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Gus E, Zhu J, Brooks SG. Postburn breast reconstruction: a scoping review. Scars Burn Heal 2023; 9:20595131231202100. [PMID: 37743873 PMCID: PMC10512695 DOI: 10.1177/20595131231202100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2023] Open
Abstract
Introduction Postburn breast deformities pose functional and aesthetic concerns for burn patients, particularly when injury occurs before puberty, as normal breast development may be hindered. Postburn breast reconstruction aims at restoration of native anatomic features, as well as re-establishment of symmetry. The objectives of this scoping review are to map the literature on scar management and breast reconstruction, highlighting strategies that are particular to postburn deformities, as well as to establish optimal timing principles. Methods A comprehensive search of the English literature across MEDLINE and EMBASE databases, including the grey literature, was conducted. Literature of all study designs were eligible, provided it discussed the treatment of postburn breast deformities. Results A total of 64 studies were included. The most common study design was case series (58%) followed by retrospective cohorts (28%). Scar contracture release with split thickness skin grafts (26%) and various techniques for nipple-areola reconstruction (22%) were the most common reconstructive procedures. Discussion Scar contracture releases predominate when there is normal breast development under a contracted skin envelope, and should be performed as soon as breast mound development is restricted. Surgical techniques widely used for postmastectomy reconstruction are required for patients with amastia or hypoplastic breasts. Conclusion Given the heterogeneity of defects, availability of donor sites, and patient preference, no standardized guideline is available. Surgeons should combine basic scar management principles with postmastectomy techniques, adapting the surgical approach to features that are particular to thermally injured patients, as well as taking into account ideal timing considerations. Lay Summary Breast deformities secondary to burn scars pose functional and aesthetic concerns for burn patients, particularly when injury occurs before puberty, as normal breast development may be hindered. Postburn breast reconstruction aims at restoration of native anatomic features, as well as re-establishment of symmetry. This literature review aimed at summarizing the available techniques to treat postburn breast deformities, as well as establishing optimal timing guidelines, given these issues may occur at any phase of breast development. When there is breast development under a scarred skin envelope, treatment entails scar contracture release and should be recommended as soon as the diagnosis is established, in order to allow the breast to further develop in an unrestricted manner. When there is absence of breast tissue, surgical techniques widely utilized for breast cancer reconstruction are warranted, and should be delayed until no further breast development is expected. Given the heterogeneity of deformities, availability of donor sites, and patience preference, no standardized guideline is available. Treatment options include several surgical techniques, in addition to non-surgical scar management, and timing considerations must take into account the patient's developmental phase and psychosocial wellness.
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Affiliation(s)
- Eduardo Gus
- Division of Plastic, Reconstructive & Aesthetic Surgery, The Hospital for Sick Children, Toronto, Canada
- Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Jane Zhu
- Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
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Salzillo R, Boriani F, Carta F, Tatti M, Atzeni M, Persichetti P, Haywood RM, Puxeddu R, Figus A. Perforator‐based chimeric anterolateral thigh flap U‐shaped insetting for total pharyngoesophageal reconstruction: Surgical technique and functional outcomes. Microsurgery 2022; 43:347-356. [PMID: 36468794 DOI: 10.1002/micr.30991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 11/02/2022] [Accepted: 11/18/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pharyngoesophageal reconstruction with the tubed anterolateral thigh (ALT) flap is burdened by possible strictures and pharyngocutaneous fistulae (PCF). We present our experience with the U-shaped insetting of perforator-based chimeric ALT flap focusing on surgical technique, complications and functional outcomes. METHODS We retrospectively included 10 patients with a total circumferential defect of the hypopharynx undergoing reconstruction with ALT flap. A perforator-based chimeric ALT flap with two independent skin paddles was harvested: the trapezoid paddle with the greater base cranially and the height oriented vertically was used for pharyngoesophageal reconstruction while the second paddle was exteriorized and used for flap monitoring and reducing tension on skin closure. Mean age was 56.4 years. Eight patients were affected by squamous cell carcinoma. Modified barium swallow radiogram and fiberoptic laryngoscopy were performed to assess strictures and PCFs. Swallowing and speech outcomes were evaluated through the Deglutition Handicap Index (DHI), M.D. Anderson Dysphagia Inventory (MDADI) and Voice Handicap Index (VHI) questionnaires. RESULTS Mean flap dimension was 7.9 × 6 × 9.2 cm. Mean ischemia time was 58.2 min (range 42-80). No flap loss nor flap-related complications were reported. Two PCFs were observed. Fiberoptic laryngoscopy documented a complete integration of the flap with no strictures or stenosis. Mean follow-up was 13.6 months (range 1-45 months). Mean DHI score was 33.8, mean MDADI score was 62.5, mean VHI score was 32.2. CONCLUSIONS The ALT flap U-shaped insetting is a reliable option for pharyngoesophageal reconstruction yielding a high success rate, low number of strictures and fistulae and good swallowing and voice outcomes.
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Affiliation(s)
- Rosa Salzillo
- University of Cagliari, Faculty of Medicine and Surgery, Department of Surgical Sciences, Plastic Surgery and Microsurgery Unit University Hospital Duilio Casula Cagliari Italy
- Campus Bio‐Medico University of Rome, Department of Plastic, Reconstructive and Aesthetic Surgery University Hospital Campus Bio‐Medico Rome Italy
| | - Filippo Boriani
- University of Cagliari, Faculty of Medicine and Surgery, Department of Surgical Sciences, Plastic Surgery and Microsurgery Unit University Hospital Duilio Casula Cagliari Italy
| | - Filippo Carta
- University of Cagliari, Faculty of Medicine and Surgery, Department of Surgical Sciences, Otorhinolaryngology Unit University Hospital Duilio Casula Cagliari Italy
| | - Melania Tatti
- University of Cagliari, Faculty of Medicine and Surgery, Department of Surgical Sciences, Otorhinolaryngology Unit University Hospital Duilio Casula Cagliari Italy
| | - Matteo Atzeni
- University of Cagliari, Faculty of Medicine and Surgery, Department of Surgical Sciences, Plastic Surgery and Microsurgery Unit University Hospital Duilio Casula Cagliari Italy
| | - Paolo Persichetti
- Campus Bio‐Medico University of Rome, Department of Plastic, Reconstructive and Aesthetic Surgery University Hospital Campus Bio‐Medico Rome Italy
| | - Richard M. Haywood
- Norfolk and Norwich University Hospital NHS Foundation Trust, Department of Plastic and Reconstructive Surgery University of East Anglia, Norwich Medical School Norwich UK
| | - Roberto Puxeddu
- University of Cagliari, Faculty of Medicine and Surgery, Department of Surgical Sciences, Otorhinolaryngology Unit University Hospital Duilio Casula Cagliari Italy
| | - Andrea Figus
- University of Cagliari, Faculty of Medicine and Surgery, Department of Surgical Sciences, Plastic Surgery and Microsurgery Unit University Hospital Duilio Casula Cagliari Italy
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Zhang Y, Liu Y, Wang T, Dong J, Dong L, Xu H. A split flap technique shifting the location of perforator entry point to lengthen the pedicle of a multiple perforator based free flap. Acta Chir Belg 2022; 122:215-221. [PMID: 35499197 DOI: 10.1080/00015458.2022.2066273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Pedicle length deficiency in microsurgical procedure is a challenging issue. The aim of this report is to present a case series of a flap-splitting technique for pedicle lengthening of large multiple perforator-based (MPB) free flaps. METHODS In this retrospective case series, we reviewed the medical records of patients who underwent free flap repair with "split flap" pedicle-lengthening technique between August 2017 and December 2021. Main outcome measures included patient demographics, indications, defect size, flap type, additional vascular pedicle length, and flap survival. RESULTS Data from 16 patients (age 38-78 years) were reviewed. Indications included breast reconstruction, repair of scalp malignancy or titanium mesh implant exposure, and repair of burn scar contracture. Flaps included ALT flap, LD flap and DIEP flap. The mean added pedicle length was 3.8 cm. Fifteen flaps survived completely and one flap was necrotic distally. No major complications occurred. CONCLUSIONS The 'split flap' technique could be an effective remedy for unexpected pedicle length deficiencies in large MPB free flaps.
