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The double free flap procedure is a preferred treatment for extensive composite defects of the oromandibular area. In this procedure, the choice and use of the flaps are both important. Flaps with adequate soft tissue are required to fill the extensive dead space for huge oromandibular defects. Such flaps, however, tend to sink and droop with time because of gravity, resulting in poor functional and aesthetic results. Here, the authors describe a procedure that avoids flap sinking and drooping, using a vascularized fibular osteocutaneous flap, which is well established for mandibular bone defects, and a rectus abdominalis musculocutaneous flap, which has a lot of soft tissue and a firm anterior rectus sheath. This method was used in 2 patients with extensive composite defects of the oromandibular area. In a patient with resection of the mobile tongue and oral floor, the anterior rectus sheath was fixed to the fibula and mandible to give a mylohyoid muscle-like structure, to prevent sinking of the reconstructed oral floor and tongue. Good swallowing function was maintained. In a patient with defects transversally from the submandibular region to the cheek, the sheath was fixed to the zygomatic arch to prevent cheek drooping. An acceptable aesthetic result was obtained.

Sternal wound infections after sternotomy are associated with high morbidity, high mortality and escalating treatment costs. Repeated radical debridement - with the removal of any hardware - and wound conditioning are the prerequisites for reconstruction. Muscle and, less frequently, omentum flaps are usually used for reconstruction. However, these flaps are associated with considerable donor-site morbidity, long operation times and aesthetic impairment. Fasciocutaneous flaps seem to be an alternative. This study presents our experience of using the second intercostal mammary artery fasciocutaneous perforator flap for defect closure in nine patients (mean age: 70.2 years). Following a retrospective chart review, we assessed data on patient demographics, the type of cardiac surgery, the prevalence of deep sternal wound infection (DSWI) risk factors, identified pathogens, surgery duration, hospitalization tim patients had undergone coronary artery bypass surgery, and two had valve replacements. The mean duration of surgery (121.4 ± 39 min) was short. The patients had a mean body mass index (BMI) of 32.8 ± 4.9 kg/m(2). An average flap size of 124 ± 22 cm(2) sufficiently covered and obliterated each defect. One mediastinal haematoma required revision surgery. One wound dehiscence at the flap and two at the donor site were managed conservatively. Our experience reveals that a fasciocutaneous flap based on the second intercostal perforator of the internal mammary artery can be an alternative, quick-to-prepare flap for covering sternal defects. In adipose patients, it has sufficient bulk, and it is large enough to cover common sternal wounds. It also has low complication and morbidity rates, and it achieves an aesthetically pleasing result., (Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Soft-tissue defects in posterior skull can be challenging for reconstruction. If related to tumor resection, these wound beds are generally irradiated and can be difficult from a recipient-vessel perspective for a free tissue transfer. Locoregional flaps might prove to be important reconstructive option in such patients. There is a very limited data on the usage of pedicled trapezius myocutaneous flaps for such defects., Methods: The authors reviewed existing study for usage of trapezius flap for posterior skull repair and used pedicled trapezius myocutaneous flaps based on the descending branch of superficial cervical artery (SCA) for reconstruction of posterior skull soft-tissue defect in an irradiated and infected wound., Results: Two patients were operated for trapezius myocutaneous flap for posterior skull defects complicated by cerebrospinal fluid (CSF) leakage and epidural abscess. There was no recipient or donor-site complication at a mean follow-up of 12.5 months. Neither of the 2 patients had any functional deficits for the entire duration of the follow-up. Although this flap was able to help in controlling the CSF leakage in the first patient, it successfully healed the cavity generated from epidural abscess drainage in the second patient., Conclusion: The large angle of rotation coupled with the ability to complete the procedure without repositioning the patients makes trapezius myocutaneous flap an attractive option for posterior skull reconstruction. In our limited experience, the pedicled trapezius flaps are a reliable alternative as they are well vascularized and able to obliterate the soft-tissue defect completely. The recipient site healed completely in infected as well as irradiated wound beds. In addition, the donor site can be primarily closed with minimal donor-associated complication.

