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The best secondary option for autologous breast reconstruction remains controversial. Limitations of the gracilis myocutaneous flap, including volume, skin paddle reliability, and donor morbidity, have been addressed by several modifications, hereby expanding its role in the decision tree for autologous breast reconstruction. This report documents the authors' experience with gracilis flap breast reconstruction.This is a retrospective case series of a prospectively maintained database of patients undergoing breast reconstruction with the free gracilis myocutaneous flap, including the transverse upper gracilis, vertical upper gracilis, and bilateral stacked vertical upper gracilis.Twenty-two patients received gracilis myocutaneous flaps. Fourteen (63.6 percent) had previous attempted breast reconstructions. Indications for gracilis donor site were previous abdominoplasty/abdominal flap (n = 15, 68 percent), insufficient abdominal tissue (n = 6, 27 percent), and patient preference (n = 1, 5 percent). Six patients underwent bilateral reconstruction, and five underwent unilateral reconstruction with bilateral stacked gracilis flaps. The skin paddle was transverse in four flaps (12 percent) and vertical in 29 (88 percent). There was one flap loss (3 percent); there were two occurrences of fat necrosis (6 percent). There were two minor donor site dehiscences (6 percent), one infection (3 percent), and one seroma (3 percent).The free gracilis flap is a versatile option for patients undergoing breast reconstruction, particularly when the abdominal donor site is unavailable. The vertical pattern is the authors' preferred technique, as it avoids some of the problems associated with transverse patterns. Stacked flaps further expand the utility of this technique, which the authors regard as the best secondary option for autologous breast reconstruction.Therapeutic, IV.

Breast reconstruction has become standard of care for female patients with breast cancer. The transverse rectus abdominis musculo-cutaneous flap (TRAMf) is the most common method of immediate or delayed autologous breast reconstruction following mastectomy. We share our experience with modified, double back cut of post-mastectomy skin in delayed pedicled TRAMf breast reconstruction, resulting in fish-shaped skin paddle. This sort of back cut is a simple, reliable way to obtain a natural, esthetically pleasant breast mound with inconspicuous hidden scars. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Background Synchronous double oral cancer represents the minority of cases of head and neck cancer. After tumor ablation, 2 separate oromandibular defects, even combined with a through-and-through oral defect, pose a serious reconstructive challenge. The ideal method for reconstruction remains controversial. Aim and Objectives Based on the peroneal vessel axis, a chimeric double-skin paddle peroneal fasciocutaneous or fibular osteomyocutaneous flap could be designed to accomplish the difficult reconstruction. Materials and Methods Six male patients, each with 2 separate oromandibular defects after tumor ablation of synchronous double oral cancer, received double-skin paddle flap reconstruction with 3 peroneal fasciocutaneous and 3 fibular osteomyocutaneous flaps. Result All 6 flaps survived; however, complications included 1 skin paddle lost due to insufficient perfusion of a visible perforator, and 1 superficial necrosis occurring over the tip of a longer skin paddle. One postoperative intraoral infection and 1 donor site infection were also reported. During follow-up, 3 months later, 1 patient succumbed to local recurrence and bony metastasis. One patient developed a new cancer in the maxillary gingiva, and another had osteoradionecrosis 8 months later. Four patients gained acceptable cosmesis with good oral competence. Conclusions A chimeric flap based on the peroneal artery could provide a segment of fibular bone, 1 or 2 skin paddles, and a cuff of the flexor hallucis longus muscle simultaneously. For 1-stage reconstruction of separate oromandibular defects after tumor ablation of synchronous double oral cancer, this design could provide all components at 1 transfer.

Purpose The reconstruction of complicated defects with 3-dimensional deficits remains challenging. The reconstruction of these defects requires not only coverage of surface but also appropriate obliteration of dead space, and muscle-chimeric perforator flaps can be a valuable option. Here, we present our experience with free latissimus dorsi (LD) muscle-chimeric thoracodorsal artery perforator (TDAP) flaps for the treatment of complicated defects. Methods A retrospective chart review was performed for patients who underwent a free LD muscle-chimeric TDAP flap procedure for the treatment of complicated wounds with 3-dimensional tissue deficits between March 2005 and October 2012. The surgical technique, clinical outcomes, and postoperative complications were evaluated. Results A total of 24 cases were included. All flaps survived and no partial flap losses were encountered. Large skin flaps of 115 cm average size were elevated, with an average of 38-cm muscle segments. The total length of pedicle was 12.2 cm on average, with 7.3 cm of common pedicle, 4.9 cm of skin paddle, and 3.4 cm of muscle segments. Muscle segments could be inset in the underlying dead space with spatial freedom. The mean follow-up period was 34.1 months. Wounds successfully healed in all cases without significant postoperative complications. The donor-site complication rate of the chimeric flap group was similar to that of the simple TDAP group. Conclusions The use of LD muscle-chimeric TDAP flaps with Y-pedicle configurations allowed efficient positioning of both skin and muscle components for their specific purposes and successful healing of complicated wounds. The muscle components of chimeric flaps acted as "filler flaps" and were an effective addition to the perforator flap technique for the reconstruction of complicated defects without the addition of significant donor-site morbidity.