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Affiliation(s)
- Yi Zhang
- Plastic and Reconstructive Surgery, Shanghai Jiao Tong University School of Medicine Affiliated Ninth People's Hospital, Shanghai, China
| | - Ying Liu
- Plastic and Reconstructive Surgery, Shanghai Jiao Tong University School of Medicine Affiliated Ninth People's Hospital, Shanghai, China
| | - Tingliang Wang
- Plastic and Reconstructive Surgery, Shanghai Jiao Tong University School of Medicine Affiliated Ninth People's Hospital, Shanghai, China
| | - Jiasheng Dong
- Plastic and Reconstructive Surgery, Shanghai Jiao Tong University School of Medicine Affiliated Ninth People's Hospital, Shanghai, China
| | - Liping Dong
- Plastic and Reconstructive Surgery, Shanghai Jiao Tong University School of Medicine Affiliated Ninth People's Hospital, Shanghai, China
| | - Hua Xu
- Plastic and Reconstructive Surgery, Shanghai Jiao Tong University School of Medicine Affiliated Ninth People's Hospital, Shanghai, China
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Kalra GS, Kalra S, Gupta S. Resurfacing in Facial Burn Sequelae Using Parascapular Free Flap: A Long-Term Experience. J Burn Care Res 2021; 43:808-813. [PMID: 34698838 DOI: 10.1093/jbcr/irab204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND It is difficult to treat large post burn sequelae (scars and defects) over face. Available methods include skin grafts, local flaps, tissue expansion, and free flaps. These surgical options should be chosen wisely, depending upon individual patient requirements and area involved. In patients with large post burn scars and defects in which the surrounding tissue is also involved, use of free tissue transfer is extremely useful. PATIENTS AND METHODS A retrospective analysis was done between 2011 and 2019 of fifty-two cases with extensive facial burn deformities in whom secondary reconstruction was done with free parascapular flap cover in or department. Outcome was assessed by direct questionnaire. RESULTS There was no complete flap loss in the series. Two cases were re-explored for venous insufficiency and suffered partial marginal necrosis. Twenty patients had to undergo further debulking procedure. Forty-seven patients were satisfied by the final outcome. CONCLUSION Post burn facial deformities are difficult to treat, in many cases there are no local options and tissue from different regions is to be used for reconstruction. Free parascapular flaps can be used as an effective method in such cases with a high level of patient satisfaction.
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Affiliation(s)
- Gurdyal Singh Kalra
- Professor and Head, Department of Plastic and Reconstructive Surgery, Sawai Man Singh Medical College and Hospital, Jaipur, Rajasthan, India
| | - Sushrut Kalra
- Post graduate trainee, Department of Plastic and Reconstructive Surgery, Sawai Man Singh Medical College and Hospital, Jaipur, Rajasthan, India
| | - Samarth Gupta
- Post graduate trainee, Department of Plastic and Reconstructive Surgery, Sawai Man Singh Medical College and Hospital, Jaipur, Rajasthan, India
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Suh YC, Kim SH, Baek WY, Hong JW, Lee WJ, Jun YJ. Super-thin ALT flap elevation using preoperative color doppler ultrasound planning: Identification of horizontally running pathway at the deep adipofascial layers. J Plast Reconstr Aesthet Surg 2021; 75:665-673. [PMID: 34815192 DOI: 10.1016/j.bjps.2021.09.051] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 09/27/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Presently, super-thin ALT flap, which is elevated above the superficial fascial plane, is gaining popularity. Although there is a huge demand for thin flaps for various types of extremity reconstruction, the technique for ALT flap thinning remains controversial. In this study, we investigated the distance and vector between penetrating points of perforators in deep and superficial fascia using color duplex and clinical measurement to suggest a reliable super-thin flap elevation technique. MATERIALS AND METHODS From June 2018 to February 2020, 44 patients with various types of defects who were treated using super-thin ALT flaps were enrolled; 69 surgically detected perforators were analyzed. All patients' flap outcomes and characteristics of the perforators were analyzed. In addition, the effects of patients' body mass index (BMI) and thickness of super-thin flap were evaluated. RESULTS The average traveling length of perforator at the deep adipofascial layer (DAL) was 2.43 cm, and the vector of traveling was randomly arranged. The mean thickness of super-thin ALT flap was 6.8 mm. The thickness of super-thin flap was not significantly correlated with patients' BMI (ranged from 17.4 to 34.2 kg/m2; p = 0.183). CONCLUSION The novel elevation technique for super-thin ALT might be useful, as evidenced by perforator traveling distance and vector in DAL. Preoperative color duplex ultrasonography is helpful to detect the running course of the perforators during elevating the flap. This anatomic concept must be considered to obtain the reliability of the super-thin ALT flap.
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Affiliation(s)
- Young Chul Suh
- Department of Plastic and Reconstructive Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Shin Hyun Kim
- Department of Plastic and Reconstructive Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Woo Yeol Baek
- Department of Plastic and Reconstructive Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jong Won Hong
- Department of Plastic and Reconstructive Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea; Department of Plastic and Reconstructive Surgery, Seoul St. Mary Hospital, The Catholic University of Korea, College of Medicine, Seoul, Republic of Korea
| | - Won Jai Lee
- Department of Plastic and Reconstructive Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young Joon Jun
- Department of Plastic and Reconstructive Surgery, Seoul St. Mary Hospital, The Catholic University of Korea, College of Medicine, Seoul, Republic of Korea.
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Hussein MA, Abdelkader R, El-Henawy AN, Makarem K. Lower Pole Breast Reconstruction Using Muscle-sparing Latissimus Dorsi Flap in Postburn Breast Deformity. Plast Reconstr Surg Glob Open 2021; 9:e3835. [PMID: 34584830 DOI: 10.1097/GOX.0000000000003835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 07/26/2021] [Indexed: 11/25/2022]
Abstract
Background: Full-thickness burns of the anterior chest wall during childhood are a devastating problem that results in significant distortion of the developing breast. This deformed burnt breast represents a serious aesthetic problem, and can lead to functional impairment as well as severe emotional trauma for patients. Methods: Patients with postburn scarring affecting the lower pole of the breast were included. Only patients with small to medium-sized breasts were targeted. The lower breast pole was reconstructed using muscle-sparing latissimus dorsi flap. All patients had been subjectively assessed, including overall patient satisfaction regarding breast aesthetics, donor site morbidity, and functional deficits of latissimus dorsi muscle, 3 months postoperatively. Results: Six patients (seven breasts) were included in this study. Muscle-sparing latissimus dorsi flap was used to reconstruct lower breast pole in all patients. A horizontally-oriented skin paddle was used in five patients, whereas a vertically oriented skin paddle was used in one patient. Average patient satisfaction was 9.1 (SD 0.6) for the reconstructed lower breast pole. For the donor site, average overall satisfaction was 9.1 (SD 0.8). Latissimus dorsi muscle function was objectively confirmed in 90% of cases after 3 months postoperatively. Patients had an average score of 3.9 (SD 0.4) for the activity score as well. Conclusions: The muscle-sparing latissimus dorsi flap is a good reconstructive tool for lower breast pole in postburn breast reconstruction. It has a reliable versatile skin paddle that can resurface the whole lower breast pole, while avoiding many of the latissimus flap morbidities.
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Abstract
The anterolateral thigh (ALT) flap is a popular flap for lower extremity reconstruction despite its varied pedicle anatomy. Beyond its use for soft tissue coverage, using the chimeric flap concept, the ALT flap is useful for tendon and ligament reconstruction and the creation of a gliding surface with the fascia lata component. The vastus lateralis muscle can be included for dead-space obliteration. The main pedicle is long and is a similar size match for major artery reconstruction. If several perforators are available, a split flap could be fashioned into a multitude of shapes all arising from the same pedicle.
