus dorsi-(para-) scapular combinations.
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Azouz SM, Castel NA, Vijayasekaran A, Rebecca AM, Lettieri SC. Lower-limb reconstruction with chimeric flaps: The quad flap . Microsurgery 2018; 39:182-187. [PMID: 29737002 DOI: 10.1002/micr.30335] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 03/19/2018] [Accepted: 04/06/2018] [Indexed: 12/22/2022]
Abstract
Early soft-tissue coverage is critical for treating traumatic open lower-extremity wounds. As free-flap reconstruction evolves, injuries once thought to be nonreconstructable are being salvaged. Free-tissue transfer is imperative when there is extensive dead space or exposure of vital structures such as bone, tendon, nerves, or blood vessels. We describe 2 cases of lower-extremity crush injuries salvaged with the quad flap. This novel flap consists of parascapular, scapular, serratus, and latissimus dorsi free flaps in combination on one pedicle. This flap provides the large amount of soft-tissue coverage necessary to cover substantial defects from skin degloving, tibia and fibula fractures, and soft-tissue loss. In case 1, a 51-year-old woman was struck by an automobile and sustained bilateral tibia and fibula fractures, a crush degloving injury of the left leg, and a right forefoot traumatic amputation. She underwent reconstruction with a contralateral quad free flap. In case 2, a 53-year-old man sustained a right tibia plateau fracture with large soft-tissue defects from a motorcycle accident. He had a crush degloving injury of the entire anterolateral compartment over the distal and lower third of the right leg. The large soft-tissue defect was reconstructed with a contralateral quad flap. In both cases, the donor site was closed primarily and without early flap failures. There was one surgical complication, an abscess in case 2; the patient was taken back to the operating room for débridement of necrotic tissue. There have been no long-term complications in either case. Both patients achieved adequate soft-tissue coverage, avoided amputation, and had satisfactory aesthetic and functional outcomes. With appropriate surgical technique and patient selection, the quad-flap technique is promising for reconstructing the lower extremity.
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Affiliation(s)
- Solomon M Azouz
- Division of Plastic and Reconstructive Surgery, Mayo Clinic Hospital, Phoenix, Arizona
| | - Nikki A Castel
- Mayo Clinic School of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota.,Division of Plastic and Reconstructive Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Aparna Vijayasekaran
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota
| | - Alanna M Rebecca
- Division of Plastic and Reconstructive Surgery, Mayo Clinic Hospital, Phoenix, Arizona
| | - Salvatore C Lettieri
- Division of Plastic and Reconstructive Surgery, Mayo Clinic Hospital, Phoenix, Arizona
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Zhang YZ, Wen SZ, Zhang HQ, Li YG, Zhao JM, Yang Y. Three-dimensional digitalized virtual planning for saphenous artery flap: a pilot study. Comput Assist Surg (Abingdon) 2016; 21:102-106. [PMID: 27973959 DOI: 10.1080/24699322.2016.1209243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVE Since the 1970s, research and applications on flap and muscle flap had solved many problems in microsurgical reconstruction. However, the traditional flap design is completely dependent on two-dimensional (2D) images. The purpose of this study was to discuss the methods in the visualization of saphenous artery flap by digitalized technique and its applications by digitalized technique. METHODS Two adult fresh cadaver specimens, one male and one female, were subject to radiographic computerized tomography (CT) scanning before and after perfused with lead oxide-gelatine mixture, whose collimation are 0.625 mm (120 kV, 110 mA, 512 × 512 matrix). Through Amira 5.4.1 software, the 2D images in DICOM format were transformed into the 3D models of the entire region. The structures of saphenous artery were observed and the digitized visible models of saphenous artery flap were established through three-dimensional (3D) computerized reconstructions methods from these data using Amira 5.4.1 software. Next six cases of soft-tissue defects of the tibia region, involving the exposure bones underwent contrast-enhanced CT angiography of lower limbs utilizing a 64-row multi-slice spiral CT after median cubital vein injection with Ultravist (3.5 ml/s). 2D images from these data in DICOM format were transformed into computer. The structures of saphenous artery flap were observed and measured using Amira 5.4.1 software. Then, all cases were treated by saphenous artery flap. RESULTS The 3D reconstructed visible models established from these datasets perfectly displayed the saphenous artery flap anatomy. In six cases, the main trunk and branched of the blood vessels in the designed flap were consistent with the surgical findings. The starting point of the saphenous artery to the average distance of the knee clearance were 119.2 ± 9.6 mm, the average diameter of the saphenous artery from the starting point were 1.5 ± 0.3 mm. The range of flap was 8.0 × 5.0 cm to 20.0 × 8.0 cm. All flaps survived well. After 8-24 months' follow-up the knee flexion was 120-140°, the straight 0-10°. There was no case appeared incision infection. CONCLUSIONS The preoperative use of 3D digitalized virtual planning for the saphenous artery flap improves the surgical accuracy, decreases the operation time and increases the survival rate of the flap.
