Functional Donor-Site Morbidity Following (Osteo-) Fasciocutaneous Parascapular Flap Transfer

Posterior Circumflex Humeral Artery Perforator Flap: A Cadaveric Study and Case Series

BACKGROUND

Reconstruction of soft tissue defects of the acromioclavicular region represents a relatively uncommon but challenging event. Many muscular, fasciocutaneous, and perforator flaps have been described, including the posterior circumflex humeral artery perforator (PCHAP) flap based on the direct cutaneous perforator of the PCHA. This study aims to describe a variant of the PCHAP flap, based on a constant musculocutaneous perforator, by means of a cadaveric study and a case series.

METHODS

A cadaveric study was conducted using 11 upper limbs. The perforator vessels originating from the PCHA were dissected and the musculocutaneous ones were identified and measured in their length and distance from the deltoid tuberosity. Besides, we retrospectively analyzed the posterior shoulder reconstruction conducted among 2 plastic surgery department (San Gerardo Hospital, Monza and Hospital Papa Giovanni XXIII, Bergamo) using the musculocutaneous perforators of the PCHA.

RESULTS

The cadaver dissection showed the presence of a constant musculocutaneous perforator arising from the PCHA. The mean pedicle length is 6.10 ± 1.18 cm, and the musculocutaneous perforator pierces the fascia at a mean distance of 10.4 ± 2.06 cm from the deltoid tuberosity. In all the cadaver dissected, the perforator of interest divided into 2 terminal branches, anterior and posterior, nourishing the skin paddle.In our case series, the mean age of the patients was 66.7 years, the mean size of the defect was 46 cm 2 , the mean operating time was 79.3 minutes, the mean length of hospital stay was 2.7 days, and the complication rate was 28.6%.

CONCLUSIONS

According to this preliminary data, the PCHAP flap based on the musculocutaneous perforator seems to be a reliable alternative in posterior shoulder region reconstruction.

Donor Site Morbidity and Quality of Life after Microvascular Head and Neck Reconstruction with a Chimeric, Thoracodorsal, Perforator-Scapular Flap Based on the Angular Artery (TDAP-Scap-aa Flap)

Extensive defects in the head and neck area often require the use of advanced free flap reconstruction techniques. In this study, the thoracodorsal perforator-scapular free flap technique based on the angular artery (TDAP-Scap-aa flap) was postoperatively evaluated regarding the quality of life and the donor site morbidity using the standardized SF-36 and DASH questionnaires (short form health 36 and disabilities of the arm, shoulder and hand scores). Over a five-year period (2016−2020), 20 selected cases (n = 20) requiring both soft and hard tissue reconstruction were assessed. On average, the harvested microvascular free flaps consisted of 7.8 ± 2.1 cm hard tissue and 86 ± 49.8 cm2 soft tissue components. At the donor site (subscapular region), only a mild morbidity was observed (DASH score: 21.74 ± 7.3 points). When comparing the patients’ postoperative quality of life to the established values of the healthy German norm population, the observed SF-36 values were within the upper third (>66%) of these established norm values in almost all quality-of-life subcategories. The mild donor site morbidity and the observed quality of life indicate only a small postoperative impairment when using the TDAP-Scap-aa free flap for the reconstruction of extensive maxillofacial defects.

Utility of parascapular flaps for regional reconstruction of upper back defects: a case series

The latissimus dorsi (LD) flap has classically been described for posterior upper quadrant trunk defects. Perforator flaps have gained popularity among reconstructive surgeons as the predictable anatomy and muscle-sparing nature of parascapular flaps make this an attractive reconstructive option. We describe the versatility of the parascapular flap for reconstruction of defects in the axilla, deltoid, scapula and paraspinal region performed in six patients over a two-year period. The history of the parascapular flap, technique, patient outcomes and technical pearls are also discussed. We recommend this flap be considered a workhorse flap for defects in the posterior upper quadrant.

Donor-site morbidity after fibula free flap transfer: a comparison of subjective evaluation using a visual analogue scale and point evaluation system

The aims of this study were: (1) to compare the visual analogue scale (VAS) with the point evaluation system (PES) in the subjective evaluation of donor-site morbidity after fibula free flap transfer; (2) to compare the functional outcomes of fibula free flap surgery between patients with a normal body mass index (BMI) and patients with a high BMI, and between skin paddle and non-skin paddle harvesting; and (3) to determine the correlation between functional outcomes and related factors. This study included 15 patients who underwent a vascularized fibula free flap transfer for oral and maxillofacial reconstruction. Demographic data, preoperative, intraoperative, and postoperative data were collected. Subjective self-evaluation of functional outcomes was done using a VAS followed by a PES. Comparison of the VAS and PES scores was assessed with Pearson's correlation coefficient. The statistical significance was set at P<0.05. The VAS score was significantly correlated with the PES score (r=0.63, P=0.01). The tourniquet times for the skin paddle group were longer than for the non-skin paddle group (P=0.02), while the satisfaction score of the non-skin paddle group was higher than that of the skin paddle group (P=0.03). The VAS is a potential option for the subjective evaluation of donor-site morbidity after fibula free flap transfer.