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Affiliation(s)
- Chung-Chen Hsu
- Department of Plastic and Reconstructive Surgery, Linkou Medical Center, Chang Gung Memorial Hospital, Chang Gung University, 5 Fu-hsing Street, Gueishan, Taoyuan 333, Taiwan, ROC
| | | | - Fu-Chan Wei
- Department of Plastic and Reconstructive Surgery, Linkou Medical Center, Chang Gung Memorial Hospital, Chang Gung University, 5 Fu-hsing Street, Gueishan, Taoyuan 333, Taiwan, ROC.
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Gehring MB, Iorio ML. Evaluation of Primary and Secondary Free Flap Desyndactylization Techniques in Hand and Digit Reconstruction: A Systematic Review. Journal of Reconstructive Microsurgery Open 2020; 05:e107-14. [DOI: 10.1055/s-0040-1721705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
AbstractObjective Injuries of the hand often require free flap reconstruction. To minimize flap loss, evidence exists to surgically syndactylize digits when repairing multiple injuries, with delayed flap division, or desyndactylization. However, evidence suggests that division of the flap at the time of inset can be accomplished with minimal negative effect. The purpose of this study was to evaluate outcomes, following hand reconstruction with free flaps utilizing either acute or staged desyndactylization techniques.Methods A systematic review utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed. Articles that described the use of a free flap for surgically syndactylized digits or multilobed flaps for coverage of multiple digits were included.Results One hundred sixty-one articles were reviewed with 34 fulfilling inclusion criteria. One hundred seventeen patients underwent 145 free flap reconstructions. Traumatic avulsions (49%) were the most common injuries, followed by burns (11%). Twenty-one (62%) papers described surgical syndactylization of digits, which were later desyndactylized and five (15%) papers included reconstruction of more than one digit with multilobed free flaps. Eight papers (24%) described both techniques. Overall, 100% of included flaps survived. Total complication rate was 6%, with six complications (67%) occurring in flaps with primary syndactylization.Conclusion Hand defects often require free flaps for reconstruction. Although free flaps for the reconstruction of digital defects is technically demanding, they result in better outcomes. With available evidence indicating complications rates less than those of staged desyndactylization, multidigit reconstruction with multilobed free flaps may be a more desirable technique.
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Meng C, Liu Y, Wang H, Sun Y, Lu S, Zhou Y, Hu J, Yu Y, Fang L, Sun Y, Hu D. Lower trapezius myocutaneous flap repairs adjacent deep electrical burn wounds. Eur J Med Res 2020; 25:63. [PMID: 33261649 PMCID: PMC7709246 DOI: 10.1186/s40001-020-00465-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 11/26/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Local tissue damage caused by electrical burns is often deep and severe. High-voltage electrical burns are common in the head, neck and torso areas. These are mostly caused by direct contact with the power supply and are often accompanied by deep injuries of the nerve, blood vessel, muscle, tendon, and bone. We must pay great attention to the clinical treatment of these parts injured by electrical burn. CASE PRESENTATION The first case involved a migrant worker who touched a 6-kV high-tension wire when welding steel; this electric shock caused burns in many places. Deep electrical burn wounds were mainly located on the left shoulder and back, characterized by widespread skin and soft tissue defect and bone necrosis. We utilized a lower trapezius myocutaneous flap to repair these wounds in the neck and back caused by deep electrical burns. The flap survived completely and the wound was effectively repaired. The function and shape of the shoulder and back after the restoration were satisfactory. The second case involved a 29-year-old who accidentally touched a high-voltage wire while working and was burned by a 30,000-V electric shock. His wounds were mainly located on the left head, neck, back and left upper limbs. We designed a 30 cm × 12 cm right trapezius myocutaneous flap which completely covered the wound surface; the electrical burn wounds on the neck and back were effectively repaired. After the electrical burn wound was repaired, the neck function returned to normal with a satisfactory shape. CONCLUSION The authors report two cases of patients who were burned by high voltage. We used lower trapezius myocutaneous flaps to repair their wounds, which achieved satisfactory clinical results. This study has provided a reliable surgical method for the clinical treatment of deep electrical burn wounds in the neck, shoulders and back.
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Affiliation(s)
- Chengying Meng
- Department of Burn, The First Affiliated Hospital of Anhui Medical University, No. 218 Jixi Road, Hefei, Anhui, 230022, People's Republic of China
| | - Yuyao Liu
- Department of Burn, The First Affiliated Hospital of Anhui Medical University, No. 218 Jixi Road, Hefei, Anhui, 230022, People's Republic of China
| | - Huan Wang
- Department of Burn, The First Affiliated Hospital of Anhui Medical University, No. 218 Jixi Road, Hefei, Anhui, 230022, People's Republic of China
| | - Youjun Sun
- Department of Burn, The First Affiliated Hospital of Anhui Medical University, No. 218 Jixi Road, Hefei, Anhui, 230022, People's Republic of China
| | - Shiping Lu
- Operating Room of Burn Department, The First Affiliated Hospital of Anhui Medical University, No. 218 Jixi Road, Hefei, Anhui, 230022, People's Republic of China
| | - Yan Zhou
- Operating Room of Burn Department, The First Affiliated Hospital of Anhui Medical University, No. 218 Jixi Road, Hefei, Anhui, 230022, People's Republic of China
| | - Jiayan Hu
- Operating Room of Burn Department, The First Affiliated Hospital of Anhui Medical University, No. 218 Jixi Road, Hefei, Anhui, 230022, People's Republic of China
| | - Youxin Yu
- Department of Burn, The First Affiliated Hospital of Anhui Medical University, No. 218 Jixi Road, Hefei, Anhui, 230022, People's Republic of China
| | - Linsen Fang
- Department of Burn, The First Affiliated Hospital of Anhui Medical University, No. 218 Jixi Road, Hefei, Anhui, 230022, People's Republic of China
| | - Yexiang Sun
- Department of Burn, The First Affiliated Hospital of Anhui Medical University, No. 218 Jixi Road, Hefei, Anhui, 230022, People's Republic of China
| | - Delin Hu
- Department of Burn, The First Affiliated Hospital of Anhui Medical University, No. 218 Jixi Road, Hefei, Anhui, 230022, People's Republic of China.
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Acartürk TO, Bengür FB. Total aesthetic reconstruction of postburn bilateral breast loss using transverse myocutaneous gracilis free flaps: A case report and literature review. Microsurgery 2020; 40:704-709. [PMID: 32749747 DOI: 10.1002/micr.30633] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 06/04/2020] [Accepted: 07/10/2020] [Indexed: 11/11/2022]
Abstract
Reconstruction of breast burns are challenging, as it includes both functional and aesthetic components. Transverse myocutaneous gracilis (TMG) flap has been used for postmastectomy breast reconstruction in the absence of abdominal donor site availability. Use of this flap for the breast burns is limited. A 32-year-old female sustained 54% second and third degree burns resulting with bilateral total breast loss. Anterior and posterior thorax, upper and mid abdomen, neck, shoulders, and bilateral upper extremities were also involved. Inner medial thighs had an ample amount of tissue and had never been used as donor sites. The left TMG (28 × 12 cm, 1,413 g) was used for right, and the right TMG (30 × 14 cm, 1,635 g) was used for the left breast, 3 months apart. The contracture on the chest wall was completely excised. Venous anastomosis to the venae commitantes was performed using a 2.5 mm coupler, followed by an end-to-end arterial anastomosis to the internal mammary artery. Flaps were inset in a fashion so that the inferior part became the inframammary fold, and the anterior and posterior wings were joined in the upper pole, creating a conical shape. Minimal wound dehiscence in the postoperative course healed with dressing changes and both flaps survived completely. Nipple reconstruction and areolar tattooing was performed. The patient was very happy with the outcome at seventh year follow-up. TMG may be a valuable option even in bilateral cases of microsurgical autologous free tissue transfer for total aesthetic reconstruction of postburn breast loss.