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Affiliation(s)
- Yuan Z Zhang
- a Department of Orthopaedics , the Affiliated Hospital of Inner Mongolia Medical University , Hohhot , People's Republic of China
| | - Shu Z Wen
- b Department of Orthopaedics , the Second Affiliated Hospital of Inner Mongolia Medical University , Hohhot , People's Republic of China
| | - Hui Q Zhang
- c Department of Special Diagnosis , Inner Mongolia Unit hospital of Chinese Armed Police Force , Hohhot , People's Republic of China
| | - Ya G Li
- b Department of Orthopaedics , the Second Affiliated Hospital of Inner Mongolia Medical University , Hohhot , People's Republic of China
| | - Jian M Zhao
- c Department of Special Diagnosis , Inner Mongolia Unit hospital of Chinese Armed Police Force , Hohhot , People's Republic of China
| | - Yong Yang
- a Department of Orthopaedics , the Affiliated Hospital of Inner Mongolia Medical University , Hohhot , People's Republic of China
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Coverage of Amputation Stumps Using a Latissimus Dorsi Flap With a Serratus Anterior Muscle Flap. Ann Plast Surg 2016; 76:88-93. [DOI: 10.1097/sap.0000000000000220] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Stalder MW, Wise MW, Dupin CL, St Hilaire H. Versatility of subscapular chimeric free flaps in the secondary reconstruction of composite posttraumatic defects of the upper face. Craniomaxillofac Trauma Reconstr 2015; 8:42-9. [PMID: 25709752 DOI: 10.1055/s-0034-1384739] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2013] [Accepted: 12/26/2013] [Indexed: 10/24/2022] Open
Abstract
High energy injuries to the upper face present challenging reconstructive problems. In some cases, initial reconstructive efforts result in unfavorable outcomes that require secondary intervention. Chimeric free flaps based on the subscapular system offer the tissue components and volume needed for these complex reconstructions. This is a series of five patients who underwent secondary reconstruction of the middle and upper face following traumatic injury. Mechanism of injury, prior attempts at reconstruction, and characteristics of the tissue defects and the flaps used in their reconstruction are described. Two patients were female and three were male. Three injuries resulted from gunshot wounds, and two from motor vehicle accidents. All patients had multiple prior failed attempts at reconstruction using local/regional tissue. Defects included symptomatic oronasal or oro-orbital fistulas, enophthalmos, and forehead contour deformities. Two of the flaps used included scapular bone and latissimus muscular components, and three included scapular bone and thoracodorsal artery perforator-based skin paddle components. All free tissue transfers were successful, and no patients suffered significant complications. Chimeric free flaps based on the subscapular system offer a valuable secondary strategy for reconstruction of composite defects of the upper face when other options have been exhausted through previous efforts.
