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Soh JY, Pannuto L, Kannan RY. A Comprehensive Flap Classification: Beyond the Reconstructive Ladder. Ann Plast Surg 2024:00000637-990000000-00450. [PMID: 38785374 DOI: 10.1097/sap.0000000000003972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
ABSTRACT Perforator flaps have progressed massively in the last years. The improved vascular imaging techniques and the use of supermicrosurgery have shifted the practice from the traditional predefined angiosomal flaps to the endless variations of custom-made flaps. In this article, we propose a broadened classification of free-style flaps in 3 categories, the angiosomal, including all traditional perforator flaps and their variations, the extra-angiosomal, including flaps that are manufactured to include tissue from a different angiosome, such as turbocharging or supercharging a flap, and neoangiosomal flaps, which are based on the process of neoangiogenesis on autologous or allogenous tissue, such as the venous flow-through flap and integra flap. With this classification, we hope to help unify the classifications and, by doing so, facilitate the exchange of ideas, techniques and knowledge.MeSH terms: surgical flap / classification, terminology as topic.
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Affiliation(s)
- Jun Yi Soh
- From the Department of Plastic Surgery, Queen Victoria Hospital, East Grinstead, United Kingdom
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Wang H, Shi Z, Zeng D, Wang H, Lv P, Li P. Repair of a "long and narrow" skin defect of the upper extremity with a modified design of a compound SCIP flap: a series of 12 cases. Eur J Med Res 2024; 29:275. [PMID: 38720374 PMCID: PMC11080178 DOI: 10.1186/s40001-024-01863-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 04/24/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Large skin lesions of the upper extremity tend to be ''long and narrow'' in shape, and the currently used repair and reconstruction protocols still have some drawbacks, including difficulty in closure of the donor area, poor cosmetic appearance of the donor and recipient areas, and low flap survival rates. The ilioinguinal flap has been more widely used for repair and reconstruction of various complex conditions. In order to improve the versatility of the flap design and to achieve better aesthetic results, we report a study on the improved design of Compound SCIP flap for repairing "long and narrow" large skin defects of the upper extremity by using a modified design of the ilioinguinal flap for the procurement of perforating blood vessels and flap excision. METHODS From April 2005 to August 2015, a total of 12 patients underwent this modified design procedure, in which the anterior branch of the fourth lumbar artery or the posterior intercostal artery was selected to provide blood supply for the perforator flap together with the superficial branch of the superficial iliac artery to meet the blood supply needs of the flap for the one-time repair of a large "long and narrow" skin defect in the upper limb. Patient demographics, flap characteristics, and associated complications were retrospectively analyzed. RESULTS 3 females and 9 males were included in this study, the mean age of the patients was 31.7 years (range, 22-44 years), the mean follow-up period was 15.3 ± 5.6 months (range, 7-24 months), and all patients had complete closure of the defect site and donor area, and all flaps survived. CONCLUSIONS The Compound SCIP flap presents some advantages in repairing 'long and narrow' skin defects in the upper limb. While ensuring the survival rate of the elongated ilioinguinal flap, it amplifies the benefits of the ilioinguinal flap and enhances skin utilization. This can serve as a beneficial choice for repairing 'long and narrow' skin defects in the upper limb.
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Affiliation(s)
- Haiwen Wang
- Department of Hand Surgery, Dongguan Chashan Hospital, Guangdong Medical University, Dongguan, 523000, China
| | - Zetian Shi
- Department of Hand Surgery, Dongguan Chashan Hospital, Guangdong Medical University, Dongguan, 523000, China
| | - Deqing Zeng
- Department of Hand Surgery, Dongguan Chashan Hospital, Guangdong Medical University, Dongguan, 523000, China
| | - Haibo Wang
- Department of Hand Surgery, Dongguan Chashan Hospital, Guangdong Medical University, Dongguan, 523000, China
| | - Pengcheng Lv
- Department of Hand Surgery, Dongguan Chashan Hospital, Guangdong Medical University, Dongguan, 523000, China
| | - Pei Li
- Department of Hand Surgery, Dongguan Chashan Hospital, Guangdong Medical University, Dongguan, 523000, China.
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Boretto JG, Holc F, Victorica PB. The Foot as a Donor Site for Reconstruction in the Hand. Hand Clin 2024; 40:249-258. [PMID: 38553096 DOI: 10.1016/j.hcl.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
The foot contains a unique collection of tissue types that can be used in the reconstruction of the hand. Numerous reconstructive options have been presented, some of which have been adopted, such as modifications to procedures that have been described in the past or even newly developed options for hand reconstruction. It is possible to reconstruct missing fingers and other hand structures using tissues taken from the foot rather than removing healthy tissue from a hand that has already been injured. This makes it possible to avoid having healthy tissue removed from an injured hand.
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Affiliation(s)
- Jorge G Boretto
- Hand and Upper Extremity Surgery Department, Prof. Dr. "Carlos Ottolenghi Institute", Hospital Italiano de Buenos Aires.
| | - Fernando Holc
- Hand and Upper Extremity Surgery Department, Prof. Dr. "Carlos Ottolenghi Institute", Hospital Italiano de Buenos Aires
| | - Pedro Bronenberg Victorica
- Hand and Upper Extremity Surgery Department, Prof. Dr. "Carlos Ottolenghi Institute", Hospital Italiano de Buenos Aires
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Wang R, Manon V, Huang AT. Perforator-based chimeric ulnar forearm microvascular free tissue transfer reconstruction of post-radiated tracheoesophageal puncture fistulae. Head Neck 2024; 46:973-978. [PMID: 38278774 DOI: 10.1002/hed.27662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 01/09/2024] [Accepted: 01/17/2024] [Indexed: 01/28/2024] Open
Abstract
Tracheoesophageal puncture (TEP) performed during total laryngectomy in the primary treatment of laryngeal cancer is the standard method for voice restoration. Following adjuvant radiotherapy, the TEP site can experience complications resulting in a tracheoesophageal fistula (TEF) with chronic leakage making oral alimentation unsafe due to aspiration. Here, we describe a technique using chimeric ulnar artery perforator forearm free flaps (UAPFF) in the reconstruction of these complex deformities. Four patients underwent chimeric UAPFF reconstruction of TEP site TEFs following primary TL with TEP and adjuvant radiotherapy. No flap failures or surgical complications occurred. Average time from end of radiotherapy to persistent TEF was 66 months (range 4-190 months). All patients had resolution in their TEF with average time to total oral diet achievement of 22 days (14-42 days). Chimeric UAPFF reconstruction is a safe and effective method to reconstruct recalcitrant TEP site TEFs.
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Affiliation(s)
- Ray Wang
- Department of Otolaryngology - Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Victoria Manon
- Department of Oral and Maxillofacial Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Andrew T Huang
- Department of Otolaryngology - Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, USA
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Ahmed Z, Cook H, Anadkat M, Ioannidi L, Marmery H, Nikkhah D. ALT in combination with triple-rolled TFL for reconstruction of a complex tendoachilles defect: technical details and rehabilitation regime. BMJ Case Rep 2024; 17:e258355. [PMID: 38296509 PMCID: PMC10831452 DOI: 10.1136/bcr-2023-258355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2024] Open
Abstract
A fit man in his 60s presented with an infected Achilles tendon (AT) following two failed repairs for a traumatic rupture. Initial debridement of necrotic tissue resulted in a large soft tissue defect requiring robust coverage. Following aggressive wound management, an anterolateral thigh flap was elevated with tensor fasciae latae (TFL) which was triple-rolled to provide soft tissue coverage and tendon reconstruction.The flap remained healthy and was monitored with a flow coupler device. Initially, the foot was placed in plantarflexion before gradually increasing the angle to neutral and a thermoplastic splint was used to offload pressure on the flap. Following 1 month of non-weight-bearing, gentle mobilisation began. Three months postoperatively, the patient could walk, had resumed indoor cycling and demonstrated a comparable heel raise with the contralateral side. MRI showed a taut TFL attached to the distal AT and ultrasound showed a smoothly gliding TFL.
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Affiliation(s)
- Zahra Ahmed
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Hannah Cook
- Plastic & Reconstructive Surgery, Royal Free London NHS Foundation Trust, London, UK
| | - Meera Anadkat
- Plastic & Reconstructive Surgery, Royal Free London NHS Foundation Trust, London, UK
| | - Lydia Ioannidi
- Plastic & Reconstructive Surgery, Royal Free London NHS Foundation Trust, London, UK
| | | | - Dariush Nikkhah
- Division of Surgery and Interventional Science, University College London, London, UK
- Plastic & Reconstructive Surgery, Royal Free London NHS Foundation Trust, London, UK
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Lee YJ, Kim J, Lee CR, Kim JH, Oh DY, Jun YJ, Moon SH. Anterolateral Thigh Chimeric Flap: An Alternative Reconstructive Option to Free Flaps for Large Soft Tissue Defects. J Clin Med 2023; 12:6723. [PMID: 37959189 PMCID: PMC10648588 DOI: 10.3390/jcm12216723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/13/2023] [Accepted: 10/18/2023] [Indexed: 11/15/2023] Open
Abstract
The anterolateral thigh (ALT) skin flap provides abundant, thin, pliable skin coverage with adequate pedicle length and calibre, and tolerable donor site morbidity. However, coverage of relatively large defects using the ALT flap alone is limited. We present our experience of using the ALT flap coupled with the vastus lateralis (VL) flap supplied by the same pedicle for large defect reconstruction. Between 2016 and 2020, ten patients with extensive lower-extremity or trunk defects were treated using the ALT/VL chimeric flap. The ALT portion was used to cover the cutaneous and joint defect while the VL part was used to resurface remnant defects, and a skin graft was performed. All flaps were based on the common descending pedicle, and branches to separate the components were individually dissected. All defects were successfully reconstructed using the ALT/VL chimeric flap. No surgery-related acute complications were observed, and the patients had no clinical issues with ambulation or running activities during the long-term follow-up period. With the separate components supplied by a common vascular pedicle, the ALT/VL chimeric flap allows us to reconstruct extensive defects with joint involvement or posterior trunk lesions. Thus, the ALT/VL chimeric flap may be a suitable alternative for extensive tissue defect reconstruction.