Background: Outcomes in management of compound tibial fractures are measured by the rate of infection and non-union. These are a function of many variables that interact in complex ways. Our aims are to describe changes in these injuries over the past decade, to determine which variables predict a poor outcome and to compare reconstructive options controlling for these variables., Methods: All compound tibial fractures reconstructed at the Princess Alexandra Hospital from 1999 to early 2009 were reviewed retrospectively. The remainder of 2009 and 2010 were reviewed prospectively. Data were collected from departmental audits, medical records and imaging., Results: 251 flaps were performed in 235 patients. Reconstructions within one week declined after 2000, which correlated with increasing Negative Pressure Dressings use (R = 0.77). Free flap use increased though the incidence of distal fractures did not (R = 0.29). Muscle flaps were consistently preferred. Injuries with a poor outcome had a greater delay or failed soft tissue reconstruction. A poor outcome was more likely in patients with a contaminated distal fracture (p = 0.0038). Outcomes in muscle and fasciocutaneous flaps were not significantly different., Conclusions: Compound tibial fracture management has evolved to temporary followed by definitive fixation. Free flap use has increased, particularly in diaphyseal injuries. Delays in reconstruction should prompt aggressive surgical management. Injuries at risk of a poor outcome can be further characterised as being distal and contaminated. Reconstructive surgeons should not be discouraged from using muscle flaps. A management algorithm based on the evidence provided is presented., Level of Evidence: Therapeutic III., (Crown Copyright © 2015. Published by Elsevier Ltd. All rights reserved.)

The palmar and digital volar skin is unique because of its glabrous nature, texture and light colour in all races. Any defect on the palmar surface not suitable for a homodigital or thenar flap remains a challenge for reconstructive surgeons. Various skin flaps have been described in the literature for palmar resurfacing. They all provide wound cover and may even match the contour satisfactorily, however, the colour and texture mismatch compromises the aesthetics of reconstruction. In our experience, the free instep flap is a more appropriate choice for palmar and volar digital resurfacing. It provides glabrous, potentially sensate, hairless skin with a better colour and texture match compared to conventional pedicled or free flaps in all cases. This paper describes our refined flap raising technique, the possibility of a neurotisation and discusses the role of the free instep flap for idealised digital and palmar resurfacing. It can provide a truly cosmetic microsurgical reconstructive option., (Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Complex traumatic upper extremity injuries frequently possess compromised local vasculature or extensive defects that are not amenable to local flap reconstruction. Free tissue transfer is required to provide adequate soft tissue coverage. The present study aimed to evaluate risk factors that contribute to postoperative complications and flap loss in complex upper extremity reconstruction., Methods: Retrospective chart review was performed for all patients undergoing free tissue transfer for upper extremity reconstruction from 1976 to 2001. Data collected included patient demographic characteristics, timing of reconstruction, location of injury, fracture characteristics, operative interventions, and postoperative complications. Statistical analysis was performed using χ(2) and Fisher exact tests., Results: In total, 238 patients underwent 285 free tissue transfers and met inclusion criteria, from which 3 were excluded because of inadequate information (n = 282). Extremities were repaired within 24 h (75 cases; 27%), in days 2-7 (32 cases; 12%), or after day 7 (172 cases; 62%). Timing of reconstruction did not significantly affect postoperative outcomes. Proximal location of injury was significantly associated with superficial (relative risk [RR], 6.5; P < .01) and deep infection (RR, 5.3; P < .01), and osteomyelitis (RR, 4.0; P < .01), although not with flap failure (P = .30). Presence of an open fracture was significantly associated with developing superficial (RR, 3.1; P = .01) and deep (RR, 1.9; P < .01) infection, as well as osteomyelitis (RR, 1.6; P < .01). Having a closed fracture did not negatively influence postoperative outcomes., Conclusions: This study supports the safety of early free tissue transfer for reconstruction of traumatized upper extremities. Injuries proximal to the elbow and open fracture were associated with a significantly higher infection rate. Gustilo grade IIIC fractures, need for interpositional vein grafts, and anastomotic revision at index operation resulted in significantly higher risk of flap loss, whereas the presence of fracture, fracture fixation, and injury location were not predictors of flap failure., (Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: The authors present the posteromedial thigh flap as an alternative source for head and neck reconstruction, and the perforator patterns and vascular anatomy of this flap were further investigated., Methods: From March to August of 2014, 23 patients underwent head and neck reconstruction with 23 posteromedial thigh flaps. The numbers, locations, and types of perforators were measured. The surgical technique and the results after reconstruction were evaluated., Results: Most perforators were located 8 to 10 cm away from the pubic crease on the reference line between the perineum and the insertion of the semitendinosus muscle. The average number of perforators was 1.7 (range, 1 to 3), and the average pedicle length was 10.3 cm (range, 8 to 13 cm). Eighty percent of the perforators (32 of 40) were musculocutaneous, and 20 percent (8 of 40) were septocutaneous. Ninety-five percent of the perforators (38 of 40) originated from the profunda femoris artery, and 5 percent (two of 40) originated from the medial circumflex femoral artery. The flap survival rate was 95.6 percent; one flap failed due to pedicle thrombosis. The donor sites were all closed primarily., Conclusions: The location of the perforators of the posteromedial thigh flap is consistent, and the pedicle length is sufficient to reach the neck region. Different reconstruction demands can be met by incorporating various soft-tissue components. The donor-site scar is well concealed, with minimal morbidity. The above advantages make the posteromedial thigh flap an excellent option for head and neck reconstruction., Clinical Question/level of Evidence: Therapeutic, IV.