Pedicled perforator flaps are also called local perforator flaps, or island perforator flaps. It combines the advantages of pedicled local flaps (good color and texture match, like-with-like reconstruction), pedicled regional flaps (up to 180° arc of rotation), pedicled distant flap (vascular reliable and larger size), and without microsurgical vascular anastomosis. For most small- to medium-sized defects, pedicled perforator flap allows linear closure of the donor site.

The anterior supramalleolar perforator flap is pedicled on the superior malleolar cutaneous branch of the anterior tibial artery. It is a fasciocutaneous flap located in the middle-distal third of the lower leg.

In a selected donor site, raising a perforator flap entails: (1) localization of skin perforators using the handheld Doppler and (2) raising the flap by performing retrograde dissection from the perforator to the source vessel until a sufficient pedicle length and size has been achieved, regardless of the origin of the harvested vessel. This manner of flap elevation was firstly introduced by Wei and coauthors in 2004 and termed as free-style concept. As a result of this concept, any skin paddle based on a substantially sized perforator, localized by an audible Doppler signal, can be potentially harvested. With a substantial number of available perforators in the body, this approach certainly increases the surgeon’s degree of freedom in terms of reconstructive options.

In 1981, an international group of surgeons under the direction of Acland published their work on the “saphenous flap” [1–3].

Resume But de l'etude Plusieurs auteurs ont utilise avec succes des lambeaux musculocutanes de grand dentele. Pourtant, la localisation et les dimensions de sa palette cutanee ne sont pas clairement definies dans la litterature. Nous avons donc realise une etude anatomique avant d'envisager des applications cliniques. Patients et methodes Vingt-six dissections sur 13 sujets anatomiques frais ont ete realisees. Le protocole consistait a catheteriser la branche thoracique de l'artere thoracodorsale pour injecter un melange de bleu de methylene et de produit radio-opaque. Les resultats etaient obtenus par mesure directe de la zone cutanee bleue et par evaluation radiographique de la zone radio-opaque, par rapport a des reperes anatomiques reproductibles. Resultats Vingt-cinq dissections etaient interpretables et donnaient des resultats superposables. La palette cutanee se situait toujours en regard des cinquieme, sixieme et septieme cotes entre la ligne axillaire en dehors et la ligne mamelonnaire en dedans. Elle mesurait en moyenne 11,75 cm de longueur (10–14) et 10,75 cm de largeur (9–12). Elle s'etendait sur 125 cm 2 de surface (110–140). Nous rapportons ensuite 12 cas de lambeaux libres de grand dentele avec prelevement d'une palette cutanee destinee a la surveillance du lambeau (quatre musculocutanes, cinq costomusculocutanes, trois de fascia avec palette cutanee). Conclusion Cette etude vient a l'appui des constatations anatomiques de Salmon, des observations peroperatoires de plusieurs auteurs et de notre propre experience clinique. Elle temoigne de l'autonomie de vascularisation cutanee par des branches issues du fascia superficiel du muscle. Elle precise la localisation et les dimensions de la palette cutanee prelevable avec le lambeau de dentele anterieur, ce qui accroit encore sa polyvalence d'utilisation.

The distally based sural neurocutaneous flap (Masquelet et al., 1992) has proved to be a useful technique for lower limb skin defect reconstruction. We report our experience in a 60 case series for the coverage of foot, ankle, and distal third of the leg with success in 58 cases and 2 failures. For one of these, a total necrosis occurred after a technical problem when harvesting the pedicle, while the second failure was due to a severe inferior limb vascular disability. In 14 cases, a partial venous congestion with a slight epidermolysis or a marginal necrosis was observed but it resolved without sequel. Seventeen patients presented with distal vascular impairment and/or neuropathies (i.e. diabetes mellitus, arteriosclerosis, vascular lesions) of the inferior limb and our experience favour a larger pedicle trimming than in normal cases to avoid venous congestion of the skin paddle. In 18 cases, when undermining of skin between the pivot-point and the defect site to be covered was too hazardous, we used an external pedicle either temporary and severed a few weeks after or skin grafted. This is a helpful mean when local condition of the skin to be undermined for pedicle tunnelling may interfere with the final issue. This one-stage simple technique, without major vascular sacrifice and with minor consequences at the donor site, is reliable for the distal third of the inferior limb, ankle, and dorsal foot aspect reconstruction, the heel-bearing zone excepted.

We describe our experience with, and evaluate the reliability of, the lateral supramalleolar flap that was used in 20 patients for reconstruction of the distal leg and foot. There were 14 men and six women, age range 20-83 years. Nine were diabetic. The causes of the skin defects included trauma, diabetic ulcer, and deep burn. Sites of defects were the lower leg, the Achilles tendon, the dorsal and lateral aspect of the foot, and the ankle. Nineteen flaps survived and provided satisfactory coverage of the defect. Four flaps showed partial necrosis and required revision. We think that the lateral supramalleolar flap is a good way to reconstruct soft tissue defects of the lower extremity. Based on a secondary vascular axis, it has a large skin paddle and a wide rotation arc that reaches the distal areas of the foot.