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Affiliation(s)
- Yoon Jae Lee
- Department of Plastic and Reconstructive Surgery, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 07345, Republic of Korea; (Y.J.L.); (J.H.K.)
| | - Junnyeon Kim
- Department of Plastic and Reconstructive Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (J.K.); (C.R.L.); (D.Y.O.); (Y.J.J.)
| | - Chae Rim Lee
- Department of Plastic and Reconstructive Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (J.K.); (C.R.L.); (D.Y.O.); (Y.J.J.)
| | - Jun Hyeok Kim
- Department of Plastic and Reconstructive Surgery, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 07345, Republic of Korea; (Y.J.L.); (J.H.K.)
| | - Deuk Young Oh
- Department of Plastic and Reconstructive Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (J.K.); (C.R.L.); (D.Y.O.); (Y.J.J.)
| | - Young Joon Jun
- Department of Plastic and Reconstructive Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (J.K.); (C.R.L.); (D.Y.O.); (Y.J.J.)
| | - Suk-Ho Moon
- Department of Plastic and Reconstructive Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (J.K.); (C.R.L.); (D.Y.O.); (Y.J.J.)
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Qing L, Luo G, Li X, Wu P, Tang J. Individualized design of thoracodorsal artery perforator chimeric flap for customized reconstruction of complex three-dimensional defects in the extremities. J Orthop Surg Res 2023; 18:367. [PMID: 37198689 DOI: 10.1186/s13018-023-03852-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 05/10/2023] [Indexed: 05/19/2023] Open
Abstract
BACKGROUND It was always challenging to accurately and effectively reconstruct the complicated defects with three-dimensional tissue deficits in the extremities. Muscle-chimeric perforator flap is an excellent choice for repairing those complicated wound. However, problems like donor-site morbidity and time-consuming intramuscular dissection still exist. This purpose of this study was to present a novel design of the thoracodorsal artery perforator (TDAP) chimeric flap for the customized reconstruction of complex three-dimensional tissue defects in the extremities. METHODS From January 2012 to June 2020, 17 patients with complex three-dimensional deficits in the extremities were retrospectively analyzed. All patients in this series underwent extremity reconstruction using latissimus dorsi (LD)-chimeric TDAP flap. Three different types of LD-chimeric TDAP flaps were performed. RESULTS A total of seventeen TDAP chimeric flaps were successfully harvested for the reconstruction of those complex three-dimensional defects in extremities. Among them, Design Type A flaps were used in 6 cases, Design Type B flaps were performed in 7 cases, and Design Type C flaps were used in the remaining 4 cases. The sizes of the skin paddles ranged from 6 cm × 3 cm to 24 cm × 11 cm. Meanwhile, the sizes of the muscle segments ranged from 3 cm × 4 cm to 33 cm × 4 cm. All the flaps survived. Nevertheless, one case required re-exploration owing to venous congestion. Moreover, the primary closure of the donor site was successfully achieved in all patients, and the mean follow-up time was 15.8 months. Most of the cases displayed satisfactory contour. CONCLUSION The LD-chimeric TDAP flap is available for the reconstruction of complicated defects with three-dimensional tissue deficits in the extremities. It provided a flexible design for customized coverage of complex soft tissue defects with limited donor site morbidity.
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Affiliation(s)
- Liming Qing
- Department of Microsurgery and Hand Surgery, Xiangya Hospital of Central South University, Changsha, 410008, China
| | - Gaojie Luo
- Department of Microsurgery and Hand Surgery, Xiangya Hospital of Central South University, Changsha, 410008, China
| | - Xiaoxiao Li
- Department of Pathology, Changsha Medical University, Changsha, China
| | - Panfeng Wu
- Department of Microsurgery and Hand Surgery, Xiangya Hospital of Central South University, Changsha, 410008, China
| | - Juyu Tang
- Department of Microsurgery and Hand Surgery, Xiangya Hospital of Central South University, Changsha, 410008, China.
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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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Chang LS, Jang DW, Kim YH, Kim SW. Diabetic foot resurfacing using microvascular tissue transfer from lateral thoracic region. Diabetes Metab Res Rev 2023; 39:e3593. [PMID: 36411967 DOI: 10.1002/dmrr.3593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 08/10/2022] [Accepted: 10/10/2022] [Indexed: 11/23/2022]
Abstract
AIMS Diabetic foot ulcer is a major complication of diabetes mellitus and amputation is often needed. Since mortality rate after amputation is comparatively high, saving diabetic foot is required not only for preserving function and life quality, but also for decreasing mortality rate. This study was designed to analyse experience of limb salvage in patients with diabetic foot using free flaps from the lateral thoracic region over a 10-year period. MATERIALS AND METHODS Between 2009 and 2018, 297 cases of diabetic foot underwent surgical procedures. We analysed the 83 cases who underwent free flap from lateral thoracic region. Patient data were reviewed retrospectively. RESULTS A total of 83 patients, 56 of them males, were included in this study. Age of patients ranged from 27 to 80 years. Twenty patients underwent percutaneous transluminal angioplasty procedures. The latissimus dorsi muscle sparing technique was used in 7 cases. A thoracodorsal artery perforator flap was used in 68 cases. A thoracodorsal artery perforator chimaeric flap was performed in 8 cases. The flap survival rate was 98.8% and the limb salvage rate was 96.4%. The mean follow-up was 6.5 years. During follow-up 14 patients suffered recurrence of foot ulcers. CONCLUSIONS Ten-year experience of using flaps from the lateral thoracic region revealed superior outcomes in terms of flap survival and limb saving compared to those in a recent meta-analysis and other reports. Long vascular pedicle technique and the chimaeric technique might be the alternative methods for multiple or vascular insufficient diabetic foot defects.
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Affiliation(s)
- Lan Sook Chang
- Department of Plastic and Reconstructive Surgery, College of Medicine, Hanyang University, Seoul, Korea
| | - Dong Woo Jang
- Shanghai MK Medical Cosmetic Surgery Clinic, Shanghai, China
| | - Youn Hwan Kim
- Department of Plastic and Reconstructive Surgery, College of Medicine, Hanyang University, Seoul, Korea
| | - Sang Wha Kim
- Department of Plastic and Reconstructive Surgery, College of Medicine, Seoul National University, Seoul National University Hospital, Seoul, Korea
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Goh E, Kulkarni S, Moura F, Norton S. Reconstruction of Soft-Tissue Defects of the Thumb Using Reverse-Flow Homodigital Flaps: A Systematic Review. J Hand Microsurg 2022. [DOI: 10.1055/s-0042-1758671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Abstract
Introduction Soft-tissue thumb defects are common reconstructive challenges, the main goals being restoration of tactile sensibility, range of movement, pulp padding, length, and cosmesis. The reverse-flow dorsoulnar and dorsoradial collateral artery flaps are homodigital flaps used to cover both distal dorsal and volar thumb defects. These flaps can be used as compound flaps including skin, fat, and/or nerves. As there is no critical analysis of these studies, this study aims to create a synthesized comprehensive systematic review.
Methods Systematic review was performed using the databases PubMed, Embase, and Medline. Eligible studies followed the inclusion criteria: English language and all studies published to date. The primary outcome was flap survival. Other data collected included anatomical area of the defect, flap constituents and dimensions, donor-site closure and complications, transfer method, reoperation, revision, and functional outcomes.
Results A total of 19 articles incorporating 189 flaps met the inclusion criteria. These flaps were categorized and analyzed as dorsoradial (50%), dorsoulnar (39%), and turnover flaps (11%). Dorsoradial flaps were used in fasciocutaneous fashion alone. Partial flap failures occurred in five cases. Dorsoulnar flaps were used as fasciocutaneous or as osteocutaneous flaps. Complete flap failure was reported in one patient alone, whereas partial necrosis was reported in four patients. Adipofascial turnover flaps had two partial flap failures reported but no complete failures. The overall complete and partial flap failure rates were 0.5 and 6.5%, respectively.
Conclusion Reverse-flow homodigital random or axial-based flaps provide a reliable means of reconstruction for soft-tissue defects with reasonable success rate and good functional outcomes. They have a consistent anatomy with a good potential for personalization and therefore increased versatility.
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Affiliation(s)
- Esther Goh
- Department of Plastic Surgery, Norfolk and Norwich University Hospitals, Norwich, United Kingdom
| | - Shreya Kulkarni
- Department of Plastic Surgery, Norfolk and Norwich University Hospitals, Norwich, United Kingdom
| | - Francisco Moura
- Department of Plastic Surgery, Norfolk and Norwich University Hospitals, Norwich, United Kingdom
| | - Samuel Norton
- Department of Plastic Surgery, Norfolk and Norwich University Hospitals, Norwich, United Kingdom
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11
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Hallock GG. Perforator and Perforator Flap Spinoffs: A Historical Journey. Plast Reconstr Surg 2022; 149:287e-296e. [PMID: 35077428 DOI: 10.1097/prs.0000000000008795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
SUMMARY The concept of the perforator has now become a fundamental topic well known in every training program. However, that has not always been so. The mere definition of the word has historically been argued relentlessly; nevertheless, its major derivative, the perforator flap, has become accepted as a basic consideration whenever flaps need be selected. However, this has not been the only spinoff derived from the author's investigations of the perforator, a point that should be stressed in addition to some reiterations of pertinent and perhaps confusing nomenclature that deserve to be reemphasized. Truly, it has been amazing to see how our ideas and innovations arise simultaneously and independently throughout the world of reconstructive surgery. A final plea is made to sustain the future-each of us must continue to contribute our passion and our knowledge to all others by means of that technology now globally so instantaneously available.
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Affiliation(s)
- Geoffrey G Hallock
- From the Division of Plastic Surgery, St. Luke's Hospital, Sacred Heart Division
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Zhou X, Zou Y, Tang L, Liu A, Zhang R, Chen Z. [The lower abdominal conjoined flap with bilateral superficial inferior epigastric arteries for repairing the large soft tissue defects on the foot and ankle]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2021; 35:1467-1471. [PMID: 34779175 DOI: 10.7507/1002-1892.202106040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To investigate the effectiveness of the lower abdominal conjoined flap with bilateral superficial inferior epigastric arteries (SIEA) for repairing the large soft tissue defects on the foot and ankle. Methods The clinical data of 18 patients with large soft tissue defects on foot and ankle treated between October 2017 and January 2020 were retrospectively analyzed, including 12 males and 6 females; the age ranged from 25 to 62 years, with a median age of 35 years. The causes of injury included machine injury in 9 cases, traffic accident injury in 5 cases, cutting injury in 2 cases, and electric injury in 2 cases. All wounds were accompanied by exposure of blood vessels, tendons, bones, and joints. Wound located at ankle in 8 cases, dorsum of foot in 6 cases, and sole in 4 cases. In the emergency department, complete debridement (the defect area after debridement was 15 cm×10 cm to 25 cm×16 cm) and vacuum sealing drainage on the wound was performed. The time from debridement to flap repair was 3-10 days, with an average of 5 days. According to the defect location and scope, the lower abdominal conjoined flap with bilateral SIEA was prepared. The size of the flap ranged from 15 cm×10 cm to 25 cm×16 cm. The length of vascular pedicle was 4.5-7.5 cm, with an average of 6.0 cm; the thickness of the flap was 0.5-1.2 cm, with an average of 0.8 cm. The abdominal donor site was closed in one-stage. Results One flap was altered as the conjoined flap with the bilateral superficial circumflex iliac artery because of the absence of the SIEA in one side. Except for 1 case of skin flap with distal necrosis, the flap healed after two-stage skin grafting repair; the rest skin flaps survived, and the wounds of the donor and recipient sites all healed by first intention. All patients were followed up 12-28 months, with an average of 16 months. The skin flap had a satisfactory appearance and soft texture, without abnormal hair growth or obvious pigmentation. Only linear scars were left at the donor site, and no complication such as abdominal hernia occurred. The foot and ankle function was satisfactory. At last follow-up, the American Orthopaedic Foot and Ankle Society (AOFAS) scores were rated as excellent in 16 cases and good in 2 cases. Conclusion The lower abdominal conjoined flap with bilateral SIEA is an ideal flap for repairing large defects of foot and ankle with less morbidity scarcely, which ascribed to its ease of dissection, adjustable thinness, and concealed donor site, as well as the flexible perforator match.
