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Background Although propeller flaps are a useful option for soft tissue defect reconstruction, reports based on the perforators of the lateral circumflex femoral artery (LCFA) are rare. We aimed to present our experience in defect reconstruction using the propeller flaps based on perforators from different branches of LCFA and apply these flaps in soft tissue defect reconstruction of the lower extremities. Methods Twenty nine patients (32 flaps) underwent defect reconstruction using propeller flaps based on the perforator of the LCFA. Defects were located from the groin to the proximal leg. According to the source vessels from which the perforator originated, flaps were categorized into types I, II, III and IV, which represented perforators from the transverse, descending, oblique, and rectus femoris branches, respectively. Type II flaps were subdivided into types IIa and IIb flaps based on antegrade and reverse flows of the descending branch. Results Flap sizes ranged from 12 × 6 cm to 30 × 15 cm (average, 22.69 × 9.19 cm) with the length of the vascular pedicle ranging from 3 to 7 cm (average, 4.86 cm). Flaps were rotated from 60° to 180° (average, 144.06°). There were 3 type I, 10 type IIa, 4 type IIb, 13 type III and, and 2 type IV flaps. Twenty-nine flaps survived after surgery. Total flap necrosis and venous congestion of the distal flap portion occurred in 1 and 2 patients, respectively. Conclusions Reconstruction using propeller flaps based on perforators of the LCFA is a safe, reliable, and versatile option for defect reconstruction of the lower extremities; however, it requires meticulous surgical dissection and patience.

Reconstruction of intraoral defects is one of the main aspects of head and neck cancer treatment. Since the advent of microvascular surgery in this field, free flap tissue transfer has become a common procedure, and various flaps have been described for soft tissue reconstruction. The lateral upper arm free flap is one of the most frequently used flaps for intraoral defect coverage. This article describes ossification of the corresponding vascular pedicle after soft tissue transfer with the lateral upper arm free flap and microsurgical anastomosis in oral cancer treatment. Similar findings in the context of the lateral upper arm free flap have never been reported in the literature; however, it is important for surgeons to know that pedicle ossification can occur. This knowledge may be helpful to avoid erroneous diagnosis of the ossification as a sign of tumor relapse/recurrence as well as to anticipate potential difficulties in the surgical approach in cases requiring reentry of the reconstructed region, for example, in relapse/recurrence of head and neck cancer.

Background Flap prefabrication is to turn a random flap into an axial flap by transferring a vascular pedicle. Methods In the past 13 years, we have prefabricated 20 flaps in 20 patients by the superficial temporal artery and its concomitant veins. Typically, a 50- to 800-mL tissue expander was implanted in the donor site. After flap maturation, the prefabricated flap was raised and transferred locally to cover the large defect on the face. All the cases were followed up regularly. Results The patients' age were between 3 and 27 years, the size of the flaps were between 3.5 × 5.5 cm and 13 × 15 cm, the superficial temporal artery length was between 10 and 15 cm. All flaps were transferred successfully: 10 of the flaps had venous congestion, partial epidermis exfoliation and flap necrosis occurred in 4 flaps. All cases were followed up for at least 1 year, the longest follow-up period was 9 years. Long-term follow-up results showed the prefabricated flap survived in good condition and had a satisfactory outcome. Conclusions Because flap prefabrication is practical, and long-term follow-ups have proved its preferable characters and stability, it is a fine method for large area facial reconstructions.

BACKGROUND Vascularized composite allotransplantation represents an important advancement in the field of reconstructive microsurgery and has continued to increase in popularity. The significant clinical morbidity associated with flap failure represents an important barrier to even more widespread use of these techniques. Early identification of vascular compromise has been associated with a higher salvage rate, yet most surgeons rely only on clinical assessment intraoperatively. Spatial frequency domain imaging (SFDI) presents a noncontact, objective measurement of tissue oxygenation over a large field of view. This study aims to evaluate the use of SFDI technology in hemifacial composite flap compromise as could occur during facial transplant. METHODS Six composite hemifacial flaps were created in three 35-kg Yorkshire pigs and continuously imaged using SFDI before, during, and after 15-minute selective vascular pedicle occlusion. Arterial and venous clamping trials were performed for each flap. Changes in oxyhemoglobin concentration, deoxyhemoglobin concentration, and total hemoglobin were quantified over time. RESULTS The SFDI successfully measured changes in oxygenation parameters in all 6 composite tissue flaps. Significant changes in oxyhemoglobin, deoxyhemoglobin, and total hemoglobin were seen relative to controls. Early and distinct patterns of alteration were noted in arterial and in venous compromise relative to one another. CONCLUSIONS The need for noninvasive, reliable assessment of composite tissue graft viability is apparent, given the morbidity associated with flap failure. The results of this study suggest that SFDI technology shows promise in providing intraoperative guidance with regard to pedicle vessel integrity during reconstructive microsurgery.

Background Controversy exists regarding whether or not, or, if so, how quickly free flaps can achieve neovascularization from the surrounding tissue bed and independence from the vascular pedicle. In this paper, we document the survival of free flaps despite early vascular pedicle thrombosis and review the literature regarding the period of time believed to be required for flap autonomy to occur. Design Case series Setting Harbor-UCLA Medical Center Patients We report 3 cases in which pedicle failures occurred within 2 weeks of free flap transfer. The first patient suffered repeated leaks from the vascular anastomosis with hematoma formation occurring on postoperative days 4, 6, and 17, ultimately requiring ligation of the pedicle. The second patient developed a salivary leak and accumulation of saliva around the pedicle, which was found thrombosed on postoperative day 11. The third patient lost Doppler signals from the pedicle on postoperative day 7 and 8, each occasion necessitating a return to the operating room for anastomotic revision. However, on postoperative day 9, the signal was lost yet again and no further revisions were attempted. Results Two of the 3 flaps survived completely and the third was noted to have near complete survival. Conclusion Microvascular free flaps can survive despite complete pedicle failure as early as 10 days after surgery. The mechanism behind this may involve the process of neovascularization. We conclude that early free flap pedicle failure does not necessarily equate to complete flap loss.