Dear Sir, We read with great interest the manuscript by Prasetyono et al. [1] titled "Practical considerations for perforator flap thinning procedures revisited". We want to discuss some points related to this article and highlight some differences between thinning a free perforator flap versus a propeller perforator flap. We absolutely agree with the authors regarding the possibility of thinning (or defatting) a flap in which the perforators are generally central, but when the perforators are lateralized we believe that the problem is completely different. Indeed, free perforator flaps are most frequently harvested with centralized perforating vessels on the skin paddle, unlike propeller perforator flaps, in which the perforators are lateralized, because of the necessity of rotation. We often achieve significant thinning of our free perforator flaps without necrosis or any skin suffering. However, thinning our propellers flaps is often more hazardous and sometimes results in extensive unexplained skin problems. Therefore, we prospectively compared five tibial posterior perforator flaps harvested with suprafascial dissection including distal 2/3 thinning (in the subcutaneous plane) of the flap and five harvested with subfascial dissection without thinning. The size and rotation were similar; i.e., 4×12±2 cm with a twist between 120° and 180°. We noted almost no distal suffering in the subfascial group versus distal problems of 10%-20% for three flaps in the suprafascial group. Moreover, all of the flaps harvested in the suprafascial plane and thinned had an initial venous congestion phase greater and more worrying than did the flaps harvested with subfascial dissection. We believe that the problem of thinning is more venous than arterial. Thinning alters the arterial vasculature little as the dermal plexus is respected, as explained by Hong et al. [2], but it could reduce venous back flow. We selected the posterior tibial perforating flap because it is clear that venous problems are much more common in the limbs, and especially the leg, than in the trunk. Regarding the article by Prasetyono et al., we note some signs of venous suffering at the edge of anterolateral thigh perforator in Fig. 5C and D; these are almost never seen in practice with this flap, which remains very reliable and reproducible. Therefore, the extensive thinning was probably involved in this phenomenon. In conclusion, perhaps the main problem with thinning is not an impaired arterial supply, but venous back flow, as the subdermal plexus is preserved. If it appears less risky for free perforator flaps or when the perforators are centered on the skin paddle, thinning can be harmful when the perforators are lateralized. For the lower limb, it seems best to avoid thinning propeller perforator flaps unless absolutely necessary.

Deep sternal wound infection (DSWI) after a cardiac operation is a rare but serious complication associated with significant morbidity and mortality. It can lead to wound dehiscence with sternal osteomyelitis and both bony and soft tissue residual defects. When the infection is eradicated, reconstruction of the thoracic wall remains the main challenge. Tissue used for covering the defect must be well nourished and sutures must be tension free. We present our unique modification of the method using the pectoral muscle axial flap with a V-Y skin paddle.

Upper thoracic wounds with exposed hardware from spinal instrumentation and previous radiation presents a subset of back wound coverage problems that lend themselves to a unique opportunity to use the distal trapezius musculocutaneous flap. The unradiated, healthy skin paddle can be transposed between the radiated skin edges to seal and cover the exposed hardware and achieve early primary healing of the back wound without the need for a skin graft. The authors review their series of the upper back radiated wounds reconstructed with the trapezius musculocutaneous flaps, immediately at the time of the spinal surgery and secondarily after the incisional wound breakdown, to cover the exposed hardware. Their contiguous skin flap design strategy, results, and complications are discussed.

The authors present the double-paddled pectoralis major myocutaneous flap (PMMF) as a successful alternative for reconstructing complex oro-cervical defects when previous micro vascularized free flaps have failed or when ever it is not possible to harvest a free flap. This method was used for the reconstruction a post-ablative defect in a 36-year-old male with a T4 squamous cell carcinoma (SCC) of the base of tongue with laryngeal involvement. The distal paddle was adapted to reconstruct a defect of the floor of the mouth and further sutured in two layers (muscle-basal mandible and skin paddle-oral mucosa) whereas the proximal skin paddle was used to close the cervical skin and the peri tracheostomy defect. Keywords: Double-paddled pectoralis flap; orocervical complex defect; micro vascularized free flaps fail.

Supplemental Digital Content is available in the text.