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Affiliation(s)
- Mark Winston Stalder
- Division of Plastic and Reconstructive Surgery, Louisiana State University School of Medicine, New Orleans, Louisiana
| | - Matthew Whitten Wise
- Division of Plastic and Reconstructive Surgery, Louisiana State University School of Medicine, New Orleans, Louisiana
| | - Charles L Dupin
- Division of Plastic and Reconstructive Surgery, Louisiana State University School of Medicine, New Orleans, Louisiana
| | - Hugo St Hilaire
- Division of Plastic and Reconstructive Surgery, Louisiana State University School of Medicine, New Orleans, Louisiana
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Mitsimponas KT, Iliopoulos C, Stockmann P, Bumiller L, Nkenke E, Neukam FW, Schlegel KA. The free scapular/parascapular flap as a reliable method of reconstruction in the head and neck region: A retrospective analysis of 130 reconstructions performed over a period of 5 years in a single Department. J Craniomaxillofac Surg 2014; 42:536-43. [DOI: 10.1016/j.jcms.2013.07.023] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Revised: 06/05/2013] [Accepted: 07/31/2013] [Indexed: 10/26/2022] Open
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Karle WE, Anand SM, Clain JB, Scherl S, Buchbinder D, Smith ML, Urken ML. Use of a combined latissimus dorsi scapular free flap revascularized with vein grafting to the internal mammary artery in a vessel-depleted and previously irradiated neck. Head Neck 2012; 35:E328-32. [PMID: 23152141 DOI: 10.1002/hed.23194] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2012] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND For patients who have extensive prior treatment, use of the internal mammary artery/vein (IMA/IMV) or cephalic vein has been shown to be a reliable option. Additionally, for those patients who require vascularized bone and extensive soft tissue reconstruction, the combined latissimus dorsi scapular free flap (mega-flap) is an excellent option. METHODS We reviewed 3 cases in which extensive prior surgery and radiation precluded the use of traditional recipient vessels in the neck. RESULTS Three patients with major jaw deformities were reconstructed using a mega-flap. In all cases, saphenous vein grafting succeeded in achieving arterial inflow from the IMA to the subscapular artery. Venous egress was achieved using a vein graft to the IMV in 1 patient and a transposed cephalic vein in the remaining 2 patients. CONCLUSIONS This approach of restoring large oral cavity defects for patients with extensive prior therapy and comorbid conditions has proven to be reliable and reproducible.
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Affiliation(s)
- William E Karle
- Albert Einstein College of Medicine, New York, New York; Thyroid Head and Neck Cancer Foundation, New York, New York
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Abstract
BACKGROUND Forequarter and hind-limb amputations are used with curative and palliative intent in the setting of proximal limb, thorax, or truncal malignancies. For these large defects that require a free flap, the distal portions of these limbs can be harvested as fillet flaps and represent the "spare parts" concept of surgical reconstruction. METHODS The authors performed a retrospective review of 27 patients (mean age, 51.4 years) who had undergone immediate reconstruction with free fillet extremity flaps between 1991 and 2008. Seventeen patients received preoperative radiotherapy, and 21 received preoperative chemotherapy. Resections included seven hemipelvectomies, 16 forequarter amputations, and four hindquarter amputations. RESULTS The mean defect size was 1126 cm (range, 480 to 3500 cm). All 27 flaps survived and all wounds healed. Four patients (15 percent) had complications; three patients developed partial flap necrosis and required operative débridement, and there were two episodes of flap vascular compromise. Mean follow-up time was 14 months. One patient was lost to follow-up. Eight patients (30 percent) were still alive at the end of the study. The remaining 18 patients died within 22 months of resection, for a mean survival of 7 months. There was no cancer recurrence within the flap itself. Phantom pain occurred in 11 patients. At the time of discharge, pain, tissue necrosis, and infection were improved in all patients. CONCLUSION The use of the fillet flap is oncologically sound, has no associated donor sites, has an acceptable incidence of major complications, and allows for a healed wound with an improvement in the quality of life.