Oncologic resections near the shoulder create challenging reconstructive problems. In addition to severe contour defects and the risk for functional deficits resulting from contractures, there may be exposed bone and peripheral nerves rendering simple skin graft closures suboptimal long term. The lateral arm flap is a versatile septofasciocutaneous flap based on the posterior branch of the radial collateral artery in the lateral intermuscular septum of the upper arm. This paper details our experience with 3 patients who underwent wide local excision or radical resection of soft tissue tumors of the upper arm and closure with pedicled lateral arm fasciocutaneous flaps. Flap size ranged from 6 × 10 cm to 5 × 15 cm. Two flaps were transferred as 180-degree pivotal flaps; 1 flap was transferred as an advancement flap. There were no immediate postoperative complications or long-term functional deficits. The pedicled lateral arm flap is a safe and reliable option for soft tissue coverage of anterolateral shoulder defects. The vascular pedicle lies deep within the mid-upper arm and is rarely at risk during extensive tumor extirpation. The adjacent donor site allows for a single operative field without the need for repositioning and furthermore results in a skin paddle requirement that is one half the width of the original defect.

Background The distally based medial hemisoleus (MHS) flap was found useful for repairing soft-tissue defects of the lower third of the leg; however, its reliability is controversial. We used a combination of static and dynamic techniques to investigate the vascular supply of distally based MHS muscle flaps to better establish their use in repair of lower-third leg defects. Methods We performed an anatomic study of 18 cadaver legs. For 6 legs, we performed dynamic angiography, which allowed for obtaining MHS muscle radiographs after pulsed injection of contrast medium in distal pedicles. Results The mean length of MHS muscle was 25.4 cm, the mean width was 6.9 cm, and the mean surface area was 87.5 cm. A mean of 3 distal posterior tibial vascular pedicles was directly connected to this medial subunit. These pedicles were present in all 18 cadaver legs. We observed complete opacification of the 6 MHS muscles through distal pedicles. Radiography revealed opacification of a vascular path from 1 distal pedicle to 1 proximal vascular pedicle of the MHS muscle. The mean level of this main distal pedicle was 14.5 cm to the tip of the medial malleolus. The level was at 38.2%, on average, from the bottom of the entire tibia. Conclusions The distally based MHS muscle flap has constant blood supply, so it could be a useful flap to repair soft-tissue defects of the lower third of the leg. Moreover, knowledge of the average location of the main distal pedicle can help in increasing the use of the distally based MHS flap.

Objective The posterior thigh region has been neglected as a donor site for free perforator flaps, likely due to difficulties in positioning the patient during surgery. This study describes the clinical application of the posterior thigh perforator flap based on the third perforating artery of the profunda femoris artery (PFA). Methods The free posterior thigh perforator flap based on the third perforating artery of the PFA was used for reconstruction of soft tissue defects in nine patients between February 2010 and May 2014. Results Flap sizes ranged from 12 × 7 cm to 20 × 13 cm. The length of the vascular pedicle averaged 10.28 cm, and the mean diameters of the third perforating artery and venae comitantes were 1.68 and 1.14 mm, respectively. All of the perforators originated from the PFA. Of the 9 free flaps used in 9 patients, 7 flaps survived completely. There were no early complications in these flaps. During the follow-up period, no patient experienced cold intolerance, scar contracture, or scar pain. There were no functional impairments at the donor or recipient sites. Conclusions The posterior thigh flap based on the third perforating artery of the PFA is an excellent option for reconstructing soft tissue defects. The anatomical location of the third perforating artery is relatively consistent. The vascular pedicle is relatively longer and has large caliber vessels. The scar at the donor site can be well concealed with low morbidity. The skin color and texture of this flap show satisfactory results.

BACKGROUND We conducted an experimental study to investigate if it would be possible to re-elevate a flap at a standard flap site if its vascular pedicle was mutilated previously and there was a preexisting scar formation at the pedicle site. MATERIALS AND METHODS Thirty-five male Sprague-Dawley rats were divided into 3 groups. In the control group (n = 5), animals received a procedure in which unilateral axial pattern abdominal flap was elevated, and then sutured to its original place. The remaining 2 groups underwent 2-stage procedures. In the first stage, scar tissue was created with either a skin incision (group 2, n = 15) or excision (group 3, n = 15) at the prospective pedicle site of the abdominal flap. In the second stage, abdominal flap was raised in 5 rats as a scar-pedicled flap at day 7, day 21, and day 42. Flaps were sutured in their places. Seven days later, flap survival was evaluated. RESULTS Control flaps had complete survival (day 7, 95.5%; day 21, 94.8%; and day 42, 94.5%). Group 2 and group 3 flaps raised on day 7 (group 2, 65.4%; group 3, 63.9%) and on day 21 (group 2, 65.7%; group 3, 66.7%) showed decreased survival compared to control group flaps (P < 0.05). On day 42, group 1 flaps had better survival when compared to group 2 flaps (82.6% vs 70.0%, P < 0.05). Group 1 flaps showed progressive vascular network formation as evidenced by contrast medium first in the proximal two thirds of the flaps on day 7, and later via visualization of the axial pattern vascular tree on day 42. In group 3, approximately half of the flap was filled with barium contrast and no single pedicle was identified on day 42. CONCLUSIONS Preexisting scar tissue and pedicle division in the pedicle site of a standard flap diminished dimensions of surviving flap when compared to control flaps. Incision-scar-pedicled flaps achieved better survival compared to excision-group flaps, particularly in the late postoperative period. The study findings showed that it may be possible to raise a flap from previously mutilated site secondary to scar formation and pedicle injury.