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Affiliation(s)
- Xin Zhou
- Department of Burn and Plastic Surgery, the Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou Sichuan, 646000, P.R.China
| | - Yonggen Zou
- Department of Burn and Plastic Surgery, the Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou Sichuan, 646000, P.R.China
| | - Lin Tang
- Department of Burn and Plastic Surgery, the Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou Sichuan, 646000, P.R.China
| | - Anming Liu
- Department of Burn and Plastic Surgery, the Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou Sichuan, 646000, P.R.China
| | - Renquan Zhang
- Department of Orthopedics, People's Hospital of Chongqing Banan District, Chongqing, 401320, P.R.China
| | - Zenggang Chen
- Department of Orthopedics, People's Hospital of Chongqing Banan District, Chongqing, 401320, P.R.China
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13
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Hallock GG. The free flap man: An heroic 50-year odyssey via multiple flaps. Microsurgery 2021; 42:66-70. [PMID: 34773421 DOI: 10.1002/micr.30834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 06/09/2021] [Accepted: 09/17/2021] [Indexed: 11/11/2022]
Abstract
Most lower extremity challenges can be solved by a solitary free flap. Yet if multiple wounds exist in a single extremity, or if bilateral extremities are involved, then multiple free flaps by necessity may be required to preserve ambulatory capabilities. Even rarer is their need in a sequential fashion. Thus is the uniqueness of this steelworker who at the young age of 23 sustained bilateral foot and ankle molten steel immersion injuries, initially salvaged by skin grafts virtually directly on bone. Over the next 50 years there were repeated episodes of graft instability that required five different free flaps to provide stable soft tissue coverage. Amputation was avoided, allowing minimal interruption at work as a bus driver until retirement. This patient's long journey was only possible due to the virtue of persistence, proving the value of that trait inherent within the true microvascular surgeon. It should be no wonder that appropriately this is the "free flap man."
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Affiliation(s)
- Geoffrey G Hallock
- Division of Plastic Surgery, Sacred Heart Campus, St. Luke's Hospital, Allentown, Pennsylvania, USA
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Auricchio AM, Mazzucchi E, Rapisarda A, Sabatino G, Della Pepa GM, Visconti G, Salgarello M, Olivi A, La Rocca G. Chimeric Anterolateral Thigh Flap in Skull Base Reconstruction: A Case-Based Update and Literature Review. Brain Sci 2021; 11:brainsci11081076. [PMID: 34439694 PMCID: PMC8393429 DOI: 10.3390/brainsci11081076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 08/14/2021] [Accepted: 08/16/2021] [Indexed: 11/16/2022] Open
Abstract
Oncologic and traumatic neurosurgery may have to cope with the issue of skull base defects, which are associated with increased risk of meningitis, epidural abscess and cerebro-spinal fluid (CSF) leak. The aim of skull base reconstruction is to repair the dural exposure and to separate the intracranial contents from the nonsterile sino-nasal cavities and extracranial space. Currently, many different surgical techniques have been described, and one of the most performed is the use free flap. In the present paper we performed a case-based update and literature review of the use of chimeric anterolateral thigh free flap harvested from rectus femoris, reporting the case of a 68-year-old man with recurrent spheno-ethmoidalis plane meningioma.
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Affiliation(s)
- Anna Maria Auricchio
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, 00168 Rome, Italy; (A.M.A.); (A.R.); (G.S.); (G.M.D.P.); (A.O.); (G.L.R.)
| | - Edoardo Mazzucchi
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, 00168 Rome, Italy; (A.M.A.); (A.R.); (G.S.); (G.M.D.P.); (A.O.); (G.L.R.)
- Department of Neurosurgery, Mater Olbia Hospital, 07026 Olbia, Italy
- Correspondence:
| | - Alessandro Rapisarda
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, 00168 Rome, Italy; (A.M.A.); (A.R.); (G.S.); (G.M.D.P.); (A.O.); (G.L.R.)
| | - Giovanni Sabatino
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, 00168 Rome, Italy; (A.M.A.); (A.R.); (G.S.); (G.M.D.P.); (A.O.); (G.L.R.)
- Department of Neurosurgery, Mater Olbia Hospital, 07026 Olbia, Italy
| | - Giuseppe Maria Della Pepa
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, 00168 Rome, Italy; (A.M.A.); (A.R.); (G.S.); (G.M.D.P.); (A.O.); (G.L.R.)
| | - Giuseppe Visconti
- UOC Chirurgia Plastica, Dipartimento Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (G.V.); (M.S.)
| | - Marzia Salgarello
- UOC Chirurgia Plastica, Dipartimento Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (G.V.); (M.S.)
| | - Alessandro Olivi
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, 00168 Rome, Italy; (A.M.A.); (A.R.); (G.S.); (G.M.D.P.); (A.O.); (G.L.R.)
| | - Giuseppe La Rocca
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, 00168 Rome, Italy; (A.M.A.); (A.R.); (G.S.); (G.M.D.P.); (A.O.); (G.L.R.)
- Department of Neurosurgery, Mater Olbia Hospital, 07026 Olbia, Italy
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15
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Morarasu S, Ghetu N, Coman CG, Boicu D, Spiridon IA, Gardikiotis I, Danciu M, Pieptu D. New Chimeric Groin Flap: Experimental Model in Rats. Ann Plast Surg 2021; 86:721-725. [PMID: 33009145 DOI: 10.1097/sap.0000000000002561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
AIM Increased emphasis is on using tissue substitutes and stem cells to improve flap applicability and survival rates. To accomplish this, the first step is to have a versatile experimental flap, easy to harvest and use as a template. We sought to develop a reliable experimental chimeric groin flap with free mobility and reliable bloods supply that can be twisted, relocated, and integrated easily with other materials. MATERIALS AND METHODS Ten male Wistar rats were included. The flap consists of a 2.5-cm skin paddle centered on the medial branch of the inferior epigastric artery and a 4.5/2-cm fat pad supplied by the lateral branch of the inferior epigastric artery. After being raised, flaps were resutured in their anatomical position. Flaps were followed up for 15 days. At the end of the study, the viability of flaps was analyzed by ultrahigh-frequency ultrasound, nontargeted contrast study, and histology assessment. RESULTS All flaps survived without significant complications. Nontargeted microbubbles spread evenly in both the superficial and deep flap. Ultrasound assessment at day 15 showed no significant areas of necrosis or edema. Histology examination of 3 random flaps confirmed vessel patency and flap viability. CONCLUSION We propose a simple, easy to harvest and reliable experimental flap which offers a main advantage of all-around mobility through its chimeric design. It is a suitable model for bioengineering studies as it can be used as a template for integration of tissue substitutes or stem cells, between its 2 components.
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Affiliation(s)
| | | | | | | | | | | | - Mihai Danciu
- Department of Pathology, Grigore T Popa University of Medicine and Pharmacy, Iasi, Romania
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Augmentation of Perforator Flap Blood Supply with Vascular Supercharge or Flap Prefabrication: Evaluation in a Rat Model. Plast Reconstr Surg 2021; 147:1105-1115. [PMID: 33890892 DOI: 10.1097/prs.0000000000007893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Vascular supercharge and flap prefabrication are two surgical maneuvers to improve flap blood supply. Although these techniques have been studied intensively, few studies have focused on the differences between supercharge and prefabricated flaps regarding their flap survival areas, vasculatures, and hemodynamics. METHODS In this study, 21 male Sprague-Dawley rats were divided into three groups as follows: group A, single perforator flap; group B, supercharge flap; and group C, prefabricated flap. Flap survival was measured 1 week after flap elevation. Indocyanine green angiography was applied to visualize flap vascularity and to analyze flap hemodynamics. Von Willebrand factor immunohistochemical staining was applied to assess the number of microvessels in the choke zone of the abdominal wall. RESULTS The flap survival areas were expanded significantly in the arteriovenous supercharge group and the vascular bundle prefabricated group compared with that in the single-perforator group (81.34 ± 8.12 percent and 75.51 ± 8.08 percent versus 46.27 ± 10.01 percent, respectively; p < 0.05). Hemodynamic analysis suggested that although a significant increase in arterial infusion could be achieved with flap prefabrication, the venous effusion of the prefabricated flap was the worst among the three groups, indicating greater susceptibility to compromised venous return. Active neovascularization was confirmed by an increased number of microvessels in group C. Specifically, the dilatation of choke vessels and the newly formed vessels of the prefabricated pedicle could be appreciated by indocyanine green angiographic mapping. CONCLUSIONS Both vascular supercharge and flap prefabrication can augment the blood supply of the perforator flap but by means of different mechanisms. Because a supercharge flap is less susceptible to venous compromise, it is suggested to first consider the use of vascular supercharging when feasible.
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Fritsche E, Giesen T, Hug U. [An introduction into the use of fabricated chimeric flaps in replantation surgery of digits]. HANDCHIR MIKROCHIR P 2021; 53:364-369. [PMID: 33902134 DOI: 10.1055/a-1348-1310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Since microsurgical finger replantations started to be successfully performed at the beginning of the 1960 s, there has been an evolution in the techniques for restoring blood flow to the amputated fingers. Initially, end-to-end anastomoses were performed. Later on, vascular grafts - predominantly vein interpositional grafts - were successfully used for difficult avulsion injuries. These vascular grafts were extended by microvascular flaps in the form of flow-through flaps in cases with simultaneous soft tissue loss. A further development of these techniques has been achieved by the replantation of amputated fingers with the help of fabricated chimeric flaps. The amputated finger is anastomosed microsurgically with a flap "in tabula" before the actual replantation. Only then is the fabricated chimera replanted as a construct. The latest development so far is heterotopic replantation with secondary replantation in the form a fabricated chimeric flap. By way of introduction, we describe three cases in which we have successfully applied this concept of fabricated chimeric flap surgery for orthotopic thumb replantations.
