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Background: Breast reconstruction with implants is a real challenge in patients with large breast volume. Skin-reducing inverted-T mastectomy is the best solution for these patients. Delayed wound healing or necrosis at the T-junction area can be seen in this procedure, although it may also lead to severe conditions such as the exposure and loss of implant. In this article, the use of local pedicled flap for the management of these situations was discussed., Methods: Between April 2010 and July 2015, 54 patients underwent breast reconstruction by inverted-T skin-reducing mastectomy and immediate implant-based breast reconstruction at our clinic. During the postoperative follow-up period, necrosis at the T-junction area was observed in 8 patients. All the patients received proper wound care, and the necrosis was surgically debrided. The defect was closed with Limberg-like rectangular flap., Results: The mean age was 45.2 (range, 33-54) years. The mean body mass index was 25.57 ± 6.53 (range, 21.2-35.2) kg/m. The mean follow-up was 10.9 (range, 4-19) months. Two patients had implant exposure at the defect site after the debridement. There was no implant loss in any of the patients., Conclusions: The Limberg-like rectangular flap can be used as a salvage option in complicated skin-reducing mastectomies and can be considered as a safe and effective method because of its easy-to-use nature, low cost, and no need for microsurgery experience.

The main focus of this paper is the selection of proper vessels for successful free tissue transfer in lower extremities which have suffered extensive trauma. The selection of proper recipient vessels for traumatized lower extremities still presents difficulties for surgeons. This review will provide a general guideline for the selection of proper recipient vessels in traumatic lower extremity reconstruction and describe the possible reasons why some recipient vessels present more problems than others., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

To assess the functional deficits in gait and balance after fibular osteoseptocutaneous flap harvest, a case-control study in a hospital-based biomechanical laboratory was conducted. Eleven patients receiving fibula osteoseptocutaneous flaps were enrolled as study group and 10 age-matched and healthy subjects as a control group. The average postoperative period at the time of evaluation was 27.4 months (range: 10 to 68 months) and the average age at the time of evaluation was 52.1 years (range: 38 to 76 years). The balance test by Smart Balance Master and gait analysis were used for objective assessment of the donor leg function postoperatively. No statistical differences were observed in the kinetic and kinematic variables of gait analysis except double support time in both the groups. There were also no significant differences in simple static balance test (eyes open, eyes closed, swaying vision, eyes open with swaying surface, and sway-referenced vision and support). Significant differences were observed in more difficult task (eye closed with swaying support) and in the use of ankle strategy for maintaining maximum balance. In the dynamic balance test only specificity of the forward left direction determined significant difference in reaction time of movement control of gravity. The results of ankle strategy usage and dynamic balance indicated deficits of ankle muscle torque. Necessary postoperative physical training is required for ankle muscle torque and vestibular sense.

After multiple thoracotomies, local muscles are often transected or sacrificed for the treatment of intrathoracic infection. In these conditions, free tissue transfers are described as an alternative. Five anterolateral thigh musculocutaneous free flaps were used for the treatment of complicated large chronic empyema defects and bronchopleural fistulas with a special flap inset and gauze-packing method, the so-called tissue plug technique. All flaps survived completely without complication. There was no sign of recurrent infection, and the bronchopleural fistulas were sealed and the empyema cavities completely obliterated. We concluded that the tissue plug technique is an alternative for the management of difficult empyema cavities and bronchopleural fistulas in selected patients where the soft tissue flap is not enough to fill the complete dead spaces.