The Keystone Design Perforator Island Flap is a fasciocutaneous perforator flap resembling two end-to-end VY flaps. We used a modification of the original design to avoid extending the incision into an elliptical pattern, and maintained a trailing skin bridge whilst incising fascia in a tunneling fashion. Thirty patients underwent 32 flaps mainly on the lower leg to close defects that would traditionally require skin grafting. All flaps survived completely, with minor complications in four patients. All but five patients were allowed unrestricted ambulation after surgery. The modified design is straightforward to learn, has reliable perfusion, and provides a simpler recovery for patients., Clinical Questions/level of Evidence: Therapeutic, IV.

Background: Squamous cell carcinoma (SCC) is a fairly common tumor of the oral cavity. This tumor may affect any part of the mucosa of the oral cavity especially the tongue, the floor of the mouth and lips. The encountered intra-oral defects after tumor resection are often large and require climbing up the reconstruction ladder to more complex reconstructive options for accepted functional and cosmetic results to be achieved. However, most of the patients are old with medical co-morbidities requiring fast, simple, less morbid reconstructive option such as local flaps. The myocutaneous submental island flap has emerged as a simple and fast reconstructive technique that provides thin, pliable tissue with adequate volume and reliable blood supply. However, one major concern regarding the utility of the submental flap for repair of post-ablative tumor defects is the presumed interference with adequate lymph node neck dissection., Methods: In this study, we present a cohort of thirty-six consecutive patients who were operated for oral SCC. All patients were offered submental island flap reconstruction of their resultant defects together with ipsilateral selective neck block dissection of levels I, II, III and IV; and the nodal yield of each level was tested pathologically., Results: Nodal harvest was ≥ 12 in 88 % of the patients. Complications were encountered in two patients (5.5 %)., Conclusion: Our data suggest that adequate cervical lymph nodes dissection, specifically level I and II cervical lymph nodes, can be fulfilled with concomitant submental island flap elevation.

Purpose: To evaluate the feasibility and reconstructive efficacy of the thinned anterolateral thigh (ALT) flap for the reconstruction of head and neck defects., Patients and Methods: A retrospective review was performed of 43 patients who had undergone reconstruction of head and neck defects with a thinned ALT flap from January 2009 through December 2013 at the Second Xiangya Hospital. The methods for flap thinning and defect reconstruction and reconstructive efficacy are reported., Results: The flaps were 5 cm × 7 cm to 9 cm × 14 cm, and all were harvested from a single cutaneous perforator. Postoperatively, 40 flaps survived completely and 3 flaps experienced partial necrosis. Venous compromise occurred in 2 cases, both of which were salvaged after operative exploration. Of the 43 donor sites, 41 were closed directly and resulted in only linear scars, and 2 were closed using full-thickness skin grafts because the defect was larger. All the patients were followed for approximately 6 to 36 months, and they were satisfied with the esthetic and functional results of the donor and recipient sites after reconstruction., Conclusion: With the high success rate of flap transplantation, satisfactory functional and esthetic results, and lower complication rates at the donor and recipient sites, the use of thinned ALT flaps can be a good choice for the reconstruction of head and neck defects in obese patients., (Copyright © 2015 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Until recently, no single, universally accepted surgical method has existed for all types of concealed penis repairs. We describe a new surgical technique for repairing concealed penis by using an advanced musculocutaneous scrotal flap., Methods: From January 2010 to June 2014, we evaluated 12 patients (12-40 years old) with concealed penises who were surgically treated with an advanced musculocutaneous scrotal flap technique after degloving through a ventral approach. All the patients were scheduled for regular follow-up at 6, 12, and 24 weeks postoperatively. The satisfaction grade for penile size, morphology, and voiding status were evaluated using a questionnaire preoperatively and at all of the follow-ups. Information regarding complications was obtained during the postoperative hospital stay and at all follow-ups., Results: The patients' satisfaction grades, which included the penile size, morphology, and voiding status, improved postoperatively compared to those preoperatively. All patients had penile lymphedema postoperatively; however, this disappeared within 6 weeks. There were no complications such as skin necrosis and contracture, voiding difficulty, or erectile dysfunction., Conclusions: Our advanced musculocutaneous scrotal flap technique for concealed penis repair is technically easy and safe. In addition, it provides a good cosmetic appearance, functional outcomes and excellent postoperative satisfaction grades. Lastly, it seems applicable in any type of concealed penis, including cases in which the ventral skin defect is difficult to cover.