Purpose Drawbacks of the conventional supraclavicular overlay of the pectoralis major myocutaneous flap (PMMF) include the resultant unesthetic cervical bulge and the limited cephalad extension that limits its use to mandibular or cervical defects. This study discusses the technique and comparative advantages of a more esthetic subclavicular route through the clavipectoral fascia that allows an increased arc of rotation to reconstruct orofacial defects. Materials and Methods Patients with orofacial defects that were reconstructed with a PMMF through the modified subclavicular route were included in this retrospective cohort study, which aimed to compare the gain in extension accorded through the modified subclavicular tunnel over an initial conventional supraclavicular overlay. Outcome variables included the dimension of each skin paddle and the cross-sectional area of each flap. Other variables, such as age and gender, also were investigated. Complications that arose from this technique were statistically compared with these variables and with those from previously reported studies. All data analyses were performed using Pearson χ2 and correlation tests. Results Twelve patients (7 women and 5 men) who underwent a primary reconstruction with the PMMF during a 1-year period from November 2010 to November 2011 were selected for this study. All 12 flaps survived; 3 developed minor postoperative complications that resolved within the 3-month review period. A PMMF with an average dimension of 12.75 × 6.0 × 3.725 cm and cross-sectional area of 20.65 cm2 could pass through this modified tunnel, achieving an average gain in extension of 3.2 cm that enabled the reconstruction of defects up to and above the level of the oral commissure. Apart from skin paddle dimension, all other variables were not found to be statistically related to the extension accorded by the modified route. Complications that occurred appeared to be related only to the cross-sectional area of the flap. Conclusion The increased cephalad extension afforded by this modified subclavicular route through the clavipectoral fascia permitted the reconstruction of orofacial defects that would otherwise have required free vascularized grafts with microvascular surgery and avoided the unesthetic cervical bulge from conventional supraclavicular overlays of the PMMF.

Vascularized free fibula transfer is an attractive option for the treatment of segmental bone defects because of faster union rates, fewer fatigue fractures, rapid hypertrophy, and less resorption compared with nonvascularized bone transfer. It is classically indicated for those patients with segmental bone defects >6 to 8 cm. The presence of several peroneal artery fasciocutaneous perforators also makes the inclusion of a skin paddle possible. Although rare, the surgeon must be aware of possible complications associated with this procedure. A careful operative technique is necessary for obtaining excellent surgical outcomes.

The incidence of peri-implantitis, marginal bone loss, implant success, and survival rates of 52 dental implants placed through the skin paddle and 23 implants through the neighboring gingiva were investigated. Mixed linear model was adopted to analyze the influence of radiation and skin paddle on marginal bone loss and peri-implantitis.The incidence of peri-implantitis in implants placed through the skin flaps was higher (32.7%) than that of implants placed through the oral mucosa (8.7%). According to the mixed linear analysis, no significant difference in the amount of marginal bone loss was observed between the 2 groups: implants placed through the skin graft had marginal bone loss of 0.39 ± 0.14 mm at 1 year and 0.50 ± 0.23 mm at 5 years, and implants placed through the oral mucosa had marginal bone loss of 0.32 ± 0.12 mm and 0.52 ± 0.21 mm at the same time intervals. The 1-year and 2- to 5-year cumulative survival rates of the implants placed through the skin were 100% and 98%, respectively, and those of implants placed through the oral mucosa were both 95.65%. The 1-year and 2- to 5-year cumulative success rates of the implants placed through the skin were 92.30% and 79.38%, respectively, and those of implants placed through the oral mucosa were 91.30% and 82.59%, respectively.Implants can be successfully placed and maintained in lining defects covered with a skin paddle; hence, this treatment modality may be considered reasonable and reliable for the functional and aesthetic rehabilitation of patients with oromaxillofacial reconstructions.

Medication-and especially Bisphosphonate-related osteonecrosis of the jaw (MRONJ/BRONJ, also known as bisphosphonate-induced osteonecrosis and antiresorptive drug-induced osteonecrosis) is considered a therapy-resistant form of osteonecrosis. Despite this conservative and surgical treatment, regimens have been attempted and recommended in the years since it was first identified.

Background Composite defects of the oral cavity are often the result of trauma or advanced-stage tumor extirpation. The resultant deformity frequently requires a three-dimensional reconstruction of bone and soft-tissue. The fibula free flap is the preferred method of reconstruction, with various modifications focused on providing supplemental soft-tissue coverage. The objective of this study was to ascertain both anatomic and clinical data regarding the proximal peroneal perforator and its contribution to the evolution of the fibula free flap. Methods Ten cadaver lower extremities were dissected to isolate the most proximal perforator supplying skin over the proximal lateral lower leg. Data were recorded regarding perforator presence, location, and course. Furthermore, review of clinical cases in which the proximal perforator was used in fibula free flap design was performed for operative data collection. Results Cadaveric dissections revealed the proximal perforator to be present in 90 percent of specimens. Most commonly, the perforator, originating from the peroneal artery, traveled a short intramuscular course through the soleus muscle prior to supplying the overlying skin. In all clinical cases, the perforator was easily located with Doppler prior to incision, and there were no cases of flap failure or skin paddle loss. Flap inset was found to be optimal in all cases, with no tethering or undue tension. Conclusions The proximal peroneal perforator was found to be anatomically reliable and clinically useful in composite oral cavity reconstruction following tumor removal. The gained separation between skin paddles allows for greater versatility in flap design and inset. Clinical question/level of evidence Therapeutic, IV.