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Prantl L, Babilas P, Roll C, Jung M, Nerlich M, Kinner B, Schreml S, Fuechtmeier B. The use of ‘fasciocutaneous’ and ‘osteofasciocutaneous’ parascapular flaps for lower limb reconstruction: a retrospective study of 20 patients. J Plast Reconstr Aesthet Surg 2009; 62:973-80. [DOI: 10.1016/j.bjps.2007.11.070] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2006] [Revised: 09/05/2007] [Accepted: 11/24/2007] [Indexed: 10/22/2022]
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Technical refinements of composite thoracodorsal system free flaps for 1-stage lower extremity reconstruction resulting in reduced donor-site morbidity. Ann Plast Surg 2008; 60:386-90. [PMID: 18362565 DOI: 10.1097/sap.0b013e3180dc9a77] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
A multitude of local flaps has been suggested for lower extremity reconstruction. However, the gold standard for defect coverage remains free tissue transfer. In this regard, the scapular vascular axis is a well-established source of expendable skin, fascia, muscle, and bone for use in free flap reconstruction of defects requiring bone and soft tissue in complex 3-dimensional relationships. Composite bone and soft-tissue flaps derived from the subscapular vascular axis include the osteocutaneous scapular flap, the "latissimus/bone flap," and the thoracodorsal artery perforator-scapular osteocutaneous flap.Patient outcome following reconstruction of lower extremity defects with composite free flaps from the thoracodorsal system were analyzed. Here, we demonstrate the execution of technical refinements on free composite flap transfers based on the thoracodorsal vascular axis, thus resulting in a stepwise reduction of donor-site morbidity.
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Abstract
Complex trauma to the forearm often involves significant damage to or loss of bone, muscle, skin, tendons, and neurovascular structures. Treatment focuses on regaining long-term hand function, which is best achieved by combining plastic and orthopedic surgical expertise in a team that includes experienced upper arm rehabilitation therapists. The reconstruction goal is to restore a level of hand function that allows the patient to incorporate the injured hand back into daily activities. We define complex defects as those involving significant segmental loss of one or more tissue types. This article provides a framework by which these often formidable and overwhelming injuries can be approached, and discusses some of the surgical options used to reconstruct complex defects of the forearm.
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Affiliation(s)
- Karim Bakri
- Mayo Clinic, Division of Plastic Surgery, 200 First Street SW, West 12 Mayo, Rochester, MN 55905, USA
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Hwang JH, Kim ES, Kim KS, Kim DY, Lee SY. Latissimus Dorsi Muscle and Its Short Perforator-Based Skin Compound Free Flap. Ann Plast Surg 2007; 58:381-7. [PMID: 17413879 DOI: 10.1097/01.sap.0000243998.35882.7d] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Some authors have described the latissimus dorsi muscle and its short perforator-based skin compound flap based on the same thoracodorsal vessels. This flap procedure involves separating the skin island from the underlying latissimus dorsi muscle and rotating the skin island over the musculocutaneous perforator emerging from the latissimus dorsi muscle. As with all surgical procedures, there are various advantages and disadvantages. However, to the best of the authors' knowledge, there are no reports on the use of the flap in a consecutive series. Between 1997 and 2005, the flap was used to reconstruct below-knee structures in 26 patients (23 males and 3 females) by the 2 senior authors at the Chonnam National University Medical School. The clinical outcomes of this procedure were evaluated. Satisfactory results were obtained in most patients. However, there were 2 marginal necroses in the excessively large skin flaps, 1 partial necrosis over the distal edge of a skin flap, and 1 total flap failure caused by infection. The marginally and partially necrotized skin flaps were treated successfully with split-thickness skin grafts. However, another flap procedure was required to cover the defect in the case of flap failure. The donor sites were closed primarily in all patients, and the skin flaps were rotated between 40 degrees and 180 degrees. This flap allows the surface of the latissimus dorsi musculocutaneous flap to be expanded without additional donor morbidity. In addition, the flap procedure is safe and easy to perform. Moreover, the flap provides sufficient flexibility, even though it has less independent flap mobility than the chimeric flap. Therefore, the flap may be a convenient and reliable alternative for the reconstruction of large and irregular-shaped wounds.
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Affiliation(s)
- Jae Ha Hwang
- Department of Plastic and Reconstructive Surgery, Chonnam National University Medical School, Gwangju, Dong-gu, Gwangju, Korea
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Abstract
Chest wall reconstructions can be complex and challenging procedures and may require a multidisciplinary approach. The most common indications for chest wall reconstruction are the repair of defects due to tumor ablation, infection, radiation necrosis, congenital deformities, and trauma. Flap reconstruction by plastic surgery is often required when skin is removed as part of the chest wall resection or when radiation therapy is given pre- or post-operatively. Tissue flaps may be needed to provide vascularized tissue over alloplastic materials used to stabilize the chest wall, to cover vital structures of the chest cavity, to fill dead space, and to improve cosmesis.