Incredibly complicated multidimensional defects have always strained the ingenuity of the reconstructive surgeon. Secondary perhaps to vascularized composite allotransplantation as a solution to this dilemma, the compound flap has been developed to be a more useful and available alternative. Their greatest versatility has been proven by its subtype, the chimera flap. The chimera flap itself consists of multiple flaps, the latter possibly composed of bone, skin, muscle, and so on, where each part has an independent vascular supply, and each part is independent of any physical interconnection whatsoever with the other components, except where joined ultimately only to a common vascular pedicle. An appellation for this concept was first introduced a quarter century ago in this very journal, a time frame now the impetus for a recapitulation of its origin and subsequent history that proves that it has eventually withstood the test of time and has been successfully assimilated into the reconstructive repertoire.

The perfusion territory of the pedicled internal mammary artery perforator flap has been described, but the number of perforators to be included in the flap's pedicle is controversial. We studied the vascular territory of the dominant perforator and the contribution of additional nondominant perforators to it. Therefore, the dominant perforators in 9 fresh cadavers and the nondominant perforators in 4 of these, were injected with water-based ink. The dominant perforator vascularized a territory extending from the superior border of the clavicle to the xiphoid, and from midsternal to the anterior axial fold, with a mean craniocaudal length of 19.4 cm (range, 17.0-24.0) and a mean mediolateral width of 18.6 cm (range, 16.0-22.5). Additional injection of nondominant perforators did not lead to any substantial enlargement of this territory. One single dominant perforator vascularizes a large part of the hemithorax, allowing for various flap designs. Nondominant perforators do not have to be included in the vascular pedicle of the internal mammary artery perforator flap, which leads to less donor-site morbidity.

The lateral thigh flap based on the second and third perforator of profunda femoris vessel has not become very popular. We describe a technique of flow-through pedicle for this flap. The flow-through technique makes this flap very simple to transfer. The flap was used successfully in 6 cases for reconstruction for defects in the leg and forearm. The flow-through pedicle is ideal for lower limb reconstruction. The anastomosis becomes very easy and safe, even if the recipient vessels are deep in the intermuscular septum. We had no flap failures. The flap has a very predictable anatomy. Large flaps from anteriolateral and posterior part of midthigh can be safely elevated. The flap can meet a variety of requirements as it can be thin skin-alone flap, a fasciocutaneous flap, or even a musculocutaneous flap. A simple pinch test gives a fair idea of expected flap thickness. The dissection requires strong retraction of the anterior thigh muscles, but the dissection is safe and simple. The donor-site morbidity is very minimal.

A bulky appearance is one of the major patient complaints after extremity reconstruction after fasciocutaneous flaps. Serial debulking procedures with staged excision are required to improve aesthetic and functional outcome, but these methods risk injury to the vascular pedicle and often require multiple procedures for adequate thinning of the flap. We suggest the use of power-assisted suction lipectomy for the debulking of fasciocutaneous flaps in the upper and lower extremities as a safe, effective, and efficient procedure.From 2006 to 2009, we performed power-assisted suction lipectomy on the upper and lower extremities of 16 flaps in 15 patients who had previously undergone reconstruction with fasciocutaneous flaps after a traumatic injury.There was 100% flap survival without any complications. Only 2 of the 16 (12.5%) flaps required a secondary revision for further contouring.In our experience power-assisted suction lipectomy is a safe and excellent adjunct in fasciocutaneous flap debulking and reduces the number of secondary revision procedures necessary. We recommend its use as an adjunct in debulking and contouring flaps used in extremity reconstruction.

The main aim of the treatment of fingertip amputations with no indication of replantation was to establish the functional and esthetic construction. The critical point in the utilization of the bone and nail tissue as a graft for reconstruction was to choose a flap that is sufficiently vascular to nourish these grafts. We have performed homodigital artery flaps to cover the bone and nailbed grafts taken from the amputation to restore fingertip function with an acceptable result. The venous insufficiency with the increased probability in flap failure should be taken into consideration. We proposed the preservation of some amount of soft tissue around the vascular pedicle to overcome the venous insufficiency and in our point of view, digital artery sacrifice was worth it to preserve the length of the finger and the esthetic nail appearance.

Between June 1992 and November 2002, 17 patients underwent secondary reconstruction of circumferential esophageal defects due to the failure of immediate reconstruction following ablation of thoracic esophageal cancer. Salvage reconstruction was achieved using free jejunal transfer in 13 patients (including long segment with double vascular pedicle in 2 cases), skin and/or musculocutaneous flap in 2 cases, and jejunal pull-up in 2 cases. In 5 patients, the second salvage surgery was required because of the failed first salvage. However, successful restoration of the esophagus and peroral alimentation was finally achieved in 16 of 17 patients, except 1 patient with several salvage operations using skin and musculocutaneous flap because the gut was unusable. We concluded that the preferred first choice for salvage restoration is free jejunal transfer. If the length of the esophageal defect is extensive, colonic interposition or jejunal pedicle with microvascular anastomosis for supercharging is the next option. If these procedures cannot be used, the transfer of a long jejunal segment with double vascular pedicles is recommended. Reconstruction using skin and/or musculocutaneous flap is the final option. As primary wound closure is often difficult in secondary reconstruction of the esophagus, a pectoralis major musculocutaneous flap is reliable to cover the reconstructed esophagus because skin flaps located in the neck region may be damaged by neck dissection or irradiation, and coverage of the anastomosis with muscle between the digestive tracts is effective to prevent leakage.