The anterolateral thigh (ALT) free flap has become the most widely used fasciocutaneous free flap for head and neck reconstruction.1 However, there has been no report demonstrating the indications or options for increasing arterial inflow and venous outflow to an ALT flap based on separate vascular pedicles. The overall size of the ALT flap is dependent on the number and location of perforators. Large series of ALT free flaps report flaps with average dimensions of approximately 8 × 23 cm.2 What remains uncertain is the maximum dimensions of an ALT flap that can be harvested based on a single perforator. Moreover, given that the perforators of the ALT flap sequentially arise from the descending branch of the circumflex artery as it descends down the thigh, it is likely that a long ALT flap can be more reliably harvested than a wide ALT flap. Multiple skin islands can also be created from an ALT flap either with a strip of de-epithelialization between the 2 skin islands or with complete division of the skin paddle if 2 separate perforators exist, each supplying a separate island of skin. The purpose of this article is to introduce the options and indications for supercharging and venous augmenting an ALT flap when confronted with an extensive head and neck defect that may not reliably be reconstructed with a routine ALT flap based on a single perforator.

Complicated hand and wrist defects require durable and pliable tissues which are offered by flaps, instead of skin grafts. Various dorsoulnar flap options have been used in the regional flap armamentarium of the upper limb. Poor venous drainage may be a considerable handicap when moderate to large skin paddle dorsoulnar flaps are used. In the present case, we aimed to reduce the risk of necrosis by supercharging the dorsoulnar island flap. The current literature regarding dorsoulnar island flap has also been reviewed with focus on this flap. This technique has successfully been used for a complex wrist defect in a 48-year-old man. Postoperative follow up was one year. The flap survived completely with perfect hand function. We think this modification can prevent possible venous stress in the pedicled and free dorsoulnar flaps by obtaining extraveneous drainage. The method is simple, does not need sophisticated microsurgical procedure and longer operative time.

Occasionally, the aesthetic contour of a musculocutaneous flap can be improved by using the skin paddle as a full-thickness skin graft to cover the free muscle flap. In three patients, traditional musculocutaneous free flap coverage of wounds would have resulted in excess soft tissue bulk. To optimize final contour, the subcutaneous tissue was excised, and the skin replaced as a full-thickness skin graft. Problems with postoperative flap monitoring and skin graft take were not encountered. This technique offers the microsurgeon a simple method to optimize the aesthetic results of composite free tissue transfer.

Objective To describe the anatomical relationship of the sural sensory nerve complex to the posterior crural intermuscular septum (PS), the key anatomical structure for the osteoseptocutaneous fibula skin paddle. Design Anatomical study. Subjects Twenty-two legs from 11 cadavers (7 females and 4 males). Results The lateral sural cutaneous (LSC) nerve, present in 20 of 22 legs, divides into lateral and medial branches near the head of the fibula. The LSC nerve and its medial branch course away from the PS, whereas the lateral branch tends to course toward the PS. The lateral branch courses nearest to the PS at a median distance of between 4 cm proximally and 3 cm distally. The medial branch of the LSC nerve terminates approximately in the middle of the leg, and the lateral branch of the LSC nerve terminates within 7 cm below the head of the fibula. The peroneal communicating branch is thicker than the LSC nerves; however, it is further from the PS in the upper leg. Conclusions The LSC nerve is the most consistent and accessible donor sensory nerve in the posterior leg for harvest with the osteoseptocutaneous fibula free flap. Results of this study will assist the surgeon in harvesting a sensory nerve with the osteoseptocutaneous fibula free flap, bringing this potentially sensate flap into more common use.

This study was undertaken to determine whether a less extensive delay procedure would be as efficacious as the standard delay procedure in breast reconstruction.Between July 1996 and February 1999, 15 patients underwent delay procedures prior to breast reconstruction. Six patients underwent the standard delay procedure. Nine patients underwent a less extensive skin delay procedure. Transverse rectus abdominis myocutaneous (TRAM) reconstruction was performed 1 week after delay procedures.Average operating time was 28.7 minutes for the standard delay and 19.7 minutes for the skin paddle delay. The incidences of fat necrosis were 17% in the standard delay group and 22% in the skin paddle delay group. The incidences of partial flap loss/slow healing were 17% in the standard delay group and 22% in the skin paddle delay group. The incidence of complications in each group was the same: approximately 1 per patient.Operating times were not statistically different between the two groups (p = 0.06). There was no increase in the incidence of slow healing/partial flap loss or fat necrosis in the skin delay group. The skin delay procedure for TRAM flaps seems to provide a concise delay procedure that does not increase the incidence of complications in those high-risk patients.

Pharyngeal reconstruction can be accomplished in a variety of ways, from pedicled to free revascularized tissue transfers. The use of an extra skin paddle combined with a buried radial forearm flap, which permits long-term postoperative monitoring under direct vision, has been described before. In this study, we monitored nine patients who had undergone pharyngeal reconstruction with a buried reversed radial forearm flap. Our modified technique gave better coverage of the large vessels and a better postoperative neck contour, prevented esophageal leakage and facilitated continuous postoperative patient monitoring, without any significant additional donor site morbidity.