In concert with advances in surgical reconstruction techniques and improved survival after breast cancer, both the aesthetic and functional outcomes, especially sensory recovery, of breast reconstruction have been addressed. Most studies on sensory recovery in reconstructed breasts have utilized patients' subjective responses to touch, pain, temperature, and pressure. In contrast, this report describes a case of herpes zoster that developed in a free transverse rectus abdominis myocutaneous flap, which provides objective evidence of spontaneous reinnervation after breast reconstruction.

Introduction: Breast conservative surgeries, associated with radiotherapy within the framework of conservatives treatments for breast malignant tumors, can occur deformation of the breast in 10 to 15% of cases. The deformity can be more or less important according to the size of the initial lesion and the glandular reshaping reconstruction. Our experience in oncologic and reconstructive surgery of the breast reflects us about difficult cases of breast conservative surgeries in a glandular reshaping to obtain the best aesthetic result. In this approach, the posterior glandular flap of the breast was used in specific indications. The study aims to estimate the efficiency and the tolerance of the posterior glandular flap in difficult cases of breast oncoplastic surgeries., Material and Methods: We realized a consecutive serie of 24 breast oncoplastic surgeries. We noticed 15 breast conservative surgeries of superior quadrants. The posterior glandular flap was realized in 15 cases. We used the posterior part of the breast, vascularized by musculo-cutaneous intercostal arteries to give the volume lacking in the breast. We estimated efficiency and tolerance of the posterior glandular flap than one-year operating comment, as well as the oncologic follow-up long-term., Results: In this serie of 15 cases, we did not note acute complications like infection, hematoma or cutaneous necrosis. We listed 13 cases of malignant tumors with indication of radiotherapy, and 2 cases of benign tumors. In one year, we found two patients presenting a cyst of cytosteatonecrosis (1cm and 3cm) in the site of surgery, compared to posterior flap. The glandular total average excision was 333g (30-1200). An oncologic surgical resumption was necessary in 2 cases (a case of preventive mastectomy for BRCA1, and a case of insufficient margins). We realized 12 cases of controlateral surgery at the same time for symmetry. The aesthetic result was judged at one year post-operatory: good or very good in 74% of the cases, correct in 20% of the cases, and insufficient in 6% of the cases. The oncologic follow-up did not find locoregional recurrence., Conclusion: The posterior glandular flap is an interesting contribution in oncoplastic surgery of superior quadrants of the breast to replace harmoniously the missing volume. This flap, reliable and reproductible, offers an alternative to bring of the custom-made volume without residual deformation of the breast. The aesthetic results allowed, in spite of the radiotherapy, to decrease the aftereffects of breast conservative surgery treatments, and this interesting approach deserves a wider distribution., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Evisceration of the pelvic organs (EPO) is a fairly uncommon surgical treatment that removes all organs from a patient's pelvic cavity. We use gracilis musculocutaneous flap to repair pelvic floor after EPO. Over the period from November 2013 to December 2014 we carried out EPO with reconstructive repair of the pelvic floor with gracilis musculocutaneous flap in 10 patients with locally advanced pelvic tumors. We describe the surgical procedure and surgical outcomes in these patients. Mean age of the patients was 55 years. Mean duration of EPO with the pelvic floor repair was 285 min., mean blood loss--595 mL and the average length of hospital stay--19 days. Gracilis musculocutaneous flap has a sufficient arterial supply and mobility for pelvic floor reconstruction. Necrosis of flap's distal edge occurred in one of the 10 clinical cases, while the remaining flaps were fully preserved. Complete healing of wounds with no signs of weakening of the pelvic floor muscles was observed in all cases. Pelvic floor reconstruction is an essential procedure in order to reduce complications associated with the evisceration of the pelvic organs. The Gracilis musculocutaneous flap is the logical alternative to repair pelvic floor defect. It does not contribute to complications like functional deficiency of the lower limbs, complications of stoma formation or weakening of the muscles of the anterior abdominal wall.