The superior medial thigh skin territory has previously been successfully transferred as a free flap as part of a gracilis musculocutaneous flap. However, muscle bulk can be avoided and its function preserved by instead retaining only the musculocutaneous perforators arising from the gracilis pedicle like in a true perforator flap. A clinical example of this new perforator flap is described as the gracilis (medial circumflex femoral) perforator flap. This could become an ideal skin flap because no muscle is included, a well-defined segment of skin can be reliably harvested, closure of the donor site leaves a scar in the groin that can be readily concealed, and its dominant vascular pedicle is consistent in location and already familiar to most reconstructive surgeons.

Use of the gastrocnemius as either a muscle or musculocutaneous flap has proved to be effective in the management of knee and lower leg soft-tissue defects because of its reliable constant vascular pedicle and ease of procedure with little or no functional deficit. As a muscle flap, the volume of the distal part of the muscle for coverage is small, and is even smaller when accompanied by posttraumatic disuse atrophy. Although there have been many modifications to increase the arc of rotation and dimensions of the muscle flap, the disadvantage is the skin graft on the flap donor site and the resulting deformity of the leg contour. Also, clinical limitations occur when the defect size is extensive or there is an inadequate arc of rotation or dimension. The authors present their clinical application of a gastrocnemius muscle flap with a distal adipofascial flap as a useful alternative for various sizes and types of defects. Between 1999 and 2000, gastrocnemius adipofascial flaps were used in 7 patients with various types of defects. This form of musculoadipofascial flap has not yet been described in the known literature. In the authors' opinion, this procedure is a valuable extension of local flap procedures in reconstructing relatively large defects in the region of the knee and lower extremity.

The purpose of this study was to describe a new musculocutaneous flap model in the rat. A total of 25 Wistar rats weighing 200 to 280 g were used in this experiment. In 15 rats, the vascular anatomy of the biceps femoris muscle and the cutaneous blood supply of its overlying posterior thigh skin were studied by anatomic dissection, dye injection, and microangiography using 5 rats in each group. The anatomic studies revealed that the main axial vessel supplying the biceps femoris muscle was the caudal femoral branch of the popliteal vessels. The posterior thigh skin overlying the biceps femoris muscle received a consistent musculocutaneous perforator at the center of the mid-posterior line of the posterior thigh. Based on the caudal femoral-popliteal vascular pedicle, the biceps femoris musculocutaneous flap was created in the rat, comprised of the whole muscle and its overlying posterior thigh skin. The skin paddle was designed as an ellipse with its longitudinal axis paralleling that of the extremity, generally measuring 4 x 2 cm. Island flaps were raised as described and replaced either in situ (N = 5) or transposed to a sacral defect (N = 5). Results showed that the cutaneous islands of all the flaps survived completely. Tetrazolium blue stain used to indicate muscle survival revealed that the average muscle viability was 86.7+/-3.4%. The authors conclude that the biceps femoris musculocutaneous flap is a reliable and true musculocutaneous flap model for future biological and pharmacological studies. It offers the following advantages: It has a consistent vascular pedicle and a musculocutaneous perforator, it supports a relatively large skin island, and there is no risk of autocannibalization of the flap because the flap is located dorsally.

The deltoid muscle is a reliable source of well-vascularized tissue for bulk to obliterate wounds that particularly involve the adjacent glenohumeral joint. A homologue of the gluteus maximus muscle, the deltoid muscle also has two independent dominant vascular pedicles, making this a type IIl muscle flap. Consequently, the muscle can be split vertically into two halves to form hemideltoid flaps, with the undisturbed portion still remaining innervated to preserve its function as a major arm abductor-an important point because this muscle as a whole is not usually considered expendable. Because of its short vascular pedicle, the arc of rotation is limited so that larger defects of the shoulder are covered preferably with more traditional alternatives. Hallock GG. The hemideltoid muscle flap.

The latissimus dorsi free flap is a workhorse for extremity reconstruction. One of its benefits is a long vascular pedicle that spans the zone of injury. However, it may be difficult to adequately cover this pedicle. Direct closure may be too tight, and skin grafting over the pedicle risks exposure if graft take is poor. We report a technique in which the serratus branch of the thoracodorsal artery and its overlying fascia are harvested en bloc with the thoracodorsal artery and latissimus muscle. This provides 2 flaps on a common pedicle that can easily be rotated to allow positioning and insetting. We successfully used this technique in the reconstruction of both upper and lower extremities. The serratus fascia provides excellent padded covering and is a good bed for skin grafting. The versatility of this hybrid flap will allow its use in a range of complex reconstructive procedures.

Soft-tissue reconstruction of the foot and ankle has long presented challenging problems for the plastic surgeon. Limitations of available local tissue, the need for specialized tissue, and donor site morbidity restrict the options available to the reconstructive surgeon. In an effort to solve these difficult problems, we have begun to use musculofascial flaps based on the branches of the dorsalis pedis artery. We present our early experience of 5 patients treated with an extensor digitorum brevis muscle flap with fascial extensions often containing the contents of the first web space. Our patients ranged from 6 to 60 years in age and included 4 males and 1 female. The etiologies of the wounds were secondary to trauma (N = 2), complications of surgery for rheumatoid arthritis (N = 2), and were secondary to a defect following resection of an arteriovenous malformation (N = 1). The flaps had antegrade blood flow in 3 patients and reverse flow in 2 patients. The flaps were covered with a split-thickness skin graft and the donor site was closed primarily. The donor sites healed without the need for further surgery. One patient required additional procedures. This flap proved to be both versatile and effective for closure of difficult wounds of the foot and ankle.