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Affiliation(s)
- Tahsin Oğuz Acartürk
- University of Pittsburgh, Department of Plastic Surgery, Pittsburgh, Pennsylvania, USA
| | - Fuat Barış Bengür
- University of Pittsburgh, Department of Plastic Surgery, Pittsburgh, Pennsylvania, USA
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Fujiwara M, Suzuki T, Ohta Y, Okada E, Fukamizu H, Tokura Y. Elevation of Thin Pudendal Artery Flap Using Fat Thickness Data in Vulvovaginal Reconstruction. Indian J Surg 2020; 82:169-175. [DOI: 10.1007/s12262-019-01913-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Qing L, Li X, Wu P, Zhou Z, Yu F, Tang J. Customized reconstruction of complex soft-tissue defect in the hand and forearm with individual design of chain-linked bilateral anterolateral thigh perforator flaps. J Plast Reconstr Aesthet Surg 2019; 72:1909-1916. [PMID: 31564579 DOI: 10.1016/j.bjps.2019.08.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 07/16/2019] [Accepted: 08/18/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Complex soft-tissue defects of upper extremities still have a high rate of amputation, as the reconstruction of complex soft-tissue defects is always difficult even with the largest conventional free flap. The anterolateral thigh perforator (ALTP) flap is one of the most popular procedures used for the coverage of complex soft-tissue defects of extremities. However, problems associated with donor-site morbidity and inability to repair complex soft-tissue defects in a one-stage procedure persist. The purpose of this study was to present a novel design of using chain-linked bilateral ALTP flap and its various designs for customized reconstruction of complex soft-tissue defects in the hands and forearms. METHODS From June 2009 to June 2017, we retrospectively analyzed 15 patients with complex soft-tissue defects in the hands and forearms. All patients in this series underwent extremity reconstruction using the chain-linked bilateral ALTP flaps. Three different types of chain-linked bilateral ALTP flaps were created in this study based on wound characteristics and the maximum available skin paddle size at all donor sites. RESULTS The chain-linked bilateral ALTP flaps were successfully harvested for the reconstruction of complex soft-tissue defects in the hands and forearms. Among them, ten cases were repaired with chain-linked bipaddle ALTP flaps, two cases were treated with chain-linked tripaddle ALTP flaps, and the remaining three cases were used with chain-linked multi-lobed ALTP chimeric flaps. The sizes of the skin paddles ranged from 11 cm × 7 cm to 42 cm × 8 cm. The areas of the total flaps ranged from 245 cm2 to 650 cm2 (mean 419.6 cm2). Only one case required re-exploration because of the venous congestion. The donor sites were closed directly. The mean follow-up time was 16.4 months. Most cases showed satisfactory contour. CONCLUSION The chain-linked bilateral ALTP flap is a reliable option for one-stage reconstruction of complex soft-tissue defects in the hands and forearms with limited donor-site morbidity. It also provides various flap designs, which allow for more individualized treatment approaches.
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Affiliation(s)
- Liming Qing
- Department of orthopedic, Xiangya Hospital of Central South University, Changsha 410008, China; Department of Neurosurgery, Maryland University of Medicine School, Baltimore, United States
| | - Xiaoxiao Li
- Department of orthopedic, Xiangya Hospital of Central South University, Changsha 410008, China; Department of Neurosurgery, Maryland University of Medicine School, Baltimore, United States
| | - Panfeng Wu
- Department of orthopedic, Xiangya Hospital of Central South University, Changsha 410008, China
| | - Zhengbing Zhou
- Department of orthopedic, Xiangya Hospital of Central South University, Changsha 410008, China
| | - Fang Yu
- Department of orthopedic, Xiangya Hospital of Central South University, Changsha 410008, China
| | - Juyu Tang
- Department of orthopedic, Xiangya Hospital of Central South University, Changsha 410008, China.
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Qing L, Wu P, Zhou Z, Yu F, Tang M, Tang J. A Design for the Dual Skin Paddle Circumflex Scapular Artery Perforator Flap for the Reconstruction of Complex Soft-Tissue Defects in Children: Anatomical Study and Clinical Applications. Ann Plast Surg 2019; 83:439-46. [DOI: 10.1097/sap.0000000000001814] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Qing L, Wu P, Yu F, Zhou Z, Tang J. Use of a sequential chimeric perforator flap for one-stage reconstruction of complex soft tissue defects of the extremities. Microsurgery 2019; 40:167-174. [PMID: 30901118 DOI: 10.1002/micr.30450] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 02/15/2019] [Accepted: 03/08/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND One-stage reconstruction of complex soft tissue defects of the extremities is a challenging problem. Repair of complex soft tissue defects requires adequate skin tissues to cover the large surface wound and special tissues for obliterating the dead space. The chimeric flap is one of the most popular approaches for reconstruction of complex soft tissue defects. However, the problems of donor-site morbidity and inability to repair very large defects at one-stage remain. The purpose of this study was to present our clinical experience using sequential chimeric perforator flaps for reconstruction of complex extremity defects with primary closure of the donor site. METHODS From August 2013 to March 2017, 12 patients with complex soft tissue defects underwent extremity reconstruction using sequential chimeric perforator flaps, which were composed of a chimeric anterolateral thigh perforator (ALTP) flap and an additional free perforator flap. The skin paddles were placed side-by-side to cover the large surface soft tissue defects, and the muscle component was used to obliterate the dead space. Of these patients, one was injured by a crushing accident, while the other 11 patients were injured in traffic accidents. RESULTS The size of the skin paddles ranged from 26 cm × 8 cm-10 cm × 6 cm to 30 cm × 8.5 cm-29 cm × 9 cm. The muscle paddle size ranged from 2 cm × 3 cm × 4 cm to 22 cm × 4 cm × 2 cm. All-components of the sequential chimeric flaps survived in all-patients. Vascular compromise was observed in one case. One case suffered minor wound-edge necrosis and was treated conservatively. Primary closure of donor-site was successfully achieved in all-patients, and all-donor-site wounds healed uneventfully. The mean follow-up time was 15.25 months. Most of the cases showed a satisfactory contour, and only two patients presented with mildly bulky appearance that treated with a debulking procedure. CONCLUSIONS The sequential chimeric perforator flap is an alternative procedure for reconstruct complex soft tissue defects of the extremities. This approach allows for flexible design, a larger cutaneous area, and low donor site morbidity.
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Affiliation(s)
- Liming Qing
- 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
| | - Fang Yu
- 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
| | - Juyu Tang
- Department of Hand & Microsurgery, Xiangya Hospital of Central South University, Changsha, China
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Kim SY, Lee YJ, Mun GH. Anatomical Understanding of Target Subcutaneous Tissue Layer for Thinning Procedures in Thoracodorsal Artery Perforator, Superficial Circumflex Iliac Artery Perforator, and Anterolateral Thigh Perforator Flaps. Plast Reconstr Surg 2018; 142:521-34. [PMID: 29889740 DOI: 10.1097/PRS.0000000000004619] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Thinned perforator flaps, reported techniques, and degree of thinning differ by study. This study investigated the anatomy of subcutaneous tissue according to the varying fattiness and identified which component and how much of the subcutaneous tissue layer needed to be excluded to meet target flap thickness using computed tomography. METHODS Three stratified fattiness groups consisting of 30 donors were formed for thoracodorsal artery perforator, superficial circumflex iliac artery perforator, and anterolateral thigh flaps. Thickness of the superficial fat and the deep fat layers was measured at specific points in donor sites of the three flaps and the proportion of superficial and deep fat layers to exclude to reach the target flap thickness (4, 6, and 8 mm) was calculated. RESULT The median proportion for the superficial fat layer varies depending on donor fattiness. The estimated percentage reduction of thickness after thin flap elevation along superficial fascia was approximately one-third of the whole layer. A variable proportion of each fat layer needs to be excluded to obtain required thinness and in very thick groups, part of the superficial fat layer must be removed to reach any of the target thicknesses for the three flaps. CONCLUSIONS The present study demonstrated the frequent need for superficial fat layer manipulation when obtaining a thin perforator flap. To cope with various combinations of donor-site fattiness and different required thicknesses effectively, an appropriate thinning method should have increased adaptability, including the ability to control superficial fat layer thickness.