Objectives: Successful management of post-resection bronchopleural fistula (BPF) is a challenge, and various loco-regional flaps have been used to directly cover or to enhance closure of the bronchial stump. The serratus anterior muscle (SAM) is one of the workhorse flaps, although its use as a musculocutaneous flap has been debated. Here, we present our early experience with serratus anterior musculocutaneous (SAMC) flaps for the obliteration of BPF., Methods: A retrospective review of patients with surgical management of BPF from April 2005 to June 2014 was performed. A de-epithelized SAMC flap has replaced the conventional SAM flap since August 2013. Nine of consecutive former SAM flaps and 5 consecutive later SAMC flaps were identified. A detailed review of the SAMC flap cases was performed to describe medical and surgical history, BPF diagnosis and location, and the outcome of the flap surgery., Results: All five BPFs treated by SAMC flap were greater than 1 cm in diameter and all occurred on the right side. The leading primary diagnosis of a BPF was lung cancer, and the 4 lung cancer patients all underwent previous irradiation. The average size of the skin paddle was 19 × 6.6 cm(2), and the average volume of the skin paddle was 100.3 cm(3). Recurrence of the BPF was noted in 1 patient 6 weeks after surgery. In 4 of 5 patients, viable adipose tissue was confirmed by computed tomography scans., Conclusions: The SAMC flap holds merits of a local flap such as short operation time, relative safety, no need of position change and faster recovery, with increased freedom of flap transfer and additional volume, thus widening surgical indication of the large, recalcitrant BPFs. We suggest that the SAMC flap could be safely harvested and used for management of a BPF or similar intrathoracic lesion when extensive flap length or bulk is required., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Orbitopalpebral anomalies in mandibulofacial dysostosis (Treacher-Collins syndrome) can be difficult to correct surgically and most authors recommend correction of the malar bone after the age of 8 years. We propose a new, early surgical approach for periorbital defects that involves initial implantation of autologous fat and subperiosteal malar lift with a pedicled upper eyelid flap. We prospectively studied 5 children, 3 of whom had previously had orbital reconstruction. Initial fat graft into the periorbital area was followed by a subperiosteal malar lift with lateral canthopexy, and a pedicled upper eyelid flap if needed. Two surgeons independently assessed the patients' characteristics including scleral show before and after operation, antimongoloid palpebral fissures, canthal dystopia, number 6 cleft (Tessier classification), skin quality, and surgical and ophthalmic complications. Before operation 3 patients had had ophthalmic problems. Postoperative evaluation showed improvements in scleral show, canthal dystopia, and skin quality, and correction of antimongoloid palpebral fissures and subcutaneous number 6 clefts. There were no postoperative complications. The proposed protocol gave satisfactory aesthetic and functional results in children with Treacher-Collins syndrome. We recommend that it is considered for periorbital reconstruction in all patients with a mandibulofacial deformity., (Copyright © 2015 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)

Objective: To present the clinical outcomes obtained by the first facial transplant teams worldwide, reviewing current practice and addressing controversies., Methods: A bibliographic search of Medline and Embase databases was performed, and a comparative analysis of all articles published from 1980 to the present was conducted. Two independent investigators screened the manuscripts in accordance with pre-defined criteria., Results: A total of 12 partial and 5 full facial transplants were recorded in the literature. Procedures included partial and near-total facial myocutaneous flaps, and complex osteomyocutaneous grafts. Fifteen patients had fully vascularised grafts, and two patients died of transplant-related and infectious complications., Conclusion: Facial transplantation can restore quality of life and enable the social re-integration of recipients. Results published by the first facial transplant teams are promising. However, long-term reports of aesthetic and functional outcomes are needed to more precisely define outcomes. In addition, significant technical, medical and ethical issues remain to be solved.