Background: Clinical applications and indications of the thin skin flap have been widely documented but its circulation haemodynamics are still controversial. An experiment was conducted on pigs to show the survival and circulation haemodynamics of random pattern thinned skin flap., Methods: Group I: Random pattern standard skin flaps; 5 x 5 cm (n=20 flaps), and 5 x 10 cm (n=20 flaps). Group II: Random pattern thin skin flaps; 5 x 5 cm (n=20 flaps), and 5 x 10 cm (n=20 flaps). Group III: Random pattern thin skin flaps with silicone sheet underneath; 5 x 5 cm (n=20 flaps), and 5 x 10 cm (n=20 flaps)., Results: The mean surviving skin area of the 5 x 10 cm flaps was 95.5% in Group I, 64.9% in Group II, and 33.67% in Group III. A statistically significant difference (P<0.05, ANOVA) was found between the groups. The mean surviving skin area of the 5 x 5 cm flaps was 100% in Groups I and II, and 68.2% in Group III. A statistically significant difference (P<0.05, ANOVA) was also found between Groups I and III, and Groups II and III. In microangiographical studies, the distribution of subcutaneous plexuses was clearly visible in Group I. In Group II the subdermal vascular plexus was observed less frequently and was thinner, particularly on the distal part of the flaps. In Group III dilatation of the subdermal vascular plexus was evident, particularly on the proximal section of the flaps. In the technetium-99m-labelled microspheres uptake of the 5 x 10 cm flaps, there was no statistically significant difference between the first segments in Groups I and II, Groups II and III (P>0.05, ANOVA). A significant difference was found between the second segments in Groups I and III (P<0.05, ANOVA)., Conclusion: The results obtained in this study show that the effect of subdermal vascular plexus in the survival of the random pattern thinned skin flaps is supported by flap bed osmosis and plasma imbibition.

Recently several studies have addressed the venous problem and confirmed that venous ischemia is more injurious to tissue viability than arterial ischemia of equivalent duration. There are different methods of managing venous-compromised pedicled flaps. Between June 1996 and November 2003, our center treated two submental, five Becker, nine posterior interosseous, three distally based sural, and three colon pedicled flaps (22 flaps in total), which had venous congestion either at the time of flap elevation or immediately after inset of the flap. These cases of venous congestion were managed with an immediate additional venous anastamosis. After vein anastomosis, venous congestion reduced gradually, then improved, and finally disappeared completely in the postoperative follow-up days with all flaps surviving in their entirety. Reexploration was not required for the microsurgical venous anastomosis. In conclusion, flap necrosis resulting from venous congestion causes prolonged hospitalization, multiple debridements, and additional procedures to cover the exposed structures. Additional vein anastomosis, which is a simple, rapid, and reliable auxiliary procedure, may increase complete flap survival and lead to successful end results, both functional and cosmetic.

Although many large series of free tissue transfers for head and neck reconstruction have been reported in adults, there are few studies in paediatric patients. Seventy-three free tissue transfers for reconstruction of various defects of the head and neck were performed in 72 paediatric patients between January 1990 and September 2002, at our centre. The average age at the time of reconstruction was 11.8 years (range: 2 to 17 years). Thirty-eight patients were girls and 34 were boys. There were 19 tumour resection defects, 18 congenital oro-nasal fistula defects (cleft palate), 11 posttraumatic defects, nine corrosive pharyngo-oesophageal injuries, eight burn contractures, six hemifacial atrophies and microsomia, and one facial paralysis. Thirty-nine fasciocutaneous flaps, 16 osteoseptocutaneous flaps, 10 muscle or myocutaneous flaps, and eight jejunal flaps were transferred. The mean operative time was 8 h 20 min. All flaps survived, except one partial necrosis, with 98.6% success rate. Five patients (6.8%) required re-exploration. There were two venous and three arterial thromboses. All five flaps were successfully salvaged. The average hospital stay was 18 days. This study confirmed free tissue transfer as a safe, reliable, cost- and time-effective method for the reconstruction of various head and neck defects in children.