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Luo Z, Qing L, Zhou Z, Wu P, Yu F, Tang J. Reconstruction of Large Soft Tissue Defects of the Extremities in Children Using the Kiss Deep Inferior Epigastric Artery Perforator Flap to Achieve Primary Closure of Donor Site. Ann Plast Surg 2019; 82:64-70. [DOI: 10.1097/sap.0000000000001659] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Qing L, Wu P, Yu F, Zhou Z, Tang J. Use of dual-skin paddle anterolateral thigh perforator flaps in the reconstruction of complex defect of the foot and ankle. J Plast Reconstr Aesthet Surg 2018; 71:1231-8. [DOI: 10.1016/j.bjps.2018.05.029] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 04/08/2018] [Accepted: 05/26/2018] [Indexed: 11/19/2022]
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Steve AK, White CP, Alkhawaji A, Hayakawa TEJ, Buchel EW, Morris SF. Computed Tomographic Angiography Used for Localization of the Cutaneous Perforators and Selection of Anterolateral Thigh Flap "Bail-Out" Branches. Ann Plast Surg 2018; 81:87-95. [PMID: 29746278 DOI: 10.1097/SAP.0000000000001433] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate the territory supplied by the lateral circumflex femoral artery for the consistency of a proximal perforator that could be used as an alternative pedicle for the anterolateral thigh flap if a tedious intramuscular course is encountered during elevation of the perforator used to develop the initial surgical plan. It is hypothesized that a consistent "bail-out" perforator supplying the proximal thigh would facilitate a simpler anterolateral thigh flap harvest, with minimal modification to flap design. METHODS Computed tomographic images of 9 fresh cadavers were imported using Materialize's Interactive Medical Imaging Control System software to create surface-rendered 3-dimensional reconstructions of 15 lower limbs. Perforators emerging proximally and laterally to a 3-cm radius circle drawn at the midpoint of the anterior superior iliac spine and superolateral patella were considered potential bail-out perforators and evaluated for their number emerging diameter, length, course, and location relative to the anterior superior iliac spine. RESULTS An average of 2.9 ± 1.8 perforators per limb were identified. Mean pedicle length was 111 ± 20 mm, measured from the origin in the lateral circumflex femoral artery to where the perforators emerged through the deep fascia directly overlying the thigh muscles. Average diameter at origin in the lateral circumflex femoral artery was 2.8 ± 0.8 mm, and that at emergence through the deep fascia was 1.1 ± 0.3 mm. Vessel course was predominantly musculocutaneous (90%). CONCLUSIONS A significant bail-out perforator routinely supplies the proximal anterolateral thigh and may be used as an alternative vascular pedicle for an anterolateral thigh flap if a tedious intramuscular course is encountered during elevation of a perforator identified within the conventional landmarks (3-cm radius circle at the midpoint of the anterior superior iliac spine and superolateral patella).
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Zhou T, Zhang L, Sun G, Hu Q. Ablation of Buccal Cancer and Functionality Buccal Reconstruction Using an Individuation Anterolateral Thigh Flap. J Craniofac Surg 2018; 29:e396-8. [PMID: 29489578 DOI: 10.1097/SCS.0000000000004417] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The complex area for reconstruction of the head and the neck is the buccal because of difficult anatomy of this region. This article aimed to describe our individualized design for the reconstruction of the buccal using an different categories anterolateral thigh (ALT) flap. Ninety-four patients were involved in this study. Among 94cases, the number of using the musculocutaneous ALT flap was 57, using the fasciocutaneous ALT flap was 25, and using the thin ALT flap was 12. Postoperative vessel thrombosis occurred in 8 flaps, and required operative exploration in the perioperative period, 6 flaps were complete survival after the salvages, 2 flap was failure. The ALT flap represents a very good choice for the reconstruction of the complex defects at the cheek level. The flap can replace large volumes of tissues and the skin island is large and can be used both for the tegument reconstruction and for the oral mucosa reconstruction.
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Abdelkader R, Mahdy HE, Khairalla TN, Mansour A, Zaidi NH. The Antero-Lateral Thigh Flap in Coverage of Extensive Post Traumatic Upper Limb Defects. ACTA ACUST UNITED AC 2016. [DOI: 10.4236/ss.2016.77044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Del Piñal F, Klausmeyer M, Moraleda E, de Piero GH, Rúas JS, Klich M. Foot web free flaps for single-stage reconstruction of hand webs. J Hand Surg Am 2015; 40:1152-60. [PMID: 25804365 DOI: 10.1016/j.jhsa.2015.02.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Revised: 02/02/2015] [Accepted: 02/03/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To present a method for reconstructing the digital web in posttraumatic defects using a free tissue transfer of the web from the foot and to present the functional and aesthetic results. METHODS Nine web free flaps were performed; 8 were used to reconstruct posttraumatic web losses and 1 was used to reconstruct a defect resulting from to infection. All cases involved the first (3) or second (6) webs of the hand. Web flaps were taken from the foot first web (2 patients), from the second (6 cases), and from the third (1 case) in a patient with congenital syndactyly of second foot web space. The donor site was managed by skin grafting from the instep (1 case), creation of a syndactyly (7 cases), or both (1 case). RESULTS All flaps survived without complications. Finger abduction and flexion-extension were similar to the contralateral side. No functional limitations, pain, or contracture were reported. One donor site healed with hypertrophic scars; otherwise, no donor site complications occurred. On a visual analog scale (0-10), the patient assessed appearance of the hand and the donor foot as 9.0 and 9.0, respectively, on average. One web was not well-positioned in the first operation and required revision. CONCLUSIONS The foot web free flap reconstructs the hand web by replacing it with a similar functional subunit rather than attempting to recreate the complex geometry, and allows for full function and excellent appearance of the hand. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Francisco Del Piñal
- Instituto de Cirugía Plástica y de la Mano, Private Practice and Hospital Mutua Montañesa, Santander, Spain.
| | - Melissa Klausmeyer
- Instituto de Cirugía Plástica y de la Mano, Private Practice and Hospital Mutua Montañesa, Santander, Spain
| | - Eduardo Moraleda
- Instituto de Cirugía Plástica y de la Mano, Private Practice and Hospital Mutua Montañesa, Santander, Spain
| | - Guillermo H de Piero
- Instituto de Cirugía Plástica y de la Mano, Private Practice and Hospital Mutua Montañesa, Santander, Spain
| | - Jaime S Rúas
- Instituto de Cirugía Plástica y de la Mano, Private Practice and Hospital Mutua Montañesa, Santander, Spain
| | - Maciej Klich
- Instituto de Cirugía Plástica y de la Mano, Private Practice and Hospital Mutua Montañesa, Santander, Spain
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Abstract
Several functionally limiting sequelae can follow deep thermal injury to the hand. Despite appropriate initial management, contractures are common. Whereas acute burn care is often managed by multidisciplinary, specialized burn units, postburn contractures may be referred to hand surgeons, who should be familiar with the patterns of burn contracture and nonsurgical and operative options to improve function and expected outcomes. The most common and functionally limiting sequelae are contractures of the webspace, hand, and digits. Webspace contractures and postburn syndactyly are managed with scar excision and local soft tissue rearrangement or skin grafting. The burn claw hand presents as extension contracture of the metacarpophalangeal joints and flexion contractures of the proximal interphalangeal joints. The mainstays of management of these contractures include complete surgical excision of scar tissue and resurfacing of the resultant soft tissue defect, most commonly with full-thickness skin grafts. If scar contracture release results in major exposure of the tendons or joints, distant tissue transfer may be required. Early motion and rehabilitative modalities are essential to prevent initial contracture formation and recontracture after surgical release.
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Affiliation(s)
- Duretti T Fufa
- Division of Hand and Upper Extremity Surgery, Hospital for Special Surgery, New York, NY; Division of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan.
| | - Shiow-Shuh Chuang
- Division of Hand and Upper Extremity Surgery, Hospital for Special Surgery, New York, NY; Division of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Jui-Yung Yang
- Division of Hand and Upper Extremity Surgery, Hospital for Special Surgery, New York, NY; Division of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
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Abstract
In addition to burn surgeons, skilled nurses, and therapists, hand surgeons are a key part of the multidisciplinary team caring for patients following thermal injury to the hand. Despite appropriate initial treatment and compressive therapy, contractures are common after deep burn. The most common and functionally limiting are web space and hand contractures. Web space contractures can be managed with excision followed by local soft tissue rearrangement or skin grafting. The classic burn claw hand deformity includes extension contracture of the metacarpophalangeal joints and flexion contractures of the proximal interphalangeal joints. The mainstay of management of these postburn contractures includes complete surgical release of scar tissue and replacement by full-thickness skin graft. In cases in which scar contracture release results in major exposure of the tendons or joints, distant tissue transfer is required. This review focuses on prevention and management of late sequelae of thermal injury to the hand focusing on contractures of the webspaces and hand.