Ten cases suffering from facial contour deformities caused by loss of subcutaneous tissue are presented. Three cases had hemifacial microsomia, 3 had postmaxillectomy collapsed cheek, while the remaining 4 patients had Romberg's disease. All cases were treated by the insertion of a deepithelialized, revascularized lateral intercostal flap. The flaps used had dimensions ranging from 9 cm x 6 cm to 12 cm x 14 cm. The vascular pedicle of the flap is the lateral cutaneous branch of one of the lower four posterior intercostal bundles (usually the tenth or the eleventh). The flap is designed to have the pedicle in its center, thus allowing defattening of the edges at the primary surgery and minimizing the need for secondary debulking. Nine flaps were successful and one failed. All successful flaps gave a permanent and satisfactory correction of the deformity. The difficulties and advantages of the flap are presented.

Microvascular free tissue transfer has become a very reliable reconstructive technique. Occasionally, flap compromise will occur and will require urgent flap reexploration. In the setting of complete thrombosis of pedicle vessels, thrombectomy using Fogarty #2 and #3 catheters can be effective in restoring vascular patency. Seven flaps with arterial, venous, or both vessel thrombosis were managed with thrombectomy at the time of reexploration and anastomotic revision. Six of the flaps were completely salvaged and the seventh was partially salvaged. Promptness in reexploration increased the likelihood of complete flap salvage. The use of postthrombectomy heparinization was associated with a 50% complication rate in this series. Thrombectomy of free flap vessels can be safely performed and is associated with a low incidence of rethrombosis.

The pedicled, extended serratus anterior musculocutaneous flap has been used as a pedicled flap for cervical contracture repair. This flap has a long vascular pedicle, texture and color like those of the cervical surface, and appropriate thickness. This article describes the anatomy of the flap and typical cases.

The gastrocnemius muscle flap has gained wide acceptance as a reconstructive technique for management of wounds of the knee and proximal tibia. The use of the muscle as a pedicle flap to the distal and middle femur has not been well quantified, and the proximal rotation arc has been underestimated. We report the use of the island gastrocnemius pedicle flap to reach two femur defects 21 and 26 cm above the joint line, achieved by taking advantage of the favorable location of the vascular pedicle above the joint line and the individual length of the medial gastrocnemius muscle belly. Evaluation of standard arteriograms suggests the location of the medial sural artery pedicle is an average of 32 +/- 14.5 (SD) mm above the inferior border of the femur. All vessel origins were found above the joint line by radiograph. A common sural artery origin was noted in 32% of patients at a mean distance of 35 mm proximal to the joint line. Despite a wide range, 62% of sural artery origins were within 1 cm of an axis drawn through the widest point of the femoral condyles.

The superficial circumflex iliac artery perforator (SCIP) flap was first reported in 2004, in which the concept of perforator flap was incorporated into the groin flap. Although a SCIP flap has many advantages, reports on its application to head and neck defects are limited. We present cases of SCIP flap transfer for reconstruction of various types of head and neck defects.Twelve patients underwent reconstruction using the free SCIP flap after tumor ablative surgery in the head and neck region. The flap was elevated based on the perforators of the superficial branch and/or deep branch of the superficial circumflex iliac artery. The thickness of the flap was adjusted according to the defect. The Photo Dynamic Eye infrared camera system using indocyanine green was used to detect the location of the perforators preoperatively and to confirm the blood flow after elevation of the flap. The flaps survived completely in all the cases. The mean pedicle length was 7.1 cm (range, 6-9 cm), and the mean flap size was 12.8 × 6.3 cm (range, 4 × 2 to 18 × 8 cm). No vein grafting was necessary in any patient.The advantages of the SCIP flap include 1) low donor-site morbidity; the donor site is in a hairless concealed area, primary donor-site closure is possible, and no muscular dissection is necessary; 2) adjustable thickness of the flap from a superthin flap to a bulky flap; and 3) a long vascular pedicle available.We believe that the SCIP flap will become one of the most versatile options in head and neck reconstruction.

The reconstruction of small and thin defects in the orbital area using vascularized cortex is described herein. This vascularized cortex is taken from the medial supracondyle area of the femur because a small, thin, and flexible bone can be harvested. We have treated 5 patients with orbital bony defects that would have been difficult to reconstruct using conventional free bone grafts. All flaps took perfectly, the results were satisfactory, and no functional loss occurred in the donor site. The advantages of this bone flap include rich vascularity, a long vascular pedicle of about 7 cm, easy flap elevation, and the ability to include a saphenous flap. The thinness and flexibility of the bone flap make it a suitable vascularized bone donor site for treating small, flat craniofacial bony defects such as in the orbital area.