Comparison of anterolateral thigh, lateral arm, and parascapular free flaps with regard to donor-site morbidity and aesthetic and functional outcomes

BACKGROUND

The purpose of this study was to compare the morbidity and the aesthetic and functional outcomes of primarily closed donor sites of three commonly used free flaps.

METHODS

Sixty patients who had undergone free flap reconstruction (20 anterolateral thigh, 20 parascapular, and 20 lateral arm flaps) were included in this study. The average follow-up time was 50 months (range, 6 to 135 months). Patients assessed subjective donor-site morbidity and satisfaction with the aesthetic and overall functional result using a self-report questionnaire. Outcome measures were the Disabilities of the Arm, Shoulder and Hand questionnaire; the Lower Extremity Functional Scale; and the Medical Outcomes Study 36-Item Short-Form Health Survey questionnaire.

RESULTS

No significant differences in range of motion or in questionnaire, scale, or survey scores were detected. Sensory disorders were present in 100 percent (lateral arm), 90 percent (anterolateral thigh), and 45 percent (parascapular). No correlation to flap size was detected (187 cm for parascapular and anterolateral thigh, and 70 cm for lateral arm flaps). Postoperative complications were seromas (parascapular, n = 2), hematomas (parascapular, n = 1; lateral arm, n = 2), and dehiscence (n = 4 for each flap). Patient satisfaction with the donor site was rated 2.9 for lateral arm and anterolateral thigh flaps and 2.5 for parascapular flaps (1 = excellent, 6 = poor). Seventy percent of anterolateral thigh, 85 percent of lateral arm, and 100 percent of parascapular flap patients would choose their flap again.

CONCLUSION

In terms of reducing donor-site morbidity, the parascapular flap represents a valuable alternative to the anterolateral thigh and lateral arm flaps, but side positioning and increased seroma are drawbacks.

Parascapular free flaps in skin malignancies

This study was a retrospective review of a case series of nine patients, aged 40 to 83 years, presenting to the head and neck cancer department at Wake Forest Baptist Medical Center, with a diagnosis of head and neck cutaneous squamous cell carcinoma (SCC), requiring reconstruction after surgical resection. In this group of patients, parascapular fasciocutaneous free flaps proved to be a safe, reliable, and cosmetically effective choice for reconstruction of head and neck skin cancer defects. Choosing donor tissue from a relatively non-sun exposed area can prevent potential development of new malignancies that may arise from donor sites using sun-exposed skin. We discuss the benefits and versatility of the parascapular fasciocutaneous free flap and our experience in using this flap to reconstruct complex surgical defects.

Application of AAV2-mediated bFGF gene therapy on survival of ischemic flaps: effects of timing of gene transfer

Necrosis of surgically transferred flaps is a major problem in reconstructive surgery. We investigated efficacy of a new vector system-adeno-associated viral 2 (AAV2)-mediated bFGF gene transfer to enhance survival of the ischemic flap. Thirty-eight Sprague-Dawley rats were divided into 3 gene therapy groups and 1 nontreated control of 9 or 10 each. 7.5 x 10(10) AAV2-bFGF viral particles were injected to the dorsum of each of the 29 rats; these rats were divided into 3 groups according to the timing of flap elevation. At the time of surgery, 1 week, and 2 weeks after surgery, flaps of 3 x 7 cm were raised. One week after surgery, flap viability was measured. Vascularization and immunohistochemical staining of the bFGF were evaluated of histologic sections. Flap viability was significantly improved by the AAV2-bFGF gene therapy at the time of surgery, and the flaps with the greatest survival area were found in the rats injected with AAV2-bFGF, 2 weeks before surgery. However, flap viability was significantly decreased by the gene therapy 1 week before surgery. Histologically, vascularity was increased in the groups with AAV2-bFGF injection and immunohistochemical staining showed greatly enhanced bFGF expression by gene transfer. The novel approach of AAV2-bFGF gene therapy shows encouraging manifestations in improving survival of flaps when the flaps are prefabricated during or 2 weeks before surgery.

Osteo-fasciocutaneous parascapular flap transfer for reconstruction of the first ray of the foot

BACKGROUND

Severe bone and soft tissue defects of the first metatarsal bone after trauma, tumor resection or osteomyelitis are challenging to treat. Partial amputation of the foot may be the consequence. However, due to its significance for gait, salvage of the first ray should be considered, whenever possible. One option for bone and soft tissue reconstruction, therefore, might be an osteo-fasciocutaneous parascapular flap transfer.

METHODS

Five patients with bone and soft tissue defects of the first ray of the foot but intact MTP joint were treated with osteo- fasciocutaneous parascapular flap transfer, two after tumor resection, and three after severe bone and soft tissue trauma. Patients were followed for 12-36 months clinically and radiologically.

RESULTS

All flaps survived. One revision was necessary because of venous thrombosis, which was treated successfully by thrombectomy and patch plastic. All osteosyntheses united and the scapular bone transplant adapted nicely to the new loading conditions. All patients were content with the result and would agree to have the operation again. Two patients were able to stand tiptoe and go jogging, one patient still had limitations of ADLs due to the concomitant injuries.

CONCLUSION

The osteo- fasciocutaneous flap proved to be very versatile and safe for foot reconstruction due to its favorable vascular anatomy. In all patients (partial), amputation of the foot could be avoided.