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Affiliation(s)
- Elmar Fritsche
- Kantonsspital Luzern Klinik für Hand- und Plastische Chirurgie
| | - Thomas Giesen
- Kantonsspital Luzern Klinik für Hand- und Plastische Chirurgie
| | - Urs Hug
- Kantonsspital Luzern Klinik für Hand- und Plastische Chirurgie
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18
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Hammond JB, Teven CM, Flug JA, Jokerst CE, Howarth AL, Shrout MA, Laitinen MA, Foley BM, Kruger EA, Casey WJ, Rebecca AM. The Chimeric Gracilis and Profunda Artery Perforator Flap: Characterizing This Novel Flap Configuration with Angiography and a Cadaveric Model. J Reconstr Microsurg 2021; 37:617-621. [PMID: 33592634 DOI: 10.1055/s-0041-1723824] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND A chimerically configured gracilis and profunda artery perforator (PAP) flap is highly prevalent based on recent computed tomography (CT)-imaging data. The purpose of this study is to further characterize the vascular anatomy of this novel flap configuration and determine the feasibility of flap dissection. METHODS To characterize flap arterial anatomy, lower extremity CT angiograms performed from 2011 to 2018 were retrospectively reviewed. To characterize venous anatomy and determine the feasibility of flap harvest, the lower extremities of cadavers were evaluated. RESULTS A total of 974 lower extremity CT angiograms and 32 cadavers were included for the assessment. Of the 974 CT angiograms, majority (966, 99%) were bilateral studies, yielding a total of 1,940 lower extremities (right-lower-extremity = 970 and left-lower-extremity = 970) for radiographic evaluation. On CT angiography, a chimerically configured gracilis and PAP flap was found in 51% of patients (n = 494/974). By laterality, chimeric anatomy was present in 26% of right lower extremities (n = 254/970) and 25% of left lower extremities (n = 240/970); bilateral chimeric anatomy was found in 12% (n = 112/966) of patients. Average length of the common arterial pedicle feeding both gracilis and PAP flap perforasomes was 31.1 ± 16.5 mm (range = 2.0-95.0 mm) with an average diameter of 2.8 ± 0.7 mm (range = 1.3-8.8 mm).A total of 15 cadavers exhibited chimeric anatomy with intact, conjoined arteries and veins allowing for anatomical tracing from the profunda femoris to the distal branches within the tissues of the medial thigh. Dissection and isolation of the common pedicle and distal vessels was feasible with minimal disruption of adjacent tissues. Chimeric flap venous anatomy was favorable, with vena commitante adjacent to the common pedicle in all specimens. CONCLUSION Dissection of a chimeric medial thigh flap consisting of both gracilis and PAP flap tissues is feasible in a cadaveric model. The vascular anatomy of this potential flap appears suitable for future utilization in a clinical setting.
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Affiliation(s)
| | - Chad M Teven
- Division of Plastic & Reconstructive Surgery, Mayo Clinic, Phoenix, Arizona
| | | | | | - Ashley L Howarth
- Division of Plastic & Reconstructive Surgery, Mayo Clinic, Phoenix, Arizona
| | - Max A Shrout
- Division of Plastic & Reconstructive Surgery, Mayo Clinic, Phoenix, Arizona
| | | | | | - Erwin A Kruger
- Division of Plastic & Reconstructive Surgery, Mayo Clinic, Phoenix, Arizona
| | - William J Casey
- Division of Plastic & Reconstructive Surgery, Mayo Clinic, Phoenix, Arizona
| | - Alanna M Rebecca
- Division of Plastic & Reconstructive Surgery, Mayo Clinic, Phoenix, Arizona
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19
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Yu J, Luo Z, Wu P, Tang J. Novel Design of the Chimeric Deep Inferior Epigastric Artery Perforator Flap that Provides for Three-Dimensional Reconstruction of Composite Tissue Defects of the Heel in Children. Orthop Surg 2021; 13:216-224. [PMID: 33448701 PMCID: PMC7862167 DOI: 10.1111/os.12887] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 10/21/2020] [Accepted: 10/27/2020] [Indexed: 11/28/2022] Open
Abstract
Objective The aim of the present study was to report a novel design of the chimeric deep inferior epigastric artery perforator flap (DIEP) to achieve dead space filling, Achilles tendon bridging, and skin resurfacing simultaneously with minimal donor‐site morbidity. Methods From September 2012 to May 2016, a retrospective study was carried out on six pediatric patients with composite soft tissue defects of the heel that were repaired with the chimeric DIEP flap. The chimeric flap design included a flap of the anterior sheath of the rectus, a block of rectus muscle, and a large skin paddle. All the parts were supplied by a common artery. After harvesting the flap, all element parts were inserted at the corresponding sites in a tension‐free manner. With one set of vessel anastomoses at the recipient site, accurate repair with tendon reconstruction, dead space elimination, and wound covering were accomplished. The donor site incisions were closed initially. Data on patient age, medical history, injury severity, defect size, flap dimensions, recipient vessels, donor site closure, complications, and follow‐up were collected and reviewed. Results Five of the six chimeric DIEP flaps survived without complications. The remaining one case experienced partial necrosis of the skin paddle caused by venous congestion, which healed after routine dressing changes. Primary donor site closure was accomplished in all cases. The mean follow‐up was 18.6 months (range, 10–36 months). Five patients had satisfactory aesthetic and functional outcomes; one patient needed a secondary debulking procedure. Compared to the unaffected side, the affected side showed no obvious difference for ankle movement, tiptoe function, and patient gait during the follow‐up period. Good ankle function was observed in all patients. There was no donor site breakdown, with only a slightly noticeable linear scar. Conclusion The chimeric DIEP flap reduced the operative time, solved the problem of deficiency of recipient vessels, and attained satisfactory functional and aesthetic outcomes with low donor site morbidity. Therefore, it is a promising option for three‐dimensional reconstruction of composite defects with dead space and Achilles tendon defects as well as skin loss in children.
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Affiliation(s)
- Junyi Yu
- Department of Hand and Microsurgery, Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
| | - Zhenhua Luo
- Department of Hand and Microsurgery, Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
| | - Panfeng Wu
- Department of Hand and Microsurgery, Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
| | - Juyu Tang
- Department of Hand and Microsurgery, Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
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20
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Advancements in Reconstructive Surgery Broaden Opportunities for Salvage of the Injured Lower Extremity. Ann Plast Surg 2021; 84:238-245. [PMID: 31513085 DOI: 10.1097/sap.0000000000001977] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Advancements in microsurgery have made lower extremity reconstruction possible even after major soft tissue loss or tibial nerve disruption. There is an ongoing paradigm shift in the indications for amputation versus salvage and in flap selection protocols for different areas of the lower extremity. Initial evaluation, patient selection, triage, and timing of reconstruction are essential factors that can influence functional and aesthetic outcomes. The emergence of perforator flaps and the application of new concepts such as free-style flaps, propeller perforator flaps, thinning of free flaps, and supermicrosurgery have provided reconstructive surgeons with many techniques to decrease donor-site morbidity and improve outcomes. This includes options for reconstruction on extremities with single or no adequate runoff vessels. We present a review of the major advancements in reconstructive surgery for salvage of the traumatic lower extremity.
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21
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Peroneal flap: How to harvest and clinical appraisal for head and neck reconstruction. J Plast Reconstr Aesthet Surg 2020; 74:1515-1523. [PMID: 33358676 DOI: 10.1016/j.bjps.2020.11.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 08/26/2020] [Accepted: 11/22/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND A peroneal flap, the boneless version of fibula flap, is considered as the equivalent of radial forearm flap of the lower leg. Because it is thinner than an anterolateral thigh (ALT) flap, the use of a peroneal flap is a viable option for the repair of soft tissue defects when a thin flap could bring about better functional and cosmetic outcomes. In this article, we describe the details of peroneal flap harvest and present our experience with the use of peroneal flaps for head and neck reconstruction. MATERIALS AND METHODS Between 1996 and 2017, a total of 265 peroneal flaps were used to reconstruct a variety of head and neck defects. With the same vascular anatomy and slight modifications to the harvesting technique of a fibula flap, a peroneal flap can be harvested within 1-2 h. All medical records were retrospectively reviewed. RESULTS A peroneal flap can be harvested as different types of chimeric flaps to fit a variety of head and neck defects. The peroneal flap failure rate was 3.4% and the postoperative complication rate was 12.8%. CONCLUSION A peroneal flap might be an alternative option for the reconstruction of head and neck defects.
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22
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He J, Wu P, Zhou Z, Kalsi R, Yu F, Qing L, Tang J. Versatile design of compound vastus lateralis muscle and anterolateral thigh musculocutaneous perforator free flaps for customized reconstruction of complex skin and soft tissue defects in the extremities. Microsurgery 2020; 40:783-791. [PMID: 32964525 DOI: 10.1002/micr.30644] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 06/11/2020] [Accepted: 08/21/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Compound anterolateral thigh flaps are popular for three-dimensional reconstruction of complex soft tissue defects. We present our 10-year experience using compound vastus lateralis (VL) muscle and anterolateral thigh musculocutaneous perforator (ALTP) flaps, and introduce three versatile customizations of this flap for individualized reconstruction of complex three-dimensional soft tissue defects. METHODS From May 2008 to June 2017, compound VL muscle and ALTP flaps were performed in 67 consecutive patients aged 14-75 years (62 men and 5 women). The defects were in either the lower (n = 53) or upper extremity (n = 14), and ranged in size from 8 × 4 cm2 to 25 × 6 cm2. Dead space volume ranged from 4 × 2 × 1 cm3 to 20 × 3 × 2 cm3, and all flaps were harvested from patients' thighs as one of three types. In type A, a single perforator supplied both the skin and muscle components, with the vascular bundle penetrating the muscle component. In type B, a single perforator supplied both skin and muscle components with separate branches to the skin and muscle. In type C, separate vessels supplied the skin and muscle. RESULTS In the 67 patients, 65 flaps survived, and the donor site was closed directly. Vascular compromise occurred in four patients on the first postoperative day. Two flaps were salvaged after emergency re-exploration. Flap loss occurred in two patients, and these defects were repaired using other flaps. The follow-up period ranged from 8 to 60 months (mean, 11.9 months). All flaps had satisfactory appearance and texture, and no patients experienced limited hip and knee joint mobility from the donor site operation. CONCLUSIONS Compound VL muscle and ALTP flaps are a reliable option to reconstruct complex defects of the extremities. Identifying three flap types allowed for more precise customization to cover complex defects with limited donor site morbidity.