Objective: To summarize the application of 909 anterolateral thigh myocutaneous flaps in the repair of oral and maxillofacial defects and to examine their benefits in maxillofacial reconstruction of these defects., Methods: Patients were recruited from January 2004 to December 2012 in the Department of Oral and Maxillofacial Surgery of the Second Xiangya Hospital of Central South University. All patients underwent reconstructive surgery with anterolateral thigh myocutaneous flaps, and patient age ranged from 19 to 81 years with a mean of 51.2 years. There were 761 flaps showing single lobe and 148 flaps showing a multi-island pedicle. The largest area among the single flaps was 28 cm × 12 cm, and the smallest was 4 cm × 2 cm., Results: Among the 909 transferred flaps, 882 survived and 27 showed necrosis, with a survival rate of about 97.0%. The common complications at flap donor site were poor wound healing 9.6% (87/909), localized paresthesia 61.0% (500/820), and altered quadriceps force 15.0% (123/820). No case was presented with local serious complications, and 90% of the patients achieved good functional recovery and aesthetically acceptable results after the reconstruction by anterolateral thigh myocutaneous flaps., Conclusions: The anterolateral thigh myocutaneous free flaps are more suitable for oral and maxillofacial defects than other flaps and should be preferred.

Purpose: Starting from our experience with 45 consecutive cases of regional pedicled flaps, we have underlined the effectiveness and reliability of a variety of flaps. The marketing laws as applied to surgical innovations are reviewed to help in the understanding of why regional flaps are regaining wide popularity in head and neck reconstruction., Materials and Methods: From January 2009 to January 2014, 45 regional flaps were harvested at San Paolo Hospital to reconstruct head and neck defects. These included 35 pectoralis major muscular and myocutaneous flaps, 4 lower trapezius island or pedicled flaps, 3 supraclavicular flaps, 2 latissimus dorsi pedicled flaps, and 1 fasciocutaneous temporal flap. The basic literature of marketing regarding the diffusion of new products was also reviewed., Results: Two myocutaneous pectoralis major flaps were complicated by necrosis of the cutaneous paddle (one complete and one partial). No complete loss of any of the 45 flaps was observed. At 6 months of follow-up, 2 patients had died of multiple organ failure after prolonged sepsis. The 43 remaining patients had acceptable morphologic and functional results., Conclusions: Regional and free flaps appear to compete in many cases for the same indications. From the results of the present case series, regional flaps can be considered reliable reconstructive choices that are less expensive than their free flap alternatives. The "resurrection" of regional flaps can be partially justified by the changes in the global economy and the required adaptation of developed and developing countries., (Copyright © 2015 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The primary purposes of this study were to introduce a novel fasciocutaneous free flap from the infraclavicular region based on the anterior perforator (AP) branch of the transverse cervical artery (TCA) and the retrograde external jugular vein (EJV), describe a reliable approach to flap design and elevation, and assess early clinical results., Methods: This was a prospective observational study of 7 consecutive cases of head and neck reconstruction using the infraclavicular free flap (ICFF) based on the AP of the TCA., Results: Seven patients underwent ICFF reconstruction within a 6-month period. There was 100% flap survival in all cases at 14 days. Mean dimensions of the flap were 13.3 × 6.3 cm. The EJV drained the flap in all cases but the transverse cervical vein (TCV) was used in 1 case. The retrograde EJV was used in 5 cases to increase the venous pedicle length. No vein grafts were required., Conclusion: ICFF demonstrated similar outcomes compared to conventional fasciocutaneous free flaps. This flap has the potential for common application given its consistent anatomy and donor site advantages., (© 2014 Wiley Periodicals, Inc.)

Reconstructing large defects of the extremities is a challenging problem for reconstructive microsurgeons. The latissimus dorsi musculocutaneous flap (LDMCF) is widely used for this purpose, but a skin graft is needed when the defect is wider than available flaps. We used flow-through divided LDMCFs to reconstruct large defects of the extremities in 5 consecutive patients from 2010 through 2012. The semicircular skin island was split longitudinally, and 1 skin island was advanced over the other to close a round or oval defect without a skin graft. Postoperatively, all flaps survived completely, and the mean Enneking score was 90.0%. The flow-through divided LDMCF is a reliable and versatile option for reconstructing large defects of the extremities.