Background: There have been a limited number of reports regarding calcaneal open fractures so far. Thus, the debate regarding treatment is continuing. Type IIIB open calcaneal fractures are often associated with the possibility of chronic osteomyelitis that may cause severe complications, including amputation., Methods: Between the years 1990 and 2001, 27 free tissue transfers were performed in 25 patients for reconstruction of soft-tissue defects complicated by calcaneal fracture. All of the patients underwent debridement and bone fixation procedures at the initial operation in the acute phase. Ten patients with comminuted fractures were treated by means of external fixation and 15 patients had intraarticular fractures that required internal fixation in addition to external fixation. After several aggressive debridements, free tissue transfers were performed subacutely for primary wound coverage. Muscle flaps were used in the majority of cases (n = 21). The mean follow-up period was 7 years 8 months., Results: Complete flap survival occurred in 93 percent of flaps. There was one partial and one total flap failure. The overall infection rate was 12 percent (n = 3). Two of these patients were treated successfully and one required partial calcanectomy. In all cases, solid bone union was achieved. However, 72 percent of the patients suffered from pain or degenerative changes., Conclusions: Type IIIB open calcaneal fractures require systematic and meticulous treatment. Free tissue transfer is the essential component of providing healthy tissue for achieving adequate wound healing with reduced infection rates.

Background: Reconstruction of facial skin defects requires good-quality skin cover to satisfy aesthetic expectations of patient, especially when the skin defect is on the uncovered area of the face. Limitations in the available local tissue and donor-site morbidity restrict the options., Objective: In an effort to solve these problems, we have begun to use a subcutaneous pedicled retroauricular reverse-flow flap., Methods: Between January 1997 and December 2005, reverse-flow subcutaneous pedicled retroauricular island flap was used to cover facial defects in 12 patients who underwent surgical excision of skin tumor. The patients ranged in age from 44 to 81 years with a mean age of 58 years., Results: Only one case experienced a superficial necrosis in the distal one-quarter part of the flap. The functional and aesthetic results were satisfactory for both patients and surgeons, and no tumor recurrence was observed during the 12 to 28 months (mean, 18.8 months) follow-up period., Conclusions: This flap can be used reliably for the reconstruction of facial skin defects of small and medium size. The preference of frontal branch pedicled flap enables more distal facial area defects to be covered, such as dorsal nasal, nasolabial, and upper lip, than flaps based on parietal branch.

Neophalloplasty remains one of the most challenging efforts in plastic and reconstructive surgery. The complex functional and aesthetic requirements are difficult to attain with consistency and safety. The current gold standard technique involves the use of a radial forearm tube-in-tube free flap, which also requires the placement of a stiffening prosthetic device for dual function. We report the safe use of the free fibula osteocutaneous flap to create a functional, cosmetically-acceptable penis utilizing the principles of prefabrication and controlled fistula method in one case of gender dysphoria.

An experimental study was designed to examine whether the blood supply of the muscle would be maintained by a reverse flow from the random pattern skin flap through the musculocutaneous perforators. A flap model containing rat rectus abdominis muscle and randomly based overlying abdominal skin was designed. Sixty rats were divided into four experimental groups as follows. In group I, scintigraphy and microangiography were performed in 10 and 6 rats, respectively, immediately after flap elevation. In group II, scintigraphy and microangiography were performed in 10 and 6 rats, respectively, 2 days after flap elevation. In group III, surviving skin paddle area was evaluated in 16 rats 7 days after flap elevation. After evaluation of surviving skin paddle area, the same animals were used for microangiographic (n=6) and scintigraphic (n=10) studies at the same day. In group IV, histopathologic examination was done in six flap muscles each 2 and 6 weeks after flap elevation (n=12). The mean percentage of surviving skin paddle area was 95.6 +/- 6.5% on postoperative day 7. Microangiography showed progressively developed blood flow from the skin to muscle through the musculocutaneous perforators in groups II and III, respectively. The radioisotope uptake of the operated muscle was 40.9 +/- 12.8% immediately after flap elevation (group I), 58.3 +/- 15.6% on postoperative day 2 (group II), and 70.7 +/- 25.6% on postoperative day 7 (group III). There was a significant difference only between group I and group III ( P<0.05, analysis of variance). Histopathologically prominent atrophy, lipomatoses, and fibroses were revealed at week 6. The poor circulation and viability outcomes of the muscle revealed in the study are because of immediately insufficient blood microcirculation at the distal part of the random pattern skin flap.