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Affiliation(s)
- Duretti T Fufa
- Hospital for Special Surgery, 535 E 70th Street, New York, NY, 10021, USA,
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Abstract
Burns can cause extensive and devastating injuries of the head and neck. Prevention of the initial injury must always be a priority, but once an injury has occurred, then prevention of progression of the damage together with survival of the patient must be the immediate goals. The acute care will have a major influence on the subsequent scarring, reconstructive need, and long-term outcome. In the majority of cases, the reconstruction will involve restoration of form and function to the soft tissues, and the methods used will depend very much on the extent of scarring locally and elsewhere in the body. In nearly all cases, a significant improvement in functional and aesthetic outcomes can be achieved, which, in conjunction with intensive psychosocial rehabilitation, can lead to high-quality patient outcomes. With the prospect of facial transplantation being a clinical reality, the reconstructive spectrum has opened up even further, and, with appropriate reconstruction and support, no patient should be left economically deprived or socially isolated after a burn injury.
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Affiliation(s)
- Andrew Burd
- Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong
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Abstract
The challenging reconstructive treatment of defects in the upper extremity requires a sound working knowledge of a variety of flaps. As the hand surgeon weighs the pros and cons of each possible flap to obtain definitive closure, he or she must also integrate the priorities of function, contour, and stability as well as the anticipation of further reconstructive surgery in choosing the flap of choice. This review describes the various flaps available for closure of soft tissue defects of the upper extremity. The principles of management of wounds of the upper extremity is described to guide hand surgeons in the early treatment of massive wounds that will eventually need free tissue coverage. Currently used flaps include fasciocutaneous, fascial, musculocutaneous, muscle, and osteocutaneous flaps. Flap selection is based on the characteristics of the defect including size, shape, and location, the availability of donor sites, and the goals of reconstruction. Improved techniques of microsurgery and an ever increasing repertoire of flaps provide the framework for hand surgeons to offer the most appropriate flap based on donor site, thickness, amount of tissue needed, and composition. A discussion of the selection of ideal flaps for any given defect should enable the reconstructive hand surgeon to provide the most appropriate coverage of wounds to the hand and upper extremity.
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Affiliation(s)
- Michael Neumeister
- Division of Plastic Surgery, SIU School of Medicine, Springfield, Illinois
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Chen CC, Chang HH, Tang YB, Cheng NC. Combined first dorsal metacarpal artery flap and dorsal transposition flap for correction of extensive first web space contracture: a case report and literature review. Ann Plast Surg 2011; 67:364-6. [PMID: 21301291 DOI: 10.1097/SAP.0b013e3182071a2c] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
First web space contracture is a common sequela after hand trauma and exerts tremendously negative effects on hand function. To restore hand function, it is mandatory to release contracted first web structures, which usually results in a large skin defect. Dorsal transposition flaps sometimes are not sufficient to cover the whole defect. Microvascular flaps provide abundant soft tissue, but they are lengthy procedures and exhibit risks of complete flap failure. In this study, we present an alternative approach to address this difficult clinical problem. A 25-year-old man developed extensive contracture over the first web space after trauma. After release of the contracted structures, the extensive skin defect was covered by a dorsal transposition flap with an extension to the territory of the first dorsal metacarpal artery flap. The functional and cosmetic results were excellent, without recurrence of contracture postoperatively. The combined first dorsal metacarpal artery flap and dorsal transposition flap appeared to be an effective and relatively simple method for the reconstruction of severe first web space contracture.
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Oh S, Koh S, Chung C. Twin digital and in-step neurovascularised free flaps for reconstruction of the degloved mutilated hands. J Plast Reconstr Aesthet Surg 2010; 63:1853-9. [DOI: 10.1016/j.bjps.2009.11.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2009] [Revised: 10/09/2009] [Accepted: 11/03/2009] [Indexed: 11/30/2022]
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Katsuragi Y, Katagiri H, Nagamatsu S, Kayano S, Koizumi T, Matsui T, Takagi T, Murata H, Ogata D, Takahashi M, Nakagawa M. Combined sliding flap using a single perforator enables simple closure of the donor site: a case report. J Plast Reconstr Aesthet Surg 2010; 63:e543-6. [PMID: 20080451 DOI: 10.1016/j.bjps.2009.11.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2009] [Accepted: 11/11/2009] [Indexed: 10/20/2022]
Abstract
We report the case of a 39-year-old man with a dermatofibrosarcoma protuberans (DFSP) on the right shoulder. A wide surgical excision of the tumour was performed, creating a 12-cm-wide defect. An anterolateral thigh flap created from two semicircular skin paddles was harvested and the two skin paddles were slid towards each other to cover the circular defect. The sliding technique is a useful design that preserves the suprafascial plexus and enables a single perforator to supply two split-skin paddles. Using this design, the donor site can be closed primarily without requiring a skin graft. This technique can be applied to other free flaps to reconstruct wide defects after the resection of cancers.
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Affiliation(s)
- Yoko Katsuragi
- Division of Plastic and Reconstructive Surgery, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Naga-izumi, Shizuoka 411-8777, Japan.
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Gacto P, Barrera F, Sicilia-Castro D, Miralles F, Collell M, Leal S, De La Higuera J, Parra C, Gómez-Cía T. A three-dimensional virtual reality model for limb reconstruction in burned patients. Burns 2009; 35:1042-6. [DOI: 10.1016/j.burns.2008.09.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2008] [Accepted: 09/01/2008] [Indexed: 11/16/2022]
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Tan O, Atik B, Dogan A, Uslu M, Alpaslan S. Postoperative dynamic extension splinting compared with fixation with Kirschner wires and static splinting in contractures of burned hands: A comparative study of 57 cases in 9 years. ACTA ACUST UNITED AC 2009; 41:197-202. [PMID: 17701735 DOI: 10.1080/02844310701228719] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Skin grafting is widely used for the treatment of postburn contractures. Their main disadvantage, a tendency to contract again, can be reduced and better outcomes achieved by postoperative splinting. In this study we compared the outcomes of dynamic and static splinting postoperatively. Of the 57 patients managed by split grafts, 36 (44 hands) had Kirschner (K) wires applied with static splints, whereas 21 (26 hands) had dynamic splinting. The mean age was 11 (range 2-37) and 15 (range 2-50) years in the two groups. Before and after the operation, basic hand functions were evaluated clinically, and the results analysed statistically. The mean follow-up times were 18 and 14 months respectively, and recurrence rates were 22% and 14%. We think that the postoperative dynamic splinting is superior to fixation with K-wires with or without static splints.
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Affiliation(s)
- Onder Tan
- Department of Plastic Reconstructive and Aesthetic Surgery, Medical Faculty, Ataturk University, Erzurum, Turkey.