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Affiliation(s)
- Roman J Skoracki
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX 77230-1402, USA
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Pittet B, Mahajan AL, Alizadeh N, Schlaudraff KU, Fasel J, Montandon D. The Free Serratus Anterior Flap and Its Cutaneous Component for Reconstruction of the Face: A Series of 27 Cases. Plast Reconstr Surg 2006; 117:1277-88. [PMID: 16582800 DOI: 10.1097/01.prs.0000208297.02556.a5] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The serratus anterior flap is commonly used without its cutaneous component and is covered with a skin graft. The authors have successfully used the free serratus anterior flap along with its skin paddle and have found it to be valuable for reconstruction of the face. METHODS Fresh cadaveric dissections and arteriography were performed to identify perforator vessels to the skin overlying the muscle. Clinically, free transfer of the musculocutaneous flap to the face was carried out in 27 patients, mostly for severe noma (infection) sequelae. RESULTS Anatomical dissection and arteriography revealed no cutaneous perforator vessels directly communicating with the vascular pedicle of the muscle. However, large perforators from the intercostal vessels were found passing through the muscle to reach the skin. In the clinical cases, flap survival was 100 percent in 24 patients. CONCLUSIONS The serratus anterior musculocutaneous flap is reliable and particularly well-suited for reconstruction of the face, and has many advantages. The authors speculate that the skin paddle may be vascularized by perforators from the intercostal vessels communicating with the thoracodorsal pedicle through intramuscular choke vessels.
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Affiliation(s)
- Brigitte Pittet
- Department of Plastic and Reconstructive Surgery, University of Geneva Medical Center, Geneva, Switzerland.
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Momeni A, Krischak S, Bannasch H. The thoracodorsal artery perforator flap with a vascularized scapular segment for reconstruction of a composite lower extremity defect. Microsurgery 2006; 26:515-8. [PMID: 17001635 DOI: 10.1002/micr.20279] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
High-energy trauma resulting in a composite defect of the lower extremity confronts the microvascular surgeon with more difficulties than do free flap reconstruction elsewhere in the body, since the choice of distant recipient vessels is particularly difficult. Combining principles of perforator flap surgery with those of composite tissue transfer, we designed a thoracodorsal artery perforator flap with a vascularized bone segment from the scapula for reconstruction of a composite lower extremity defect in a patient following a paragliding accident. This is the first report on the application of a composite thoracodorsal artery perforator flap with vascularized scapula in lower extremity reconstruction. Among its multiple advantages, such as preservation of latissimus dorsi function, it is a good tool for one-stage reconstruction of traumatic composite lower extremity defects because its low donor site morbidity and long vascular pedicle enables anastomosis placement outside the zone of injury.
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Affiliation(s)
- A Momeni
- Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Freiburg, Germany.
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Van Landuyt K, Hamdi M, Blondeel P, Monstrey S. The compound thoracodorsal perforator flap in the treatment of combined soft-tissue defects of sole and dorsum of the foot. ACTA ACUST UNITED AC 2005; 58:371-8. [PMID: 15780233 DOI: 10.1016/j.bjps.2004.10.026] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2003] [Accepted: 10/21/2004] [Indexed: 10/25/2022]
Abstract
Nine cases of massive soft-tissue loss of the foot were reconstructed by means of a compound (chimera) thoracodorsal artery perforator (TAP) flap, which reconstituted the different functional units (dorsum, heel, instep, weight-bearing surface). In each case, the flap consisted of a skin component isolated on its perforator in combination with a portion of latissimus dorsi muscle and/or serratus fascia, all pedicled on the thoracodorsal vessels. The pedicle length allows up to 4-6 cm of independent mobility of the skin island. The mobility of the various flap components allows the various functional units of the foot to be reconstructed without relying on multiple flaps or anastomoses. The pedicle length was sufficient to be able to perform the anastomosis out of the zone of injury. In some cases the skin island was harvested along with intercostal nerve branches, this gave us the potential to develop a sensate flap. The indications and advantages of this reconstructive method are discussed.