The free osteocutaneous fibula flap is an established method of reconstruction of maxillary and mandibular defects. The vascularity of the skeletal and the cutaneous components is provided by the peroneal artery via the nutrient artery and the septo- and musculocutaneous perforators. In rare situations, these perforators may arise from other major leg arteries. In such circumstances, the procedure has to be either abandoned or modified so that neither the vascularity of the flap nor the donor limb is compromised. We present a case of an anomalous musculocutaneous perforator, which originated from the proximal part of the posterior tibial artery, passed through the soleus muscle and supplied the skin paddle. The flap was elevated as a single composite unit and was managed by two separate vascular anastomosis at the recipient site, one for the peroneal vessels and the other for the anomalous perforator.

The vascularization of the skin paddle of 20 osteocutaneous fibula free flaps in 20 patients was studied. All skin paddles were designed over the proximal and middle third of the fibula. A parallel vascularization of the skin was found in 10 cases. In these cases, an axial (septo)musculocutaneous perforator was found to originate high in the peroneal artery or even in the popliteal artery. This branch runs parallel to the peroneal artery without any further connections with it. In 5 of these 10 cases, no other skin perforators were located within the boundaries of the skin paddle. Harvesting such a flap in the traditional way by blind inclusion of a muscle cuff results in ligation of the supplying vessel of the skin paddle and subsequent loss of the skin. In this series, this would have been the case in 5 of the 20 patients (25 percent). This might explain the bad reputation of the skin paddle of this flap. The high prevalence of the described vascular configuration in a proximally designed skin paddle justifies à vue dissection of all musculocutaneous perforators up to their origin, unless one or more septocutaneous perforators are found within the boundaries of the flap.

Although the free transverse rectus abdominis musculocutaneous (TRAM) flap provides for excellent breast reconstruction, it is not available to all surgeons for many reasons. The delayed unipedicled TRAM flap, based on the deep superior epigastric (DSEA) vessels, however, is a simple technique that caters to everyone. The superficial (SIEA) and deep inferior epigastric (DIEA) vessels are ligated via a lower transverse incision 1 week before the definitive transfer. The delayed flap is used when a skin paddle is required, which extends for more than several centimeters beyond the underlying rectus muscle on the ipsilateral side. It provides a flap with viability similar to the free TRAM flap based on the DIEA stem.

The use of a new technique for harvesting of the pectoralis major muscle in the reconstruction of locally recurrent breast cancer is presented and illustrated in two cases. This technique provides the versatility of the myocutaneous flap but avoids the significant donor site morbidity and unreliability of the skin paddle.

The flag flap is a pedicled dorsal digital flap, combining a skin paddle (the “flag”) and a vascular pedicle (the flag “pole”). Its vascularisation depends on the dorsal metacarpal arteries (DMCA). It has been described in 1963, by Holevitch [1] with harvest of a cutaneovascular pole; it has been brilliantly modified in 1979 by Foucher et al. [2–4] under the form of a unipedicled “kite” flap, although we would like to point out that Vilain has been using it since 1952 [5]. Usually harvested from the dorsum of the metacarpophalangeal region of the index finger, this flap is reliable, but it is more uncertain and less movable at the level of the other digits. Owing to its small size, it proves useful in hand traumatology because it does not sacrifice any major vascular axis. The kite flap is considered as a sensory flap (presence of a nerve supply) with a two-point discrimination, which can be assessed from 11 to 16 mm [1–6].

The inferiorly based rectus abdominis myocutaneous flap, developed by Taylor, is a reliable flap which when raised spares the anterior sheath of the muscle below the arcuate line. The muscle can fill an infected, hypovascular wound and the extensive skin paddle can cover a large cutaneous loss of substance, so the flap is perfectly suited to coverage of recurrent pressure sores in paraplegic patients. We used 11 flaps in 10 paraplegic patients for recurrent pelvic pressure sores which were ischial in six cases, trochanteric in four and sacral in one. We describe the operative technique and stress the importance of using an extraperitoneal, intrapelvic and transiliac approach. Healing was obtained in all cases without functional deficit of the abdominal wall (no abdominal herniation, one contour deformity). This flap offers two further options for treatment of recurrent pelvic pressure sores whatever their location and its indications are more and more frequent in an aging population of paraplegic patients.

Purpose: The authors analyze the advantages and disadvantages of mandibular reconstruction with a fibula free flap in a retrospective study of 29 cases, and make comparisons with the iliac free flap and the lateral brachial free flap. Material and Methods: Twenty-nine patients (22 male, 7 female) aged 5 to 70 years were studied. Functional and esthetic evaluations were performed together with radiologic examination of the bony calluses. Results: The fibula free flap has advantages for mandibular reconstruction, such as the length of bone available, low morbidity of the donor site, and the possibility of using a skin paddle. However, there is the disadvantage of not being able to reconstruct large soft tissue defects. In addition, bone vascularization is reduced when a large number of osteotomies are required. Conclusion: This reconstruction technique is satisfactory for mandibular defects measuring over 20 cm.