The vascular anatomy of the supraclavicular artery island (SAI) flap has been investigated using both cadaveric anatomic dissections and angiographic studies. Accurate preoperative evaluation and localization of its vascular pedicle confirms its location, course, anatomic variation, and improves flap success. The objective of this report is to demonstrate the utility of multislice computed tomography (CT) angiography for confirming the presence of the vascular pedicle of the SAI flap when planning head and neck reconstruction.Patients were studied using 64-multislice CT angiography (CTA) to localize the supraclavicular artery, including its origin and destination. Axial images, multiplanar reconstructions, and 3D volume-rendered images were analyzed on a Philips workstation. Radiologic image findings and clinical experience will be described.SAI CT angiography was successfully performed in 15 patients (30 shoulders) ranging from ages 22 to 81 years. Accurate identification of the main vascular pedicle was achieved in 14/15 patients. Location, course, pedicle length, and anatomic variations were reported for 23 of 30 arteries. Mean vessel diameter was found to be 1.49 mm (range, 0.8-2.0 mm) on the right and 1.51 mm (range, 1.0-2.1 mm) on the left. The mean length of the artery was 38.3 mm on the right (range, 26.6-59.6 mm) and 38.4 mm on the left (range, 24.3-67.0 mm). In all patients, the supraclavicular artery originated off the transverse cervical artery-a branch of the thyrocervical trunk. Positioning of the patient's upper extremities at the side was helpful in the identification of the supraclavicular artery and its distribution. Contrast injection site should be contralateral to the side needed for the flap if sidedness is of importance, secondary to contrast bolus artifact.Preoperative evaluation of the SAI flap with multislice computed tomography angiography is feasible in patients. A radiologic study protocol has been developed which improves the ability to detect this vessel. This technique provides a noninvasive approach to the identification of the vascular anatomy and is easily standardized/reproducible. The identification of the vascular pedicle and its anatomy can be a benefit to the surgical team during preoperative design of the SAI flap; however, clinical experience confirming these radiologic findings will be needed to optimize surgical outcome.

Free flaps are considered to revascularize from the surrounding tissue and survive without their original pedicle flow after a certain period postoperatively. We report 2 patients who developed mucosal ischemia of the transferred jejunum by ligation of its vascular pedicle 10 and 25 months after microvascular free jejunal transfer. Both patients had a history of heavy smoking, and had undergone definitive radiotherapy and previous surgery to the recipient bed. Both were treated conservatively; however, a stenotic change of the transferred jejunum remained in 1 patient. If poorly revascularized flaps, such as jejunal flaps, were transferred to the irradiated and scarred recipient bed, revascularization might never reach completion. If pedicle division is required in such cases, reanastomosis of the pedicle would be ideal regardless of the time after the transfer.

No current method of flap monitoring is ideal for use in all types of free tissue transfers. No method provides objective, easily communicated data that is identical in all types of transfers. In particular, reliable monitoring of buried transfers has proved difficult with available methods. The rat anterior thigh flap based on the external iliac vascular pedicle was introduced by us as a model of deep free tissue transfer. Four sets of 10 flaps were raised in the following groups: Group A (control), Group B (arterial occlusion), Group C (venous occlusion), and Group D (arterial and venous occlusion). Postoperative muscle flap pH was measured with a micro-pH electrode (1.2 mm) and correlated with arterial blood gas. Results showed excellent correlation of flap and serum pH over time (mean flap pH, 7.28; mean serum pH, 7.30). Arterial occlusion produced a rapid drop in flap pH of 0.66 pH units at 1 hour. Venous occlusion pH drop was 0.27 pH units at 1 hour, 0.53 pH units at 3 hours. Arterial and venous occlusion produced a pH drop of 0.55 pH units at 1 hour. The most rapid rate of pH drop occurred immediately after vessel occlusion. We have used continuous pH monitoring in 21 free tissue transfers for up to 84 hours after surgery. PH values remained constant in each transfer (range, 7.20-7.50; grand mean, 7.35). There was one flap failure among the monitored group of flaps, which was predicted by pH drop before loss of Doppler pulse.(ABSTRACT TRUNCATED AT 250 WORDS)

Advances during the last 15 years in microsurgical technique and in our understanding of vascular anatomy have led to the development of two new branches of plastic and reconstructive surgery. The first is the transfer of free composite flaps with microvascular anastomoses. The second is transposition of island flaps solely on a proximal or distal vascular bundle. Both types of operations require an adequate vascular pedicle to provide sufficient blood circulation for flap viability and survival in the recipient site.

Heterodigital pedicle flaps have 2 possible patters of vascularization: anterograde flow (Littler) or reverse flow (Adani). The Adani's flap uses the Y-V pedicle lengthening principle. The flap is raised from the adjacent uninjured finger based on the digital artery. The common digital artery is ligated and a long pedicle is formed from the 2 converging digital arteries to supply a reverse flow flap. Four patients with severe fingertips injuries were submitted to surgical treatment with the Adani's flap. All flaps integrated and provided skin coverage. The Adani's flap has a long vascular pedicle that allows a wide arch of transposition. An easier vascular dissection in a site distant from the trauma which evolves a higher diameter digital artery and proximal interphalangeal arterial system promotes a high survival rate and good functional results. Adani's flap is a reliable technique for severe fingertip injuries.

A free paraumbilical perforator-based flap fed by a muscle perforator from the inferior deep epigastric artery and with no muscle was used in 13 patients. Among them, a free thin paraumbilical perforator-based flap with a thin layer of fat, to protect the subdermal plexus of the vessels, was used in seven patients. The dominant pedicle perforator of this thin flap is usually located around the umbilicus and a large flap can be obtained. Its critical length-to-breath ratio is considered to be 4:3. The advantages of this flap are a long and large vascular pedicle, rare postoperative abdominal herniation, little bulkiness of the flap, and a relatively large skin territory. The disadvantages are technical difficulties in dissection of the perforator and anatomical variation in the location of the perforator. We believe this flap largely overcomes the problems of the conventional rectus abdominis musculocutaneous flap.

Eight patients with skin coverage of the hand by the distally based posterior interosseous island flap (DBPIIF) are presented. The first web was reconstructed in 6 and the volar and dorsal aspect of the hand in 2 patients. Primary closure of the donor sites has always been possible. An echo Doppler examination is indicated to verify the presence and size of the vessel and the direction of its flow. The dissection of the vascular pedicle, however, is frequently quite complex and time consuming. To better appreciate the cosmetic aspect of the DBPIIF and its donor site, a random study has been undertaken to compare this flap with the radial forearm and the groin flap and their corresponding donor sites. Females have more often preferred the groin flap, whereas doctors preferred the DBPIIF. Reliability, a good aesthetic result at the donor site, and the preservation of the main vessels of the hand are the specific merits of the DBPIIF.