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Affiliation(s)
- Jiqiang He
- Department of Hand & Microsurgery, Xiangya Hospital of Central South University, Changsha, China
| | - Panfeng Wu
- Department of Hand & Microsurgery, Xiangya Hospital of Central South University, Changsha, China
| | - Zhengbing Zhou
- Department of Hand & Microsurgery, Xiangya Hospital of Central South University, Changsha, China
| | - Richa Kalsi
- Department of General Surgery, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Fang Yu
- Department of Hand & Microsurgery, Xiangya Hospital of Central South University, Changsha, China
| | - Liming Qing
- Department of Hand & Microsurgery, Xiangya Hospital of Central South University, Changsha, China
| | - Juyu Tang
- Department of Hand & Microsurgery, Xiangya Hospital of Central South University, Changsha, China
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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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Abstract
A chimeric flap consists of multiple discrete tissues or flaps connected only by a common source vessel. Each component must have an independent source of circulation. Rotation of any included part only about its specific vascular supply, such as done with a propeller flap, would be possible. These characteristics, whereby the chimeric flap concept and propeller flap concept are combined, would result in a chimeric propeller flap . Such a choice will enhance overall flap insetting capabilities and versatility, while often limiting the reconstructive need to but a single donor site!
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Affiliation(s)
- Geoffrey G. Hallock
- Division of Plastic Surgery, St. Luke's Hospital–Sacred Heart Campus, Allentown, Pennsylvania
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25
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Karakawa R, Yoshimatsu H, Tanakura K, Imai T, Yano T, Sawaizumi M. Triple-lobe combined latissimus dorsi and scapular flap for reconstruction of a large defect after sarcoma resection. Microsurgery 2020; 41:26-33. [PMID: 32721049 DOI: 10.1002/micr.30627] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 04/20/2020] [Accepted: 06/26/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND In the setting of the reconstruction for a large defect, we must make the maximum use of the limited human tissue with the minimum damage. In this article, we report on reconstruction using a combination of three-skin paddle latissimus dorsi and a scapular flap for a large defect after soft tissue sarcoma resection to minimize donor site morbidity. METHODS From 2000 to 2012, six patients underwent primary reconstruction using free or pedicled triple-lobe combined latissimus dorsi and scapular flap after wide resection of soft tissue sarcoma. There were five male patient and one female, and their average age was 66.8 (range, 49-80 years). The location of the defects was the thoracic wall in three, the thigh in one, the knee in one, and the shoulder in one. The average size of the defect was 18.8 × 13.9 cm. RESULTS The average size of the ascending scapular flap and the skin paddle of the latissimus dorsi flap was 6.8 × 13 cm and 7.3 × 14.7 cm. One patient had partial necrosis of the skin paddle of the latissimus dorsi flap, which was treated conservatively. The triple-lobe combined latissimus dorsi and scapular flaps survived completely in five cases. Neither anastomosis complications nor infections were encountered. The average follow-up period was 63.67 months. All patients were satisfied functionally and esthetically with the reconstruction outcomes at the end of follow-up. CONCLUSION In conclusion, the triple-lobe combined latissimus dorsi and scapular flap is one of the options for reconstruction of a large defect after sarcoma resection to minimize donor site morbidity.
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Affiliation(s)
- Ryo Karakawa
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Hidehiko Yoshimatsu
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Kenta Tanakura
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tomohiro Imai
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tomoyuki Yano
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Masayuki Sawaizumi
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
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Pompei B, Farhadi J. Diep Flap Volume Augmentation: Literature Review and "Calzone" Flap Shaping Technique. J Plast Reconstr Aesthet Surg 2020; 73:1933-1939. [PMID: 32571688 DOI: 10.1016/j.bjps.2020.05.070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 04/07/2020] [Accepted: 05/16/2020] [Indexed: 11/18/2022]
Abstract
Breast reconstruction with DIEP flap is a well-accepted and well-established technique for autologous breast reconstruction. In the past, this reconstructive option was typically offered to a limited group of patients as previous surgeries or low BMI were considered to be an obstacle to the success of the procedure or for the achievement of a satisfactory cosmetic outcome due to the lack of available tissue. Nowadays, this does not correspond to truth anymore and DIEP flaps are performed routinely on slender patients and on women who have undergone previous liposuction or abdominal surgeries. This paper analyzes current surgical options for volume recruitment in patients with scanty abdominal tissue or with abdominal scars and presents our standardized approach for DIEP volume augmentation with the "Calzone style" bipedicled DIEP flap.
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Affiliation(s)
- Barbara Pompei
- Department of Plastic Reconstructive and Aesthetic Surgery, University of Modena and Reggio Emilia, Modena, Italy.
| | - Jian Farhadi
- Plastic Surgery Group, Zuerich, Switzerland; University of Basel, Basel, Switzerland
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Extended Use of Chimeric Medial Sural Artery Perforator Flap for 3-Dimensional Defect Reconstruction. Ann Plast Surg 2020; 82:S86-S94. [PMID: 30422844 DOI: 10.1097/sap.0000000000001697] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The medial sural artery perforator (MSAP) flap has become increasingly popular because it is thin and pliable for small to moderate defect soft tissue reconstruction. Furthermore, chimeric MSAP flap, which includes a skin paddle and a separated piece of medial gastrocnemius muscle, allowed more freedom for flap insetting, especially in 3-dimensional defect reconstruction. Here we describe our experience regarding this clinical application. PATIENTS AND METHODS From 2007 to 2016, 14 male patients (average age, 46.9 ± 14.4 years) who received either a free or pedicled chimeric MSAP flap were included. Of these 14 patients, 7 received this flap for reconstruction in the head and neck, 2 in the upper extremities, and 5 in the lower extremities. Demographic data were collected and analyzed, and a literature review was performed. RESULTS Ten patients received free chimeric MSAP flap, and 4 received the pedicled type. Thirteen of the 14 flaps (92.6%) survived, and 1 failed 2 days later owing to venous insufficiency. Venous congestion-related partial loss occurred in another case. CONCLUSIONS The chimeric MSAP flap is a good alternative for deep space obliteration or reconstruction of adjacent but separate defects in both free and pedicled flap design. Donor site morbidity is limited. However, the perforator needs to be mobilized carefully to prevent postoperative venous compromise.
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AL Deek NF. Letter to the Editor: Notes on Single Chimeric Flaps. Otolaryngol Head Neck Surg 2020; 162:593. [DOI: 10.1177/0194599819898860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Pipkorn P, Ettyreddy AR, Zenga J. Response to Notes on Single Chimeric Flaps. Otolaryngol Head Neck Surg 2020; 162:594. [DOI: 10.1177/0194599819898863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Chimeric posterior tibial artery flap: clinical application in oral and maxillofacial reconstruction. Int J Oral Maxillofac Surg 2020; 49:993-999. [PMID: 31926825 DOI: 10.1016/j.ijom.2019.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 08/15/2019] [Accepted: 12/20/2019] [Indexed: 11/20/2022]
Abstract
The objective was to describe the utility of the chimeric posterior tibial artery flap (CPTAF) in the restoration of compound defects in the oral and maxillofacial region. Patients who underwent head and neck reconstruction using a CPTAF between February 2018 and February 2019 were included. Special consideration was given to the distribution of septocutaneous perforators (SPs), indications, flap survival, and complications. Nine patients were included. All flaps survived. One patient developed a surgical site infection, which was managed conservatively. The CPTAF was raised as a bipaddle skin flap without muscle (n=1), with the gastrocnemius muscle (n=6), or with the soleus muscle (n=2). The number of SPs ranged from three to five (mean 4±0.8). The SPs were mostly located between 4cm and 20cm proximal to the medial malleolus (mean 9.5±3.8cm). The skin paddle was used to reconstruct skin or mucosal defects, whereas the muscle part was used to fill the dead space (n=7) or to support the orbital contents (n=1). The donor site healed with no associated functional complications. The CPTAF is a good option for the restoration of composite tissue defects in the head and neck region. It offers flexibility during flap inset and provides the appropriate bulk to repair defects in multiple planes.
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Ki SH, Ma SH, Sim SH, Choi MSS. Unplanned change from double free flap to a chimeric anterolateral thigh flap in recurrent laryngeal cancer. Arch Craniofac Surg 2019; 20:416-420. [PMID: 31914501 PMCID: PMC6949492 DOI: 10.7181/acfs.2019.00458] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 10/07/2019] [Indexed: 11/21/2022] Open
Abstract
Reconstruction method choice in recurrent head and neck cancer depends on surgical history, radiation therapy dosage, conditions of recipient vessels, and general patient condition. Furthermore, when defects are multiple or three dimensional in nature, reconstruction and flap choice aimed at rebuilding the functional structure of the head and neck are difficult. We experienced successful reconstruction of recurrent laryngeal cancer requiring reconstruction of esophageal and tracheostomy stroma defects using a chimeric two-skin anterolateral thigh flap with a single pedicle.
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Affiliation(s)
- Sae Hwi Ki
- Department of Plastic Surgery, Inha University School of Medicine, Incheon, Korea.,Department of Plastic Surgery, Inha University Hospital, Incheon, Korea
| | - Sung Hwan Ma
- Department of Plastic Surgery, Inha University Hospital, Incheon, Korea
| | - Seung Hyun Sim
- Department of Plastic Surgery, Inha University Hospital, Incheon, Korea
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Boahene KO, Owusu J, Ishii L, Ishii M, Desai S, Kim I, Kim L, Byrne P. The Multivector Gracilis Free Functional Muscle Flap for Facial Reanimation. JAMA FACIAL PLAST SU 2019; 20:300-306. [PMID: 29566121 DOI: 10.1001/jamafacial.2018.0048] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance A multivector functional muscle flap that closely simulates the biomechanical effects of facial muscle groups is essential for complete smile restoration after facial paralysis. Objective To determine the feasibility of a multivector gracilis muscle flap design for reanimation after facial paralysis and to analyze the effect on the smile display zone. Design, Setting, and Participants Prospective analysis of patients who underwent a double paddle multivector gracilis flap for complete facial paralysis between June 2015 and December 2016 was carried out in a tertiary hospital. Interventions The gracilis muscle was harvested as a double paddle flap and inserted along 2 vectors for facial reanimation. Main Outcomes and Measures The primary outcome measures were: (1) dental display (the number of maxillary teeth displayed on paralyzed vs normal sides), (2) exposed maxillary gingival scaffold width, (3) interlabial gap at midline and canine, (4) facial asymmetry index (FAI), and (5) dynamic periorbital wrinkling. Results There were 10 women and 2 men between ages 20 and 64 years (mean [SD], 46 [15] years). Five flaps were reinnervated with facial and masseteric nerves, 5 with masseteric nerve only, and 2 with crossfacial nerve only. There was functional muscle recovery in all cases. On average there was additional 3.1 maxillary teeth exposed posttreatment when smiling (5.5 vs 8.6; CI, 7.9 to 16.6; P < .001). The mean exposed maxillary gingival scaffold width improved from 31.5 mm to 43.7 mm (95% CI, 1.9 to 4.3; P < .001). There was no significant difference in interlabial exposure at midline (7.1 mm vs 7.7 mm; CI, -1.5 to 2.7; P = .56) but a 56.4% improvement at the level of the canines (3.9 vs 6.1; CI, 0.1 to 4.3; P = .04). The mean FAI when smiling was reduced from 9.1 mm to 4.5 mm (CI, -8.0 to -1.2; P = .01). Dynamic wrinkling of the periorbital area with smiling was noted in 4 patients. Conclusions and Relevance The gracilis flap can be reliably designed as a functional double paddle muscle flap for a multivector facial reanimation. The multivector gracilis flap design is effective in improving all components of the smile display zone and has the potential for producing periorbital-wrinkling characteristic of a Duchenne smile. Level of Evidence 4.