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Affiliation(s)
- K Van Landuyt
- Department of Plastic Surgery, University Hospital Gent, De Pintelaan 185, B-9000 Gent, Belgium.
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Halim AS, Wan Z. Anomalous arterial supply to the muscles in a combined latissimus dorsi and serratus anterior flap. Clin Anat 2004; 17:358-9. [PMID: 15108344 DOI: 10.1002/ca.10190] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The combined latissimus dorsi and serratus anterior flap has been employed for large defect reconstruction and has been shown to be reliable. These flaps are based on the subscapular-thoracodorsal vascular pedicle that usually supplies both muscles. In the case reported, serratus anterior possessed an anomalous arterial supply totally independent of the subscapular pedicle. The latissimus dorsi and serratus anterior muscles were used as a combined flap to reconstruct a massive thigh defect. The combined flap required two arterial anastomoses.
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Affiliation(s)
- A S Halim
- Reconstructive Sciences Unit, School of Medical Sciences USM, Kubang Kerian, Kelantan, Malaysia.
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Abstract
The authors present their experience in surgical reconstruction of bone lesions in posttraumatic bone defects, pseudarthrosis, and osteitis by using the free serratus anterior-rib flap. The flap was used in 12 cases: 7 cases in the upper limb, and 5 cases in the lower limb. The overall immediate success rate in our series was of 91.7%. We had only one failure, due to a venous thrombosis. In all successful cases, the rib showed good integration. This procedure seems to be very useful in the reconstruction of small and medium bone defects, especially in the upper limb.
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Abstract
Although reconstruction of complex distal lower extremity trauma has been studied extensively, the subject has rarely been evaluated in the pediatric population. The authors review their experience with 18 patients ranging from 2 to 18 years of age, who were admitted to the trauma service of the Children's Hospital of the University of Pittsburgh between 1991 and 1999 and required plastic surgery evaluation for the management of foot and ankle injuries. The mechanism of injury included motor vehicle accidents (6), lawnmower injuries (6), gunshot wounds (2), crush injuries (2), burns (1), and complex soft tissue injuries (1). The average hospitalization was 14.3 days, and, on average, 3.1 surgical procedures were required per patient. Most of the cohort required microvascular free tissue transfer (11). One patient was managed conservatively, whereas the remainder underwent surgical reconstruction by primary wound closure (1), skin graft (2), or local flap (3). No patient has required treatment of growth disturbance or late functional problems, and the entire population was ambulatory by their 3-month postoperative evaluation. Despite the severity of these injuries, with reliance on microvascular free tissue transfer, an acceptable outcome can be achieved with preservation of the ability to ambulate.
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Affiliation(s)
- Larry H Lickstein
- Department of Plastic Surgery, Cleveland Clinic, Naples, Florida, USA
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Abstract
The development of microsurgery and the expansion of plastic surgery techniques have led to a significant increase of surgical options for the salvage of the lower extremity. The traditional methods still have a role, but many authors have demonstrated a superiority of free and sophisticated regional flaps. This article gives an overview of treatment algorithms and surgical options. A therapeutic goal for the surgeon is to select the appropriate procedure with respect to the patient's medical condition and rehabilitation potential, the defect, and the surgeon's technical skills to achieve durable, permanent, pain-free, and functionally and aesthetically satisfying defect coverage.
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Affiliation(s)
- S Baumeister
- Department of Hand, Plastic, and Reconstructive Surgery, Burn Center-BG Trauma Center, Ludwig-Guttmannstrasse 13 67071, Ludwigshafen, Germany.
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Ugurlu K, Ozçelik D, Hacikerim S, Karasoy A, Bas L. The combined use of flaps based on subscapular vascular system for unilateral facial deformities. Plast Reconstr Surg 2000; 106:1079-89. [PMID: 11039381 DOI: 10.1097/00006534-200010000-00020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- K Ugurlu
- Department of Plastic and Reconstructive Surgery, Sisli Etfal State Hospital, Istanbul, Turkey
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28
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Agarwal R, Chandra R. Subscapular vascular axis for raising flaps. BRITISH JOURNAL OF PLASTIC SURGERY 1998; 51:485-6. [PMID: 9849374 DOI: 10.1016/s0007-1226(98)80035-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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