We reviewed our experience with 11 consecutive combined latissimus dorsi and serratus anterior free-muscle transplantations from 1980 to 1990. All 11 flaps were successful and there was minimal morbidity. This combined muscle flap is ideal for soft-tissue coverage in extensive lower extremity wounds, in mutilating hand injuries with dorsal and palmar defects, and in situations when a long vascular pedicle is needed to get out of the "zone of injury."

The length of the vascular pedicle is critically important in the use and safety of a free flap. A lengthening of the artery and vein, until now, has been achieved through the use of either an autologous vein interposition graft or an arteriovenous loop. In such patients, the risk is nevertheless increased and does so proportionally to the increasing length of the venous interposition. We present a 30-year-old male electrician who had lost his left forearm and most of his right ulna after high-voltage electrical trauma. Lengthening of the vascular pedicle of a free fibula flap was achieved by anastomosis to the thoracodorsal vessels for 4 weeks. After this time, the flap was raised again together with the pedicle of the latissimus dorsi and used safely for reconstruction of the ulnar defect. Postoperative recovery after both operations was uneventful and the aim of reconstruction fully realized. In our opinion, this procedure provides an interesting alternative in patients in whom the length of the vascular pedicle is crucial but the designated flap has only a short pedicle.

Background: The pectoralis major muscle may be suited for free transplantation of a segment of the muscle. We investigated the length and diameter of its vascular pedicle to determine its feasibility. Methods: The length of the pedicle, its arterial diameter, and its entry point into the muscle were determined in 17 cadaveric flaps. Results: The pedicle length up to the medial border of the pectoralis minor muscle averaged 6.6 cm. The mean external arterial diameter was 1.8 mm. and the venous diameter was consistently larger. The vascular pedicle consistently entered the muscle lateral to the midpoint of, and a mean of, 8.8 cm caudal to the clavicular line. Conclusion: The vascular length and diameter are sufficient for microvascular anastomosis. Although an anatomic landmark for the cranial border of the flap could not be defined, the sternocostal part of the pectoralis major muscle may potentially be used as a segmental free flap.

Satisfactory functional prosthetic management of the very short humeral stump is difficult, and reliable methods for humeral lengthening in this circumstance are lacking. For this reason, we have developed a lengthening procedure that uses a latissimus dorsi musculocutaneous flap with incorporated eighth, ninth, or tenth rib. The flap may be elevated without detaching its vascular pedicle. Two patients have been successfully rehabilitated with prosthetics following this procedure.

The standard rat epigastric artery flap has been a very reliable model for flap research. The purpose of this study was to describe a modified design of this flap that included only the medial branch of the epigastric artery. Axial-pattern epigastric island skin flaps, measuring 8 x 8 cm, were raised in two groups of Sprague-Dawley male rats. In group A (N = 20) the vascular pedicle consisted of the main trunk of the epigastric vessel and both medial and lateral branches. In group B (N = 20) the flap was based solely on the medial branch of the epigastric artery, excluding the large lateral branch. The flaps were elevated and then sutured back to their beds. Flap survival was studied and the amount of viable skin in both groups was compared 1 week later. The rats were photographed using a digital camera and the images were analyzed using imaging software. The mean percentage surviving flap area in group A was 86.24% and in group B it was 69.72%, which is statistically significant (p < 0.001). We believe that this flap model, with its new modified design that includes a larger flap and inclusion of only the medial branch, will broaden its application to microsurgery. The main advantage of this flap over the conventional epigastric flap is that in this model it is possible to achieve predictable and consistent necrosis in the random extension of the flap.

Free transverse colon transfers based on the middle colic vessels were used to reconstruct a pharyngoesophageal defect in 9 patients. In all patients, cancer invaded up to the oropharynx. Resection resulted in a larger pharyngostoma than normally seen following standard total pharyngolaryngoesophagectomy. In such cases, it can be difficult to achieve good swallowing function after reconstruction using the free jejunal transfer. This mainly results from a significant discrepancy between the diameter of the pharyngostoma and that of the jejunum. Compared to the jejunum, the transverse colon has a larger diameter with a longer vascular pedicle and can provide a longer, straight intestinal tube, facilitating easy passage of a food bolus. In our series, all transfers survived well and all patients had good swallowing function postoperatively. We consider that a free colon transfer is more suitable than a free jejunal transfer for pharyngoesophageal reconstruction in patients with a large pharyngostoma.

The rat saphenous flap is described as a new experimental model for free flap studies. This is a fasciocutaneous free flap based on the saphenofemoral vascular pedicle. The flap may include the entire medial aspect of the lower leg between the knee and ankle. Thirty flaps were harvested from 15 inbred rats. Each flap was transferred to the anterior neck of a recipient rat of the same inbred strain so that 15 flaps were vascularized free flaps using the standard end-to-end microvascular technique and the other 15 flaps were nonvascularized free grafts. All but two (technical failure) of the vascularized flaps showed complete survival, whereas all nonvascularized flaps completely necrosed 2 weeks after transfer. It was concluded that the rat saphenous flap has several advantages such as a long and consistent vascular pedicle, ease of harvest, and an all-or-none survival pattern. Furthermore, as a unique feature of this flap, histological analysis revealed that the rat saphenous flap is composed of the skin and underlying fascia without panniculus carnosus. We therefore suggest that the rat saphenous flap is the first true fasciocutaneous free flap model in the rat. In this paper, in addition to illustrating the anatomy of the saphenous vessels and describing a new fasciocutaneous free flap model based on these vessels, we have documented some anatomical details of the rat leg that have never been described in the literature related to the rat anatomy.