The development of microsurgical techniques has facilitated proper management of extensive head and neck defects and deformities. Bone or soft tissue can be selected to permit reconstruction with functional and aesthetic results. However, for free tissue transfer to be successful, proper selection of recipient vessels is as essential as the many other factors that affect the final result. In this article selection strategies for recipient vessels for osteocutaneous free flaps, soft tissue free flaps, previously dissected and irradiated areas, recurrent and subsequent secondary reconstructions, simultaneous double free flap transfers in reconstruction of extensive composite head and neck defects, and the selection of recipient veins are reviewed in order to provide an algorithm for the selection of recipient vessels for head and neck reconstruction.

Background: The advantages of free muscle flaps for reconstruction of lower extremity defects have been largely reported to be superior to those of fasciocutaneous flaps., Methods: One hundred seventy-four patients received 177 microsurgical free tissue transfers for distal third and ankle open tibial fractures. Patients were divided into two groups. In group I, 96 patients received 98 free muscle flaps (55.4 percent). In group II, 78 patients were treated with 79 free fasciocutaneous flaps (44.6 percent)., Results: Complete flap survival was 92.9 percent and 91.1 percent in groups I and II, respectively. Postoperative infection was 11.2 percent in group I and 12.7 percent in group II. Chronic osteomyelitis developed in 9.3 percent and 12.7 percent in groups I and II, respectively. The rate of primary bone union was 84.5 percent in group I and 81 percent in group II and the rate of overall bone union was 96.9 percent in group I and 98.7 percent in group II. Finally, 92 patients in group I and 77 patients in group II could walk without crutches at 2-year follow-up. There were no statistically significant differences between the two flaps., Conclusions: The authors achieved equal functional outcomes in both soft-tissue transfers because of (1) preoperative adequate débridement of wounds and (2) selection of proper free flaps in appropriate defects. Defects with serious tridimensionality needed free muscle flaps because they conform better to such complex defects. However, free fasciocutaneous flaps are reliable and as effective for covering the less three-dimensional distal third and ankle traumatic open tibial fractures as free muscle flaps and can better tolerate the subsequent secondary surgical procedures.

Background: Composite maxillary defects often involve the maxilla, nasal mucosa, palate, and maxillary sinus. We presented the surgical techniques and outcome of the osteomyocutaneous peroneal artery perforator (PAP) flap for reconstruction of composite maxillary defects., Methods: Six patients underwent an osteomyocutaneous PAP flap reconstruction of composite maxillary defects. The average age was 52 years. The defects were Cordeiro type II in three patients and type IV midfacial defects in another three patients., Results: No total or partial flap failures occurred. At a mean 12-month follow-up, five patients had a normal speech and were able to eat a regular diet. One patient tolerated a soft diet and had intelligible speech. One patient had ectropion develop. Excellent cosmesis was found in five patients., Conclusions: The osteomyocutaneous PAP flap represents a further refinement of the fibula flap and increases its versatility, with multiple skin paddles, bone segments, and soleus muscle independently isolated. It is a comparable reconstruction option for composite maxillary defects., (Copyright 2005 Wiley Periodicals, Inc.)