This paper reports the platysma myocutaneous flap that has been modified to be directed transversely across the midportion of the neck, with its blood supply from the posterior cervical triangle. Seven flaps have been used to reconstruct wounds of the ear, cheek, and lips in six patients. One flap had a partial skin paddle loss when the flap was harvested from the neck of a patient who had had two previous surgical wounds to the neck and may represent an alteration of the blood supply secondary to surgical scarring. The remaining six flaps were robust, and all healed without complications.

Introduction Pectoralis muscle flap is one of the most common regional flap used in orofacial reconstruction. Mobilization of pedicle and reach of the skin paddle is a technical consideration. Method Based on the anatomical difference in blood supply to clavicular and sternal head, we elaborate a tecnique to maximise the length of pedicle in maxillofacial reconstruction. Conclusion The proposed technique is reproducible and reliable and possibly increase the indications of usage of the flap.

Background In case of composite cranial defect including the dura mater, the cranial bone, and the scalp, the fascial component of the anterolateral thigh flap can be used for dural reconstruction. However, the advantages and applications of the fascial component depending on the type of defect have not been thoroughly discussed. We made the algorithm for reconstruction of composite cranial defects using the fascial component of free anterolateral thigh flaps. Patients and methods Six cases of composite cranial defects were reconstructed using free anterolateral thigh flaps with the fascial component. The type of method used was classified into 3 types. Type 1 involves separating the fascia from the flap completely and using it as a nonvascularized component. In type 2, the fascia is not separated from the flap and is instead used as a vascularized component. Type 3 involves separating the vascularized adipofascial component from the skin paddle and using it as a chimeric pattern flap. The algorithm for determining the type of fascial component is applied depending on the condition of the defect. Results All flaps were transferred successfully in every case. In 4 cases, the type 1 method was used. The type 2 and 3 methods were used in 1 case each. Cranial bone reconstruction was performed in 3 cases. There were no major complications after the procedures. Conclusions The fascial component is useful for dural reconstruction. The type of fascial component used is selected depending on the condition of the defect.

Lip reconstruction is challenging even for an experienced surgeon in that the lips play a major esthetic and functional role in the lower third of the face. Fullness of the lips symbolizes beauty particularly in females in many cultures. The lips provide an oral aperture where food is first introduced into the gastrointestinal tract and initiate peristalsis in coordination with the tongue and the palate by closing of the mouth. They also participate in articulation of speech and expression of intimacy and serve a crucial role in human interactions. Without the proper functioning of the lips, purely labial consonants (b, p, m, and w) and dentolabial consonants (f and v) cannot be pronounced.

The vascularized iliac osteocutaneous flap has been used successfully for jaw reconstruction. To obtain a better contour of the reconstructed area in large upper and lower jaw resections, the transferred bone actually needs to be osteotomized. Single closing-wedge osteotomy of the iliac flap for mandibular reconstruction has been previously described. In this article, the modified multiple osteotomized perforator-based versatile free iliac osteocutaneous flap is described. Eleven cases were enrolled. Seven patients had wide anterior mandibular resections due to oral cavity and mandibular tumors; 3 patients had a defect due to explosive injury and 1 patient had complicated orbitomaxillary defect due to blast injury. Skin paddle was based on the perforators. In 8 patients, the bony segment was divided into 3 segments by 2 osteotomies, whereas in 2 patients the bony segment was divided into 4 segments by 3 osteotomies. In 10 cases, the flap was used for anterior mandibular defects, whereas in 1 case the flap was customized to fit an L-shaped defect at the naso-orbito-maxillary region. The overall flap success rate was 100%. No resorption or morbidity related to the osteotomy of the bony segments was observed. The size of perforator skin paddle was 6 to 8 × 15 to 18 cm. Physical and radiologic examinations showed proper bone healing without any additional complications. The modified multiple osteotomized free osteocutaneous iliac flap can provide a safe and versatile bony segment to be arranged and adapted to reconstruct complex mandibular and maxillofacial defects.

BACKGROUND The fibula flap has been widely used for reconstruction of composite bone and soft-tissue defects. The skin paddle of the fibula flap has played a critical role in providing a cutaneous component and good monitor for the bone component. In this report, the authors designed a perforator-based sural neurocutaneous flap instead of a peroneal perforator flap to enlarge a skin paddle for wound coverage. METHODS A novel chimeric flap was harvested based on the peroneal artery, and consisted of a sural neurocutaneous flap and a fibular graft. The sural neurocutaneous flap was elevated based on a single peroneal perforator and connected with the bone component by means of the peroneal artery. Two patients with complex bone and soft-tissue defects were treated by using this chimeric flap. In case 1, the radius defect was 8 cm in length and the soft-tissue defect measured 23 × 10 cm. In case 2, the distal radius was injured and the defect was 16 cm in length. The area of soft-tissue defect was 23 × 8 cm. In this case, the fibula head was used for wrist reconstruction. The soft-tissue defects in the two cases stretched across the palmar and dorsal surfaces of the forearm. RESULTS The lengths of the bone components were 10 and 16.5 cm, respectively, and the areas of the skin components were 24 × 12 cm and 25 × 10 cm, respectively. Both chimeric flaps survived completely without complications. The follow-up period was 42 months in case 1 and 16 months in case 2. Complete bone union was observed in both cases, and no remarkable degeneration of the fibular head occurred in case 2. The sural neurocutaneous flap showed good texture match and contour. No serious donor-site complications occurred. The two patients were satisfied with their daily lives relative to the severity of their injuries. CONCLUSION The chimeric flap composed of a sural neurocutaneous flap and a fibular graft by means of the peroneal artery is a good candidate for reconstruction of long bone defects associated with extensive soft-tissue defects in the extremities.