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Karonidis A, Yao SF. Chimeric anterolateral thigh free flap for head and neck reconstruction. J Plast Reconstr Aesthet Surg 2009; 62:e85-6. [DOI: 10.1016/j.bjps.2008.08.031] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2008] [Revised: 08/25/2008] [Accepted: 08/28/2008] [Indexed: 11/19/2022]
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Kimura N, Saitoh M, Okamura T, Hirata Y, Itoh Y, Sumiya N. Concept and Anatomical Basis of Microdissected Tailoring Method for Free Flap Transfer. Plast Reconstr Surg 2009; 123:152-62. [DOI: 10.1097/prs.0b013e3181934756] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Karacaoglu E, Gokce A. Perforator-Based Reverse Radial Forearm Flap to Reconstruct Multiple Third-Degree Burn Defects of the Fingers: . J Burn Care Res 2008; 29:398-402. [DOI: 10.1097/bcr.0b013e3181667949] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mun G, Jeon B, Lim S, Hyon W, Bang S, Oh K. Reconstruction of Postburn Neck Contractures Using Free Thin Thoracodorsal Artery Perforator Flaps with Cervicoplasty: . Plast Reconstr Surg 2007; 120:1524-32. [DOI: 10.1097/01.prs.0000282040.39007.1d] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gao JH, Ogawa R, Hyakusoku H, Lu F, Hu ZQ, Jiang P, Yang L, Feng C. Reconstruction of the face and neck scar contractures using staged transfer of expanded "Super-thin flaps". Burns 2007; 33:760-3. [PMID: 17521819 DOI: 10.1016/j.burns.2006.10.386] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2006] [Accepted: 10/10/2006] [Indexed: 11/28/2022]
Abstract
BACKGROUND The authors introduced the "Super-thin flap" concept, which is sometimes called the subdermal vascular network (SVN) flap, in 1994. Since 1994, we have reconstructed face and neck scar contractures using various types of "Super-thin flaps." In this report, we introduce expanded "Super-thin flaps" for reconstruction of the face and neck for the first time in a patient. METHODS Since 2000 we have used 21 expanded flaps to reconstruct 21 face or neck scar cases in nine males and 12 females. In the first operation, an expander was inserted on the fascia of the pectoralis major muscle, and then about 1,000 cc of saline was injected during a 2-month period. In the second operation, the flap was thinned primarily and applied to the recipient site. Three weeks after the second operation, the pedicle of the flap was cut down and sutured. RESULTS Flap size ranged from 4 cm x 14 cm to 10 cm x 22 cm. Expanded volume ranged from 800 cc to 1,200 cc. All flaps survived completely and scar tissues were replaced with normal skin. Flaps did not shrink after the operations, and contractures did not recur. CONCLUSION Advantages of the expanded flaps are presented: (1) Large flaps can be harvested because of the expander; (2) Extremely thin flaps can be safely employed; (3) Texture and color match are good; (4) Donor site can be closed primarily; and (5) Microsurgery is not required. However, the disadvantage of the method is the requirement for two or three operations.
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Affiliation(s)
- Jian-Hua Gao
- Department of Plastic and Reconstructive Surgery, Nanfang Medical University, Guangzhou, China
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Motamed S, Hasanpoor SE, Moosavizadeh SM, Arasteh E. Treatment of flexion contractures following burns in extremities. Burns 2006; 32:1017-21. [PMID: 17027161 DOI: 10.1016/j.burns.2006.04.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2005] [Accepted: 04/04/2006] [Indexed: 11/30/2022]
Abstract
In order to release and cover defects in burn contractures over joints, several surgical procedures have been proposed. Skin grafting is easy to do, but it requires immobilization, and tends to contract again, different types of flaps without skin grafting are alternatives. These flaps have their specific indications, limitations and some disadvantages such as a bulky, unattractive appearance in donor or recipient sites, partial necrosis, and sometimes patients dissatisfaction. Considering these points, the authors proposed a new technique composed of a Y-V advancement in the middle and two scar releases proximal and distal to the joint which were covered with full thickness skin grafts. This seems to have some advantages in both case of technique and more patients satisfaction. In the current study, the authors presented their results with different methods of treatment, which they performed for burn flexion contractures in limbs. Ninety-one operations were performed in 74 patients, the method of reconstruction included skin grafting in 43 contractures, local flaps in 16, pediculated flaps in 11, and the new combined approach in 21 cases. Width of scar was one of the main factors for selection of choice option. This proposed technique is especially appropriate for scars which cover 10-60% of joint surface area. Advantages of this combined technique are coverage of joint area with a pretty normal skin flap, and enough scar lengthening due to combination of Y-V advancement and skin grafted released areas.
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Affiliation(s)
- S Motamed
- Department of Plastic and Reconstructive Surgery, Shahid Beheshti University of Medical Sciences, 15 Khordad Hospital, South Aban St., Karim-Khan Blvd., Tehran 15987, Iran.
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Rashid M, Zia-Ul-Islam M, Sarwar SUR, Bhatti AM. The ‘expansile’ supraclavicular artery flap for release of post-burn neck contractures. J Plast Reconstr Aesthet Surg 2006; 59:1094-101. [PMID: 16996435 DOI: 10.1016/j.bjps.2005.12.058] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2005] [Accepted: 12/28/2005] [Indexed: 12/01/2022]
Abstract
UNLABELLED Soft tissue defects in the cervico-facial region can result from trauma, tumour excision or post-burn scarring. All rungs of the reconstructive ladder offer possible reconstructive options for these defects. The supraclavicular artery based flap is an extremely reliable local flap for this purpose. It offers thin and pliable skin with good colour match and minimal donor site morbidity. An additional advantage, in our experience, is that this skin can stretch postoperatively to allow further improved neck contour and mobility. MATERIALS AND METHODS Between June 2000 and January 2004, 27 patients underwent reconstruction of neck defects after release of post-burn contractures with the supraclavicular artery based skin flap at our hospital. After discharge the first follow-up visit was on the 10th postoperative day. The patients were advised to wear a custom made Watusi splint for 3 to 4 months. The patients were subsequently followed up at 3 months, 6 months and 1 year. The dimensions of the flap were measured and the patients photographed at the time of discharge and at subsequent visits. RESULTS All the flaps survived completely. The average operating time for contracture release and flap coverage was 2 h. The hospital stay ranged from 5 to 8 days. Follow-up ranged from 1 to 4 years with an average of 22 months. Complications included epidermolysis (n=2) and delay in donor site healing (n=2). Almost all patients had some widening of the donor site scar. In our experience the width of the flap increased in the postoperative period. At the time of surgery, the width of the flap ranged between 9 and 12 cm. At the 3-month follow-up there was an average increase in width of 24.2%. At 6 months, the average increase in width was 42.8% of the original flap width. At 1 year the average flap expansion was 63% of the original. The length of the flap ranged from 18 to 24 cm and generally remained unaltered during follow-up.
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Affiliation(s)
- Mamoon Rashid
- Department of Plastic Surgery, Combined Military Hospital, Rawalpindi, Pakistan.
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Ulkur E, Acikel C, Evinc R, Celikoz B. Use of rhomboid flap and double Z-plasty technique in the treatment of chronic postburn contractures. Burns 2006; 32:765-9. [PMID: 16837137 DOI: 10.1016/j.burns.2006.01.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2005] [Accepted: 01/10/2006] [Indexed: 11/28/2022]
Abstract
BACKGROUND Multiple reconstructive methods have been used for the treatment of postburn scar contractures including skin grafting, geometric relaxation techniques, local flaps and free flaps. PURPOSE In the present study, the authors evaluated efficiency of the use of rhomboid flap and double Z-plasty technique in the treatment of chronic postburn contractures. METHODS Twelve white male with postburn scar contracture were treated using rhomboid and double Z-plasty technique. The cause of burn, duration of contracture, postoperative follow-up period, preoperative and postoperative motion lag of joints and improvement in motion were recorded. CONCLUSIONS All operations were successful. Severe contracture lines crossing flexion folds can be released effectively by using rhomboid flap and double Z-plasty technique without distorting the specialized flexion areas and with broken scar lines which is essential to avoid from recurrence.
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Affiliation(s)
- Ersin Ulkur
- GATA Haydarpasa Egitim Hastanesi, Department of Plastic and Reconstructive Surgery and Burn Unit, Tibbiye Caddesi, 34668 Istanbul, Turkey.