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Affiliation(s)
- Kofi O Boahene
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - James Owusu
- Mid Atlantic Permanente Medical Group, McLean, Virginia
| | - Lisa Ishii
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Masaru Ishii
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Shaun Desai
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Irene Kim
- University of California Los Angeles, Santa Monica
| | | | - Patrick Byrne
- Johns Hopkins University School of Medicine, Baltimore, Maryland
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Kim YH, Kim GH, Pafitanis G, Miller R, Kim SW. Limb Salvage Using Combined Linking Perforator Free Flaps. INT J LOW EXTR WOUND 2019; 19:44-50. [DOI: 10.1177/1534734619864240] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Microsurgical free tissue transfer is the most effective method for extensive reconstruction of lower limb defects. The purpose of this report is to describe our experience of using microsurgically fabricated combined linking perforator flaps for one-stage reconstruction of extensive lower limb defects. Between April 2008 and November 2016, 16 cases of extensive lower defects were reconstructed using combined linking flaps. Of the patients, 10 were males, and the mean age was 45.3 years (range = 20-76 years). The flaps used were thoracodorsal artery perforator flaps together with deep inferior epigastric artery perforator flaps or anterolateral thigh flaps. There were no total flap failures; however, 3 anterolateral thigh flaps were partially lost and required skin grafts. One wound disruption healed conservatively. Donor site healing was achieved primarily without any dehiscence. The follow-up period was 15.4 months (range = 8-24 months). The use of combined linking perforator flaps for lower limb defects is uncommon; however, in cases of extensive limb defects these flaps can salvage limbs by means of one-stage operations.
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Affiliation(s)
| | | | - Georgios Pafitanis
- The Royal London Hospital, Barts Health NHS Trust, London, UK
- Queen Mary University of London, London, UK
| | - Rob Miller
- The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Sang Wha Kim
- Seoul National University Hospital, Seoul, Korea
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Qing L, Wu P, Yu F, Zhou Z, Tang J. Sequential chimeric deep circumflex iliac artery perforator flap and flow-through anterolateral thigh perforator flap for one-stage reconstruction of complex tissue defects. J Plast Reconstr Aesthet Surg 2019; 72:1091-1099. [DOI: 10.1016/j.bjps.2019.02.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Revised: 01/14/2019] [Accepted: 02/12/2019] [Indexed: 11/15/2022]
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Ettyreddy AR, Chen CL, Zenga J, Simon LE, Pipkorn P. Complications and Outcomes of Chimeric Free Flaps: A Systematic Review. Otolaryngol Head Neck Surg 2019; 161:568-575. [PMID: 31109239 DOI: 10.1177/0194599819844997] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Ablations of locally advanced or recurrent head and neck cancer commonly result in large composite orofacial defects. Chimeric flaps represent a unique surgical option for these defects, as they provide diverse tissue types from a single donor site. The purpose of the study was to consolidate the literature on chimeric flaps with regard to postoperative complication rates to help inform surgical decision making. DATA SOURCES The librarian created search strategies with a combination of keywords and controlled vocabulary in Ovid Medline (1946), Embase (1947), Scopus (1823), Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and Clinicaltrails.gov (1997). REVIEW METHODS Candidate articles were independently reviewed by 2 authors familiar with the subject material, and inclusion/exclusion criteria were uniformly applied for article selection. Articles were considered eligible if they included patients who received a single chimeric flap for reconstruction of head and neck defects and if they provided data on complication rates. RESULTS A total of 521 chimeric flaps were included in the study. The major complication rate was 22.6%, while the minor complication rate was 14.0%. There were 7 flap deaths noted in the series. Median operative time and harvest time were 15.0 and 2.5 hours, respectively. CONCLUSION Chimeric flaps represent a viable option for reconstruction of complex head and neck defects and have complication rates similar to those of double free flaps and single free flaps with locoregional flap while only modestly increasing total operative time.
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Affiliation(s)
- Abhinav R Ettyreddy
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Collin L Chen
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Joseph Zenga
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
| | - Laura E Simon
- Bernard Becker Medical Library, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Patrik Pipkorn
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
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Patel SY, Meram AT, Kim DD. Soft Tissue Reconstruction for Head and Neck Ablative Defects. Oral Maxillofac Surg Clin North Am 2019; 31:39-68. [PMID: 30449526 DOI: 10.1016/j.coms.2018.08.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Soft tissue reconstruction of head and neck ablative defects is a broad, challenging, and subjective topic. The authors outline goals to keep in mind when deciding on a primary reconstructive option for defects created by oncologic resection. Factors considered in local, regional, and distant flap selection are discussed. Based on the goals of reconstruction and factors involved in flap selection, a defect-based reconstructive algorithm is developed to help choose the ideal reconstructive option. The authors also discuss indications, pearls, pitfalls, and challenges in the harvest and inset of commonly used soft tissue flaps for head and neck reconstructive surgery.
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Affiliation(s)
- Stavan Y Patel
- Department of Oral and Maxillofacial Surgery/Head and Neck Surgery, Louisiana State University Health Science Center, 1501 Kings Highway, Shreveport, LA 71103, USA.
| | - Andrew T Meram
- Department of Oral and Maxillofacial Surgery/Head and Neck Surgery, Louisiana State University Health Science Center, 1501 Kings Highway, Shreveport, LA 71103, USA
| | - Dongsoo D Kim
- Department of Oral and Maxillofacial Surgery/Head and Neck Surgery, Louisiana State University Health Science Center, 1501 Kings Highway, Shreveport, LA 71103, USA
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Franchi A, Häfeli M, Scaglioni MF, Elliot D, Giesen T. The use of chimeric musculocutaneous posterior interosseous artery flaps for treatment of osteomyelitis and soft tissue defect in hand. Microsurgery 2019; 39:416-422. [PMID: 30779433 DOI: 10.1002/micr.30434] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 12/30/2018] [Accepted: 01/25/2019] [Indexed: 11/08/2022]
Abstract
INTRODUCTION There is growing evidence of the superior ability of muscular tissue to clear bacterial bone infection. Unfortunately, in the hand, there are almost no small local muscular flaps, and muscular transfers to the hand are mainly microsurgical free transfers. In this report, we present the results of the use of a chimeric posterior interosseous flap including part(s) of the forearm muscles to treat osteomyelitis and soft tissue defect of hand from a series of patients. PATIENTS AND METHODS Four male patients with an average age of 32 years (range 20-46 years), were affected by acute osteomyelitis in hand. Previous fracture fixation with percutaneous K-wires was the cause of bone infection in three case. In one case, the osteomyelitis was a consequence of an open fracture. The bones affected were four metacarpals and one proximal phalanx, all with a minimal cortical defect (from the K-wire) obscuring a larger medullary infection, which required extensive bone and overlying soft tissue debridement, leaving a soft tissue defect to be reconstructed of size ranging from 2 x 4 cm to 5 x 7 cm. The soft tissue defects were due to concomitant superficial infection and consequent debridement. All patients were treated with bone debridement and a chimeric posterior interosseous flap, which included part of the extensor digiti minimi and/or extensor carpi ulnaris to fill the intramedullary canal of the bones. No fixation of bone was necessary. RESULTS The skin paddle of the flaps ranged from 2 x 5 cm to 5 x 6 cm, replicating the defect area, plus a teardrop tail of skin circa 1.5 cm wide and as long as the pedicle of the flap. The muscular components of the flaps used to fill the intramedullary canals ranged from 1 x 1 x 1.5 cm to 1.5 x 1.5 x 4 cm. All flaps survived and osteomyelitis resolved in all cases without major complications. At the final follow-up at 16 months (range 12-26 months), assessment of the hands using TAM, Power Grip and Key Pinch Strength measurements and, where appropriate, Kapandji scores, demonstrated satisfactory hand function. CONCLUSION The chimeric posterior interosseous flap including part of the muscles of the forearm may be a robust solution for augmenting the flap bulk and may be used in cases of severe osteomyelitis of the hand.
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Affiliation(s)
- Alberto Franchi
- Kantonsspital Luzern, Klinik für Hand-und Plastische Chirurgie, Lucerne, Switzerland
| | - Mathias Häfeli
- Kantonsspital Graubünden, Departement Chirurgie, Handchirurgie, Chur, Switzerland
| | - Mario F Scaglioni
- Kantonsspital Luzern, Klinik für Hand-und Plastische Chirurgie, Lucerne, Switzerland
| | - David Elliot
- Broomfield Hospital, St Andrew's Centre for Plastic Surgery and Burns, Chelmsford, Essex, United Kingdom
| | - Thomas Giesen
- Swissparc AG, Hand Surgery Service, Zürich, Switzerland.,Clinica Ars Medica, Centro Manoegomito, Gravesano, Switzerland
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Moreno MA, Bonilla‐Velez J. Clinical pathway for abbreviated postoperative hospital stay in free tissue transfer to the head and neck: Impact in resource utilization and surgical outcomes. Head Neck 2019; 41:982-992. [DOI: 10.1002/hed.25525] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 09/12/2018] [Accepted: 10/01/2018] [Indexed: 11/05/2022] Open
Affiliation(s)
- Mauricio A. Moreno
- Department of Otolaryngology – Head and Neck SurgeryUniversity of Arkansas for Medical Sciences Little Rock Arkansas
| | - Juliana Bonilla‐Velez
- Department of Otolaryngology – Head and Neck SurgeryUniversity of Arkansas for Medical Sciences Little Rock Arkansas
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Brunetti B, Tenna S, Barone M, Cassotta G, Casale M, Persichetti P. Bipaddle chimaeric forehead flap: A new technique for simultaneous lining and cutaneous reconstruction in case of full thickness defects of the nose. Microsurgery 2018; 39:124-130. [PMID: 30221388 DOI: 10.1002/micr.30376] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Revised: 07/15/2018] [Accepted: 08/24/2018] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Many techniques have been described to treat full thickness nasal defects. The authors introduce the bipaddle chimaeric forehead flap (BCFF), a new alternative technique to achieve simultaneous lining and cutaneous reconstruction in case of full thickness hemi-nasal defects, presenting surgical details and applications for its clinical use. PATIENTS AND METHODS From June 2015 to April 2017, 10 patients presenting with oncological full thickness defects involving nasal sidewall and/or nasal ala were reconstructed with the BCFF technique. Mean age was 69.4 years. The chimaeric flap was composed of 2 paddles (cutaneous and periosteal), nourished by a single supratrochlear pedicle, which were used to independently reconstruct the deficient cutaneous and mucosal layers of the nose. Cartilage grafts were used in 8/10 patients. RESULTS Mean surgical time was 114 minutes. An intermediate thinning operation was performed in 3 out of 10 patients. All the flaps survived with no partial necrosis or cartilage exposure observed. Viability and mucosalization of the periosteal paddle was documented both intra-operatively (during the 2nd stage of the operation) and postoperatively (with fiberoptic rhinoscopy performed 3 months after the procedure). Clinical follow-up period ranged from 4 to 24 months postoperatively. The final result was judged sufficient, good and excellent in 1, 5, and 4 cases, respectively. CONCLUSIONS The BCFF technique may be a new alternative approach to address full thickness hemi-nasal defects with no extra donor site morbidity, allowing primary placement of structural cartilage grafts and immediate definition of the nasal subunits to be reconstructed.