Background: Poliomyelitis is a disease that can render affected individuals incapacitated to a variable degree. A normal lifespan is expected and therefore the patients deserve every effort at curative cancer resection and reconstruction. Those with lower extremity paralysis rely heavily on their upper limbs and torso for ambulation; therefore, their compromised limbs may be a better donor site for flaps., Methods: All poliomyelitis patients with lower extremity paralysis over a 20-month period who underwent head and neck reconstruction were selected for a retrospective review. Perioperative complications were noted and outpatient follow-up was performed., Results: Three patients underwent reconstruction of defects using the posterior tibial artery flap. Two patients required reconstruction of a buccal defect and one patient required soft palate reconstruction. All patients healed without complications and none required reexploration. At a mean follow-up of 10 months, there was no incidence of donor limb vascular compromise, cold intolerance, or long-term paresthesias., Conclusions: The posterior tibial artery free flap has been used successfully in the past; however, its popularity has been limited because of sacrifice of the posterior tibial artery. Nevertheless, in patients with lower extremity paralysis, this flap may fulfill the requirements of a thin, pliable flap with minimal hair that has a long pedicle and a reliable blood supply. Most importantly, the use of this flap obviates the need to use flaps that fulfill the same requirement, such as forearm flaps, that would be taken from patients' functioning limbs.

This article discusses the indications for and the advantages and principles of flap combinations and the selection of two pairs of recipient vessels for double free-flap transfers in reconstruction of extensive composite head and neck defects.

Background: Massive defects of the head and neck regions after resection of advanced carcinoma often require two flaps for optimal reconstruction. This study focuses on the selection of proper recipient vessels., Methods: A total of 262 free-flap transfers were performed in 130 patients using the two-flap approach (one patient received two flaps twice)., Results: For microvascular anastomosis of inner flaps (intraoral lining-bone reconstruction flaps), the ipsilateral facial artery was used in 56 flaps (42.8 percent), the ipsilateral superior thyroid artery was used in 49 flaps (37.4 percent), and a branch of the internal jugular vein was used as recipient vein in 101 flaps (77.1 percent). For external flaps (soft-tissue-external skin reconstruction flaps), the ipsilateral superior thyroid artery was used in 59 flaps (50.4 percent) and the transverse cervical artery was used in 19 flaps (16.2 percent). In 14 patients the inner flaps provided distal run-off for external flap revascularization. Only seven flaps required vein grafts; they were all used for external face reconstruction (2.8 percent). There were six total (2.3 percent) and 12 partial (4.6 percent) flap failures., Conclusions: Recipient vessel selection and preparation in primary head and neck cancer reconstruction requiring two simultaneous flaps should take into consideration (1) avoidance of unnecessary destruction during tumor ablations and preservation of as many neck vessels as possible, (2) length and diameter match between flap pedicles and recipient vessels to avoid vein grafts, and (3) possible need of another free-flap reconstruction for flap failure, complication, recurrence, or secondary primary cancers. The previously radiated or operated neck does not preclude the use of recipient vessels from that side. Distal run-off of the inner flap for external flap revascularization should be avoided if possible. Once those principles are observed, two-flap reconstruction for primary cancer presents no more difficulties than single-flap reconstruction.

In this study, the authors explored the feasibility of transplanting a "pectoral skin flap" as an alternative model for composite skin allotransplantation research. Genetically inbred male Lewis rats (LEW; RT1l) (n = 13), weighing 250 to 300 gr, were used as recipients and Brown Norway rats (BN; RT1n) (n = 8) rats were used as donors. Five Brown Norway rats had bilateral and three had unilateral flap harvest with a total of 13 flap transplantations to Lewis rats. All flaps were transplanted to the groin regions of the recipients and microsurgical anastomoses with 10-0 nylon were performed between the axillary vessels of the flaps and the femoral vessels of the recipient animals. The mean operation time was 55 min, with an ischemia time of 25 min. All transplantations were successful immediately postoperatively. The recipient animals were treated with Cyclosporine A (16 mg/kg/day) from the day of the surgery for 1 week, and then discontinued. One flap developed infection at postoperative day 11 and one flap had partial (50 percent) necrosis. The early signs of rejection started 8 to 9 days after the cessation of the immunosuppressive treatment, and all flaps were acutely and uniformly rejected within 3 to 4 days. The feasibility of harvesting two flaps from one donor animal allowed saving donor animal lives and reducing donor-specific variables.