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Tsai FC, Mardini S, Chen DJ, Yang JY, Hsieh MS. The classification and treatment algorithm for post-burn cervical contractures reconstructed with free flaps. Burns 2006; 32:626-33. [PMID: 16777339 DOI: 10.1016/j.burns.2005.12.009] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2005] [Accepted: 12/15/2005] [Indexed: 11/18/2022]
Abstract
Neck contractures after burn produce restrictions in motion and unacceptable aesthetic outcomes. Proper planning and tissue selection is essential to minimize donor site morbidity while optimizing outcomes. A classification system and treatment algorithm aids in achieving this goal. Between December 1999 and January 2003, 40 burn patients underwent release and reconstruction with free perforator flaps. Neck extensibility and zone of injury were evaluated. Choice of reconstruction was based on available tissue, restriction degree and zones involved. Cervical territories were classified according to movement restrictions and amount of improvement. Reconstructive territories were classified as central above (CA), central below (CB), central above and below (CAB) and lateral (L). Single, split, double and preexpanded free flaps were used for the reconstructions. Maximal gain in motion was noted at 4 weeks and maintained for the average 11 months follow-up. Types of reconstructive territories showed significant effects on range of motion while etiology and time between injury and reconstruction showed no impact on the functional outcome. Classification of neck territories aids in improving outcomes while minimizing donor morbidity. The central above territory, when reconstructed with free flaps, yielded the most rewarding improvement. A classification and treatment algorithm aids in achieving significant improvements in range of neck motion while taking into consideration the donor sites.
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Affiliation(s)
- Feng-Chou Tsai
- Department of Plastic Surgery, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan
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Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Understand the attributes and unique niche for compound flaps and their limitations. 2. Comprehend a proposed schema for further clarifying the classification of all types of compound flaps that is differentiated on the basis of the distinct vascular supply to each flap subtype. 3. Appreciate that minor technical modifications of known flaps of any type in general do not necessarily create a new category of flap. BACKGROUND A unique niche exists for compound flaps because of their extraordinary capability to allow repair of massive defects where the simultaneous restoration of multiple missing tissue components is demanded. The guidelines from the previous "simplified" classification schema need to be updated to allow a more complete clarification and further standardization of this concept. METHODS Compound flaps can be partitioned into two major classes that in turn are further differentiated into various subtypes according to their inherent pattern of circulation. RESULTS The subdivisions of compound flaps are those with a solitary source of vascularization and those with combinations of sources of vascularization. Those with a solitary source include composite flaps, defined as multiple tissue components all served by the same single vascular supply, and thereby consisting of dependent parts. Those flaps with combinations of sources of vascularization include (1) conjoined flaps, defined as multiple flap territories, dependent because of some common physical junction, yet each retaining its independent vascular supply; and (2) chimeric flaps, defined as multiple flap territories, each with an independent vascular supply, and independent of any physical interconnection except where linked by a common source vessel. CONCLUSIONS Although many technical modifications have improved and will improve the reliability and versatility of compound flaps, these maneuvers alone should not be confused with creating distinct flap types but rather acknowledged to be only important variations. With this understanding, this revised nomenclature system for compound flaps is intended to be a means of standardizing communication and to facilitate research agendas on a common ground, fully realizing its primary role still only to serve as a convenient guideline.
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Affiliation(s)
- Geoffrey G Hallock
- Division of Plastic Surgery, The Lehigh Valley Hospital, Allentown, Pa., USA.
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Adani R, Tarallo L, Marcoccio I, Fregni U. First web-space reconstruction by the anterolateral thigh flap. J Hand Surg Am 2006; 31:640-6. [PMID: 16632060 DOI: 10.1016/j.jhsa.2005.12.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2005] [Revised: 12/07/2005] [Accepted: 12/07/2005] [Indexed: 02/02/2023]
Abstract
Four patients with severe contracture of the first web space were treated with an anterolateral thigh perforator flap. The flap size ranged from 10 to 13 cm in length and from 7 to 8 cm in width. The donor site was closed directly and thinning of the flap was performed in all cases. All flaps survived and there were no re-explorations. Web space opening was maintained over the follow-up period. There was an average postoperative increase of the angle of the first web space of 61 degrees. The thinned anterolateral thigh flap provides a pliable vascularized tissue for resurfacing the skin after release of severe contracture of the first web space and represents a reliable alternative to other flaps.
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Affiliation(s)
- Roberto Adani
- Department of Orthopaedic Surgery, University of Modena and Reggio Emilia, Modena, Italy.
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Nojima K, Brown SA, Acikel C, Arbique G, Ozturk S, Chao J, Kurihara K, Rohrich RJ. Defining Vascular Supply and Territory of Thinned Perforator Flaps: Part I. Anterolateral Thigh Perforator Flap. Plast Reconstr Surg 2005; 116:182-93. [PMID: 15988266 DOI: 10.1097/01.prs.0000170801.78135.00] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The anterolateral thigh perforator flap is increasingly being used for trauma and reconstructive surgical cases. With the thinned flap design, greater survivability and a decrease in donor-site morbidity are observed. To increase our knowledge of the vascular territories in these flaps, an anatomic study was performed to determine pedicle number, location, and diameter; accompanying veins; vascular territory; and where surgical incisions can be made safely during thinning, as opposed to the "danger zone." METHODS Thirteen anterolateral thigh perforator flaps were harvested from seven adult cadavers. The largest perforator arteries were cannulated, and flaps were thinned to a thickness of 6 to 8 mm, with a 2.5-cm radius from the perforator retained. Vascular territories were quantified before and after thinning by nonradiographic and radiographic methods. A series of dyes were injected: red dye for skin (photography) followed by Omnipaque for the whole flap (radiography) before thinning, and blue dye for skin (photography) and lead oxide for the whole flap (radiography) after thinning. Pedicle locations were determined by ratios of anatomical landmarks. Danger zone measurements were derived at specific thicknesses using lateral radiographs of each flap. RESULTS In anterolateral thigh perforator flaps, the mean perforator artery diameter at the fascia level was 1.00 +/- 0.08 mm (range, 0.84 to 1.11 mm) and the mean number of perforator arteries was 1.69 +/- 1.03 (+/-SD). Perforator pedicles were located near the midpoint of the line between the anterior superior iliac spine and the lateral aspect of the patella in the vertical axis. The mean vascular territories were 256 +/- 52.5 cm2 (photography) and 351 +/- 72.8 cm2 (radiography) in unthinned flaps and 211 +/- 65.7 cm2 (photography) and 289 +/- 106.6 cm2 (radiography) in thinned flaps. Differences in overall vascular territories after thinning were 83.3 percent (photography) and 81.8 percent (radiography) compared with unthinned flaps. Four respective vascular territory maps were drawn showing surgical territories using percentile confidence intervals (98th and 90th) and averages. From the skin at thicknesses of 4, 6, and 8 mm, the 98th percentile danger zones were 33 to 37 mm (proximal to distal), 30 to 35 mm, and 27 to 31 mm from the pedicle in the vertical axis, respectively; in the horizontal axis, they were 30 to 34 mm (medial to lateral), 28 to 31 mm, and 25 to 29 mm. CONCLUSIONS These data define anterolateral thigh perforator flap pedicle location, number, and diameter before harvesting, surgical danger zones during thinning, and vascular territories after thinning. The authors' guidelines provide surgeons with anatomical vascular territory maps to design and harvest specific flaps for optimal results.
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Affiliation(s)
- Kimihiro Nojima
- Department of Plastic and Reconstructive Surgery, Jikei University School of Medicine, Tokyo, Japan
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Abstract
The prototypical conjoint or so-called "chimeric" free flap heretofore has been composed of several large independent flaps, each supplied by a separate major branch, that ultimately arise from a common source vessel. The perforator-based type of chimeric flap is a relatively new concept, usually involving multiple muscle perforator flaps each based on a solitary musculocutaneous perforator, but still arising from the same "mother" vessel. This principle of split cutaneous perforator flaps has been now successfully adapted to the medial suralMEDIAL GASTROCNEMIUS perforator free flap on 2 separate occasions. As a chimeric flap, there was greater flexibility in insetting, and overall flap width may be larger but still narrow enough to allow primary donor site closure; and yet, by definition, only a single recipient site was needed for any microanastomoses. This is further proof that the perforator-based chimeric free flap may be an option for any muscle perforator flap donor site, so that potential donor territories for conjoint flaps have become virtually unlimited.
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Affiliation(s)
- Kazufumi Sano
- Division of Orthopedic Surgery, Kenwakai Otemachi Hospital Fukuoka-ken, Japan
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