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Affiliation(s)
- Beniamino Brunetti
- Plastic, Reconstructive and Aesthetic Surgery Department, Campus Bio-Medico University School of Medicine, Rome, Italy
| | - Stefania Tenna
- Plastic, Reconstructive and Aesthetic Surgery Department, Campus Bio-Medico University School of Medicine, Rome, Italy
| | - Mauro Barone
- Plastic, Reconstructive and Aesthetic Surgery Department, Campus Bio-Medico University School of Medicine, Rome, Italy
| | - Gabriella Cassotta
- Plastic, Reconstructive and Aesthetic Surgery Department, Campus Bio-Medico University School of Medicine, Rome, Italy
| | - Manuele Casale
- Otorhinolaryngology Department, Campus Bio-Medico University School of Medicine, Rome, Italy
| | - Paolo Persichetti
- Plastic, Reconstructive and Aesthetic Surgery Department, Campus Bio-Medico University School of Medicine, Rome, Italy
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Sokoya M, Bahrami A, Vincent A, Kadakia S, Inman J, Saman M, Ducic Y. Preoperative radiation and complication rates after double free flap reconstruction of head and neck cancer. Am J Otolaryngol 2018; 39:558-560. [PMID: 29937104 DOI: 10.1016/j.amjoto.2018.06.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 06/06/2018] [Accepted: 06/15/2018] [Indexed: 11/18/2022]
Abstract
INTRODUCTION In this study, we explore whether preoperative external beam radiation affects complication rates in patients that have undergone double simultaneous free tissue transfer for head and neck defects. STUDY DESIGN, SETTING, SUBJECTS AND METHODS Approval was obtained from the JPS Institutional Review Board. We performed a retrospective analysis of patients who underwent double free flap reconstruction of head and neck defects between August 1997 and April 2017. Minimum follow up was 6 months. Patients were grouped according to preoperative radiation status (XRT vs non-XRT). The chi-squared test was used for all comparisons. P-values and 95% confidence intervals (CI) were reported as (P, 95% CI). RESULTS 90 flaps were performed on 45 patients. The most common flap combination utilized was fibula plus radial forearm free flap (RFF) in 17 out of 45 patients. There were no statistically significant differences in frequency of flap failure (0.35, -15.9-20.1), wound infection (0.75, -22.1-19.3), hematoma (0.16, -5.3-36.7), or fistula formation (0.69, -22.5-24.6). There were also no statistically significant differences in cardiac complications (0.57, -10.3-28.2) and DVT (0.22, -12.4-25.3). CONCLUSION Our findings suggest that double free flap patients who had preoperative radiation are not more likely to have complications compared to non- radiated patients. Simultaneous double free flaps should be reserved for the most complex cases. Extensive discussion should be had with the patient about possible morbidity and mortality.
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Affiliation(s)
- Mofiyinfolu Sokoya
- University of Colorado School of Medicine, Department of Otolaryngology, USA
| | - Arash Bahrami
- Department of Otolaryngology-Head and Neck Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
| | | | - Sameep Kadakia
- Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, TX, USA
| | - Jared Inman
- Department of Otolaryngology Head and Neck Surgery, Loma Linda University Medical Center, USA
| | | | - Yadranko Ducic
- Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, TX, USA.
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Song D, Li Z, Zhou X, Zhang Y, Peng X, Zhou B, Lü C, Peng W, Mao H. [Application of combined transverse upper gracilis flap and adductor magnus perforator flap in breast reconstruction]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2018; 32:707-713. [PMID: 29905049 PMCID: PMC8414009 DOI: 10.7507/1002-1892.201801001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Revised: 04/26/2018] [Indexed: 11/03/2022]
Abstract
Objective To explore the clinical application of combined transverse upper gracilis flap and adductor magnus perforator flap in breast reconstruction of breast cancer patients after mastectomy. Methods Between August 2016 and February 2017, the combined transverse upper gracilis flap and adductor magnus perforator flap was used in 12 cases of breast cancer patients who received modified radical surgery for breast reconstruction. All patients were females with the age of 32 to 59 years (mean, 41.5 years). There were 7 cases in left side and 5 cases in right side. Eight cases were received breast reconstruction by one-stage operation and 4 cases by two-stage operation. In one-stage operation cases, pathological diagnosis includes invasive ductal carcinoma in 4 cases and invasive lobular carcinoma in 4 cases. The disease duration ranged from 2 to 9 months (mean, 4.5 months). In two-stage operation cases, the time interval between mastectomy and breast reconstruction ranged from 12 to 70 months (mean, 37.4 months). The length of flap was 20-28 cm, the width of flap was 5.5-7.5 cm, the thickness of flap was 2.5-4.5 cm. The length of gracilis flap pedicle was 6.5-9.2 cm, the length of adductor magnus perforator flap pedicle was 7.5-10.4 cm. The weight of flap was 295-615 g. Results The ischemia time of flap ranged from 95 to 230 minutes (mean, 135 minutes). All flaps were successfully survived. All incisions of recipient donor sites healed by first intention. All patients were followed up 7-14 months (mean, 9.5 months). The reconstructed breasts' shape, texture, and elasticity were good and no flap contracture deformation happened. Only linear scar left in the donor sites, but the function of thighs was not affected. No local recurrence happened during follow-up. Conclusion With appropriate patient selection and surgical technique, the combined transverse upper gracilis flap and adductor magnus perforator flap can be a valuable option as an alternative method for autologous breast reconstruction.
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Affiliation(s)
- Dajiang Song
- Department of Oncology Plastic Surgery, Hunan Province Cancer Hospital, Changsha Hunan, 410008, P.R.China
| | - Zan Li
- Department of Oncology Plastic Surgery, Hunan Province Cancer Hospital, Changsha Hunan, 410008,
| | - Xiao Zhou
- Department of Oncology Plastic Surgery, Hunan Province Cancer Hospital, Changsha Hunan, 410008, P.R.China
| | - Yixin Zhang
- Department of Plastic and Reconstructive Surgery, the Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200000, P.R.China
| | - Xiaowei Peng
- Department of Oncology Plastic Surgery, Hunan Province Cancer Hospital, Changsha Hunan, 410008, P.R.China
| | - Bo Zhou
- Department of Oncology Plastic Surgery, Hunan Province Cancer Hospital, Changsha Hunan, 410008, P.R.China
| | - Chunliu Lü
- Department of Oncology Plastic Surgery, Hunan Province Cancer Hospital, Changsha Hunan, 410008, P.R.China
| | - Wen Peng
- Department of Oncology Plastic Surgery, Hunan Province Cancer Hospital, Changsha Hunan, 410008, P.R.China
| | - Huangxing Mao
- Department of Oncology Plastic Surgery, Hunan Province Cancer Hospital, Changsha Hunan, 410008, P.R.China
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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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Sung IH, Jang DW, Kim SW, Kim YH, Kim SW. Reconstruction of diabetic lower leg and foot soft tissue defects using thoracodorsal artery perforator chimeric flaps. Microsurgery 2018; 38:674-681. [DOI: 10.1002/micr.30314] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 02/06/2018] [Accepted: 02/16/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Il Hoon Sung
- Department of Orthopaedic Surgery, College of Medicine; Hanyang University; Seoul Korea
| | - Dong Woo Jang
- Shanghai MK Medical Cosmetic Surgery Clinic; Shanghai China
| | | | - Youn Hwan Kim
- Department of Plastic and Reconstructive Surgery, College of Medicine; Hanyang University; Seoul Korea
| | - Sang Wha Kim
- Department of Plastic and Reconstructive Surgery, College of Medicine; Seoul National University, Seoul National University Hospital; Seoul Korea
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Graboyes EM, Hornig JD. Evolution of the anterolateral thigh free flap. Curr Opin Otolaryngol Head Neck Surg 2018; 25:416-421. [PMID: 28786847 DOI: 10.1097/moo.0000000000000394] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW To review the recent literature on the evolution and advanced uses of the anterolateral thigh (ALT) free flap in reconstruction of oncologic defects of the head and neck. RECENT FINDINGS The ALT free flap is a versatile flap that can be harvested in a chimeric fashion with independent, vascularized skin, muscle, fascia, nerve and bone. Various techniques for chimeric flap harvest and flap inset have been described for reconstruction of pharyngocutaneous, oromandibular and radical parotidectomy defects. These reports expand the indications for the ALT free flap while demonstrating good functional and aesthetic outcomes. SUMMARY The ALT free flap remains popular for reconstruction of head and neck oncologic defects because of its versatility. Continued evolution in chimeric flap harvest techniques for pharyngocutaneous, osseous and radical parotidectomy defects highlights novel advanced reconstructive uses for the ALT free flap.