The purpose of this study was to evaluate the outcomes of second salvage surgery with extended vertical lower trapezius island myocutaneous flap (TIMF) reconstruction for patients with re-recurrent oral cavity and oropharyngeal squamous cell carcinoma (SCC). The subjects were 23 patients with advanced re-recurrent oral and oropharyngeal SCC undergoing second salvage surgery and reconstruction with a TIMF. A TIMF with a skin paddle measuring 6 cm × 7 cm to 10 cm × 22 cm was used to reconstruct the major defects. Three patients experienced minor complications: minor flap failure ( n = 1), wound dehiscence at the donor site ( n = 1), and an orocutaneous fistula ( n = 1). The patients were followed for 3–72 months. Fifteen patients were alive with no evidence of disease, two were alive with disease, and six died of local recurrence or distant metastases. Second salvage surgery remains an effective treatment modality for select patients with advanced re-recurrent oral and oropharyngeal SCCs, and the extended vertical lower TIMF is a large, simple, and reliable flap for reconstructing the major defect following second salvage surgery.

Summary Background It is reported that the salvage rate of free flaps is inversely related to the time interval between the onset of pedicle impairments and their clinical recognition. Monitoring of free flaps is therefore of major importance and clinical monitoring remains the most used technique because of lack of low-cost and non-invasive techniques. The authors suggested an efficient, simple and cheap technique to detect early thrombotic events in monitoring free flaps with skin paddle. Methods In this multicentre prospective study, measurements of capillary glucose and lactate in the flaps were done. These parameters were compared to standardized clinical monitoring during the first five days. Two sets of data (eventful versus uneventful postoperative period) were analyzed to define the thresholds of lactate and glucose values for diagnosis of pedicle complications, and to establish parameters for this screening test. Results Over a period of 19 months, 37 patients were included. With 5 pedicle impairments, complication thresholds were defined as lactate ≥ 6.4 mmol L−1 and glucose ≤ 3.85 mmol L−1, in order to obtain a sensitivity of 98.5% and a specificity of 99.5% for the test. Modifications of capillary glucose and lactate measurements appeared in average 5.7 hours earlier than clinical symptoms in pedicle impairments. The mean cost of a five-day monitoring was about 90 USD. Conclusion This simple and cheap technique could be used as a routine technique in monitoring free flaps to improve safety of this reconstructive technique.

The anterolateral thigh flap is currently the frontline choice for head and neck reconstruction. The authors used a chimeric anterolateral thigh flap for reconstruction of a through-and-through oropharyngeal defect. Because of the absence of suitable recipient vessels in the proximity of the defect, the authors recruited the internal mammary vessels. To gain extra pedicle length, the authors converted the chimeric anterolateral thigh flap into a sequential iatrogenic chimeric anterolateral thigh flap. This new flap concept consists essentially of the division of the skin paddle of the anterolateral thigh that is based on two perforators, and the creation of a sequential chimeric flap by reconnecting the pedicles in the opposite order. A functionally good and aesthetically pleasing result was obtained.

The main drawback of the latissimus dorsi myocutaneous flap for large defect repairs is the relatively small skin paddle size that can be raised to allow primary closure of the donor site. In this article, the authors describe a novel design of the flap using multiple separate skin paddles, with each paddle nourished by independent perforators, to repair very large defects while maintaining primary donor-site closure.After the size of the defect was calculated, its total area was split into two or three skin paddles and marked on the back skin so that the largest width of each paddle did not exceed 8 cm. A multilobed skin paddle was designed with a total area that was much larger than traditional latissimus dorsi flaps. After harvesting the flap, several smaller skin paddles were transferred and rejoined at the recipient site.From June of 2009 to March of 2012, this method was used to restore posttraumatic and postoncologic defects of the head in seven cases and lower limb defects in two cases. Seven flaps were raised as bilobed flaps, and two flaps were raised as trilobed flaps. The donor site was closed primarily in all cases. One case was complicated by partial necrosis of one paddle and required further local flap coverage. Donor-site breakdown was not observed in any of the cases.The multilobed myocutaneous latissimus dorsi flap enables a customized reconstruction of large defects for all types of patients and direct closure of the donor site.Therapeutic, IV.