Free vastus lateralis flaps for maxillofacial reconstruction were used in 30 patients. On the basis of its anatomy, this flap can be inserted as a musculocutaneous or musculofascial transplant in slim or normal-weight patients if extensive defects exist. The microvascular transfer is facilitated and accelerated by the long and high-caliber vascular pedicle and flap raising, which can be performed at the same time as tumor resection. We see indications for the musculocutaneous transplant in almost all sections of the oral cavity, particularly for tongue reconstruction; the vastus lateralis flap can be inserted in a purely muscular form for defect coverage on the scalp in connection with split skin. The donor defect is minimal functionally and aesthetically, and the success rate is approximately 90% for all flap transfers.

Upper extremity reconstruction is very challenging due to the unavailability of expendable local muscles. A review of the literature reveals that the latissimus dorsi muscle has been used for functional restoration of elbow extension and flexion as well as soft-tissue coverage of upper arm and shoulder defects. In addition, the latissimus dorsi muscle has been used for forearm reconstruction. Although we have been unable to find any reports of the use of the latissimus dorsi muscle for pure coverage of complex elbow wounds, we have successfully used the latissimus dorsi transposition flap to cover complex elbow defects in a one-staged procedure for patients. In 3 of 4 patients, the latissimus dorsi transposition flap was the first choice. In the other patient, the latissimus dorsi flap was successfully used as an alternative choice for coverage of an open, comminuted elbow fracture after a failed rectus abdominis free tissue transfer. A technique is described for coverage of complex elbow defects by transferring a latissimus dorsi muscle on its vascular pedicle with or without an overlying skin island. This procedure is safe, one-staged, and results in minimal donor morbidity. The latissimus dorsi transposition flap provides reliable coverage of complex elbow defects and should be considered the flap of choice for coverage of the elbow.

The fibrovascular integration of a biomaterial scaffold was examined in a rabbit model. Eight disks of expanded polytetrafluoroethylene measuring 2 x 2 x 0.2 cm were placed adjacent to dissected vascular pedicles in the ears of four rabbits and sealed between leaves of silicone sheeting. Fibrovascular outgrowth from the vascular pedicles completely integrated the biomaterial scaffolds by 6 weeks and was sufficient to sustain split-thickness skin grafts. Division of the distal vascular pedicle allowed isolation of the blood flow circuit to the construct. Successful microsurgical transfer was achieved in one construct. This model has proved useful in the study of tissue engineering of biomaterials for reconstruction and may well have use in the study of neovascularization as an isolated event.

Four patients with free tissue transfer using ascending cutaneous branches of circumflex scapular vessels are herein presented. The free ascending scapular flap is located on the superior vertical axis, differentiated with the scapular flap horizontally and the parascapular flap vertically designed. The flap is an excellent choice because of easy dissection, a constant artery and venous system, 2- to 3-mm-diameter vessels, and sufficient length of the vascular pedicle. All flaps survived completely with a fairly thin skin. The shoulder donor site could be closed primarily. No functional deficit of the shoulder was observed.

The rectus abdominis muscle and myocutaneous free tissue transfer is a well-recognized donor site for reconstruction of complex head and neck defects. Four composite deformities were successfully managed using this donor site. The rectus abdominis myocutaneous "sandwich" flap was used for closure of a pharyngocutaneous fistula and to provide intraoral lining and external coverage for a composite mandibular defect. The rectus muscle flap was used to obliterate a compound frontal sinus injury and an orbitomaxillary defect. All flaps were based on the deep inferior epigastric vascular pedicle.

The latissimus dorsi muscle has provided a useful flap for studying and defining the principles of the myocutaneous method. Clinically, it has yielded a valuable myocutaneous unit, based on its various pedicles. It has also provided the microvascular surgeon with a versatile unit that supplies a large volume of tissue with a long vascular pedicle. Investigation of the vascularity of the latissimus dorsi unit has led to better understanding of the vascularity of the muscle, and has extended the range of application of the myocutaneous method.

The radiovolar area of the forearm constitutes a versatile source of composite tissues for pedicle flap reconstruction of the hand and free-flap reconstruction for many areas of the body. The skin is thin and relatively hairless, and the vascular pedicle is long and of large caliber. The flap can be harvested to contain vascularized tendons and bone. The skin can be reliably reinnervated. The principal disadvantage, that this is a conspicuous donor site, has not been a source of concern for our patients. Nineteen of the 20 (95%) free flaps survived completely.

The tensor fascia lata (TFL) muscle, together with the overlying skin of the anterolateral thigh, makes a reliable musculocutaneous unit. It can be lengthened safely by taking the fascia lata and the skin of the anterolateral mid and lower thigh to within 8 cm of the knee. The skin of the longer flap is supplied by large perforating musculocutaneous arteries, the terminal branches of the vascular pedicle of the muscle. The shorter flap can easily be transposed over the trochanteric area, while the larger flap will cover not only the trochanter but also the ischial and sacral areas. The flap serves equally well as a transposition, island, or free flap. The anatomical and vascular basis of the flap is presented, together with its application in 21 patients. Possible further applications of the flap, including anterior rotation, are discussed.

Based on our clinical experience, various methods of donor or recipient vascular pedicle coverage for an arterialized or free flap are reported. The vascular pedicle may be placed in the subcutaneous space either by incising the skin along the full length of the vascular route or by passing it through a subcutaneous tunnel. It has been our experience that the vascular pedicle can also be covered by either a local flap or a free skin graft. On rare occasions, a narrow skin flap strip including the vascular pedicle can be lifted en bloc and rotated toward the base of the area transferred.