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Affiliation(s)
- Evan M Graboyes
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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A Novel Application of Double-Paddle Peroneal Chimeric Flap as External Sentinel Monitor in Hypopharyngeal Reconstruction. Ann Plast Surg 2017; 78:S70-S75. [PMID: 28195888 DOI: 10.1097/sap.0000000000001009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Monitoring the viability of buried free flaps in hypopharyngeal reconstruction is difficult. Various methods have been proposed to monitor these buried flaps, but limitations remain. METHOD We present a method of using double-paddle chimeric peroneal flaps that permanently externalizes a flap skin paddle as a monitoring paddle in hypopharyngeal reconstructions. This study was performed in a medical center in southern Taiwan; between 2013 and 2015, 10 patients underwent double-paddle chimeric peroneal flap reconstruction in advanced stages of hypopharyngeal cancer. We retrospectively reviewed the medical records from these surgeries, searching for either short-term postoperative complications or long-term follow-up morbidity and researched relevant articles for comparisons with other monitoring methods. RESULTS None of the 10 flaps underwent total loss. The rate of stenosis and that of fistula formation was 10%. The average postoperative hospital stay was 39 days. Six of 10 patients were able to resume at least a soft diet after reconstruction, and none of the patients experienced significant complications. CONCLUSIONS The peroneal flap is a useful flap because it is thin and pliable, has minimal donor site morbidity in patients without peripheral vascular disease, and has the potential of multiple skin paddles so that one skin paddle can be used for monitoring the buried flap. Using this method, direct clinical monitoring is feasible, and early detection of vascular complications is possible. Furthermore, the drawbacks of using a monitoring paddle produced by a deepithelialized bridge can be avoided.
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Fernández Garrido M, Pereira N, López Fernández S, Vega C, Masià J. Turbocharged bilateral pedicled DIEP flap for reconstruction of thigh defect without recipient vessels: A case report. Microsurgery 2017; 38:324-327. [PMID: 29193249 DOI: 10.1002/micr.30280] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 10/29/2017] [Accepted: 11/17/2017] [Indexed: 11/08/2022]
Abstract
Reconstruction of thigh defects is usually straightforward, but in cases of poor soft tissue quality, free flap reconstruction is not possible due to the absence of recipient vessels. The turbocharge technique may increase the viable, vascularized area of a flap. In this report we present a case of the use of a turbocharged bilateral pedicled DIEP flap for reconstruction of thigh defect without recipient vessels. A 29-year-old woman who underwent neoadjuvant chemotherapy plus radiation therapy for a leiomyosarcoma on the left thigh. Six weeks later, complete tumor excision and a femoropopliteal bypass with contralateral saphenous vein was performed. In the following days the wound had dehiscence, infection, necrosis of the surrounding muscles and exposure of femoropopliteal bypass. No recipient vessels were available for free flap and critical limb ischemia due to bypass thrombosis was detected. The reconstruction of a large thigh defect (30 × 12 cm) and the coverage of a femoropopliteal bypass with a turbocharged bilateral pedicled DIEP flap was performed. A flap including the entire infraumbilical tissue was designed and the anastomosis of the proximal stump of the right inferior epigastric vessels with the distal ends of the inferior left epigastric vessels was performed to increase the viable area. The flap survived without any complications during the postoperative period. At 12-month follow up, coverage was stable with no tumor recurrence. Our result suggests that a turbocharged bilateral pedicled DIEP flap may be an option for reconstructing large tissue defects when no recipient vessels are available for free flap.
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Affiliation(s)
- Manuel Fernández Garrido
- Department of Plastic Surgery, Hospital de la Santa Creu i Sant Pau, Universitat Autonóma de Barcelona, Barcelona, Spain
| | - Nicolás Pereira
- Department of Plastic Surgery, Fellow Breast, Lymphedema and Reconstructive Microsurgery, Hospital de la Santa Creu i Sant Pau, Universitat Autonóma de Barcelona, Barcelona, Spain.,Plastic Surgery and Burns Department, Hospital del Trabajador, Santiago, Chile.,Plastic Surgery Department, Clínica Las Condes, Santiago, Chile
| | - Susana López Fernández
- Department of Plastic Surgery, Hospital de la Santa Creu i Sant Pau, Universitat Autonóma de Barcelona, Barcelona, Spain
| | - Carmen Vega
- Department of Plastic Surgery, Hospital de la Santa Creu i Sant Pau, Universitat Autonóma de Barcelona, Barcelona, Spain
| | - Jaume Masià
- Department of Plastic Surgery, Hospital de la Santa Creu i Sant Pau, Universitat Autonóma de Barcelona, Barcelona, Spain
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Massarelli O, Vaira LA, Biglio A, Gobbi R, Piombino P, De Riu G. Rational and simplified nomenclature for buccinator myomucosal flaps. Oral Maxillofac Surg 2017; 21:453-459. [PMID: 28936552 DOI: 10.1007/s10006-017-0655-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 09/13/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Reconstruction of moderate-sized mucosal defects of the oral cavity or oropharynx represents a surgical challenge. Buccinator myomucosal flaps seem to provide "ideal reconstruction" of oral/oropharyngeal defects because they carry a thin, mobile, well-vascularized, and sensitive tissue, like that excised or lost. Nevertheless, these flaps are not immediately popular because of confusion surrounding the complex terminology used to name them. METHODS After a retrospective study on our experience and a literature review, the authors propose a new rational and simplified nomenclature for the classification of buccinator myomucosal flaps, which clarifies the source vessel, the composition of the flap, and the type of transfer. RESULTS According to this nomenclature, six types of buccinator myomucosal flaps are described. CONCLUSIONS This proposed nomenclature may bring a consensus on the classification of buccinator myomucosal flaps and can help their spread.
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Affiliation(s)
- Olindo Massarelli
- Department of Maxillofacial Surgery, Sassari University Hospital, Viale San Pietro 43B, 07100, Sassari, Italy
| | - Luigi Angelo Vaira
- Department of Maxillofacial Surgery, Sassari University Hospital, Viale San Pietro 43B, 07100, Sassari, Italy.
| | - Andrea Biglio
- Department of Maxillofacial Surgery, Sassari University Hospital, Viale San Pietro 43B, 07100, Sassari, Italy
| | - Roberta Gobbi
- Department of Maxillofacial Surgery, Sassari University Hospital, Viale San Pietro 43B, 07100, Sassari, Italy
| | - Pasquale Piombino
- Department of ENT, University of Campania "Luigi Vanvitelli" Hospital, Via Pansini 5, 08131, Naples, Italy
| | - Giacomo De Riu
- Department of Maxillofacial Surgery, Sassari University Hospital, Viale San Pietro 43B, 07100, Sassari, Italy
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Bassi KK, Shah AA, Verma PK, Pandey BB. Soft Tissue Tumors of Lower and Upper Limb and Various Reconstructive Options with Pedicled Flaps and Review of Literature—an Experience from Mahavir Cancer Sansthan. Indian J Surg Oncol 2017; 8:361-378. [DOI: 10.1007/s13193-017-0625-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Accepted: 02/13/2017] [Indexed: 10/20/2022] Open
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49
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Henn D, Abouarab MH, Hirche C, Hernekamp JF, Schmidt VJ, Kneser U, Kremer T. Sequential chimeric medial femoral condyle and anterolateral thigh flow-through flaps for one-stage reconstructions of composite bone and soft tissue defects: Report of three cases. Microsurgery 2017; 37:824-830. [DOI: 10.1002/micr.30209] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 07/15/2017] [Accepted: 07/21/2017] [Indexed: 11/06/2022]
Affiliation(s)
- Dominic Henn
- Department of Hand; Plastic, and Reconstructive Surgery, BG Trauma Center Ludwigshafen, Department of Plastic and Hand Surgery, University of Heidelberg; Heidelberg Germany
| | - Mohamed H. Abouarab
- Department of Hand; Plastic, and Reconstructive Surgery, BG Trauma Center Ludwigshafen, Department of Plastic and Hand Surgery, University of Heidelberg; Heidelberg Germany
- Department of Plastic and Reconstructive Surgery and Burns; Faculty of Medicine, University of Alexandria; Alexandria Egypt
| | - Christoph Hirche
- Department of Hand; Plastic, and Reconstructive Surgery, BG Trauma Center Ludwigshafen, Department of Plastic and Hand Surgery, University of Heidelberg; Heidelberg Germany
| | - Jochen F. Hernekamp
- Department of Hand; Plastic, and Reconstructive Surgery, BG Trauma Center Ludwigshafen, Department of Plastic and Hand Surgery, University of Heidelberg; Heidelberg Germany
| | - Volker J. Schmidt
- Department of Hand; Plastic, and Reconstructive Surgery, BG Trauma Center Ludwigshafen, Department of Plastic and Hand Surgery, University of Heidelberg; Heidelberg Germany
| | - Ulrich Kneser
- Department of Hand; Plastic, and Reconstructive Surgery, BG Trauma Center Ludwigshafen, Department of Plastic and Hand Surgery, University of Heidelberg; Heidelberg Germany
| | - Thomas Kremer
- Department of Hand; Plastic, and Reconstructive Surgery, BG Trauma Center Ludwigshafen, Department of Plastic and Hand Surgery, University of Heidelberg; Heidelberg Germany
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Comprehensive Analysis of Donor-Site Morbidity following Free Thoracodorsal Artery Perforator Flap Harvest. Plast Reconstr Surg 2017; 138:899-909. [PMID: 27307340 DOI: 10.1097/prs.0000000000002396] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The authors evaluated donor-site morbidity following free thoracodorsal artery perforator flap harvest comprehensively and investigated patient-and operation-related factors that might contribute to adverse outcomes. METHODS A retrospective analysis was conducted for all cases of free thoracodorsal artery perforator flap reconstruction performed between January of 2002 and December of 2014. Donor-site morbidity was evaluated in three aspects: postoperative complications, scar-related problems, and functional impairment. The Quick-Disabilities of the Arm, Shoulder and Hand questionnaire was administered postoperatively to assess donor-site function. RESULTS A total of 293 patients were analyzed. The median follow-up period was 19.0 months. Donor-site complications developed in 33 patients (11.3 percent). Wound dehiscence (7.4 percent) and seroma (3.0 percent) were the most common complications. Harvesting thoracodorsal artery perforator flaps on multiple perforators or segmental latissimus dorsi muscle-chimeric flaps increased the rate of seroma formation but did not affect other donor-site morbidities significantly. Patient American Society of Anesthesiologists classification was a significant predictor of wound dehiscence and overall donor-site complications. Thirty-one patients (10.6 percent) had scar-related problems, including 18 hypertrophic and 13 widened scars. A transverse skin paddle design had a significant protective effect on developing scar-related problems, compared with the nontransverse design. The mean Quick-Disabilities of the Arm, Shoulder and Hand questionnaire score was 2.68 (range, 0 to 18.2), and 90 percent of patients scored less than 10. Flap dimensions were positively correlated with the questionnaire score. CONCLUSIONS The present study suggests that the free thoracodorsal artery perforator flap is associated with low donor-site morbidity and minimal dysfunction. Careful consideration of patient condition and thoughtful planning could further minimize donor-site morbidity. CLINICAL QUESTION/LEVEVL OF EVIDENCE Therapeutic, IV.
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