Background: A transverse musculocutaneous gracilis flap provides good autologous reconstruction for small- and medium-sized breasts. Although the procedure is well adapted for bilateral breast reconstruction, no publication has specifically addressed simultaneous bilateral cases., Methods: From 2010 to 2014, the authors performed seven simultaneous bilateral breast reconstructions using transverse musculocutaneous gracilis flaps. The results with respect to operative data, immediate complications, second-stage reconstruction, and patient satisfaction after >1 year of follow-up were studied retrospectively., Results: The mean operative time was 7 h and 48 min (range, 6-9 h). Three minor complications occurred: two cases of limited flap necrosis and one case of donor-site wound dehiscence. Surgical revision was not required, and there was no flap failure. A second-stage operation was performed in 71% of the patients to improve the aesthetic results and flap volume. On average, 167 cm(3) of fat was injected per breast. After a mean follow-up of 27 months, the satisfaction rate was 86% without significant functional deficits., Conclusions: A transverse musculocutaneous gracilis flap is an effective and safe option for simultaneous bilateral reconstruction. The operating time is shorter than that for other autologous procedures with similar complication rates and high patient satisfaction levels., (Copyright © 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Total pelvic exenteration (TPE) is a rare operation in which the pelvic contents are removed entirely. Several options for pelvic floor and vaginal reconstruction have been described including transverse rectus abdominis musculocutaneous (TRAM) or deep inferior epigastric perforator (DIEP) flaps. The transverse musculocutaneous gracilis (TMG) flap has been introduced for breast reconstruction as a free flap. We adopted the pedicled TMG flap for reconstructions after TPE. To the best of our knowledge, this is the first report of this method in the literature., Methods: Between November 2011 and February 2014, 12 patients underwent TPE and reconstruction with unilateral (six patients) or bilateral (six patients) pedicled TMG flaps. Five patients underwent vaginal reconstruction with bilateral TMG flaps. We describe the operative procedure and the outcome of the operation in these patients., Results: The total mean operative times for TPE with or without vaginal reconstruction were 467 ± 12 and 386 ± 59 min, respectively. The TMG flaps had enough vascular tissue and mobility for reconstructing the TPE defects. There was distal edge necrosis in one out of 18 flaps, while the rest survived completely. During the follow-up, complete wound healing with no signs of weakening of the pelvic floor was observed in all cases., Conclusions: Soft-tissue reconstructions are needed to reduce complications associated with TPE, to secure the pelvic floor and to reconstruct the vagina in select patients. The TMG flap is a logical flap choice that does not lead to functional deficits, complicate the abdominal ostomies or weaken the abdominal wall. It reduces the length of operation compared to that of abdominal flaps., Level of Evidence: IV, therapeutic., (Copyright © 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Aims: The aim of this study was to report our experience of using distally based spilt vastus lateralis musculocutaneous flaps for soft-tissue defects around the knee joint - a new technique., Material and Methods: Cadaver dissection studies were conducted in three cadavers to demonstrate perforators entering the lower third of the vastus lateralis muscle arising from the superior lateral genicular artery. Its application in eight clinical cases for the reconstruction of soft-tissue defects around the knee joint is reported., Results: Seven out of eight flaps survived well without any flap loss. One flap with a skin island measuring 12 × 20 cm suffered a loss of 2 cm distally. This was later treated with skin grafting. Six out of eight donor sites were closed primarily. Six patients achieved full functional range of motion by 3 months. One patient had a 10° limitation of knee extension. One patient had foot drop due to primary injury and walks with a limping gait., Conclusions: This flap is a new reconstructive option for knee defects. It can reach distally up to the tibial tuberosity and does not require an intraoperative change of position. The donor site can be closed primarily and is hidden inside the clothing. The function of the knee is not affected as the majority of the muscle is kept in continuity., (Copyright © 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Objective: The purpose of this study was to assess the therapeutic efficacy of oral perforated defect reconstruction with a double anterior (anterolateral and anteromedial) thigh flap through the modified lateral lip-submandibular approach., Materials and Methods: From July 2010 to August 2013, eight patients with oral perforated defects secondary to oral cancer ablation involving the superior partial mandible or the posterior partial maxilla, with immediate reconstruction by double anterior (anterolateral and anteromedial) thigh flaps, were retrospectively enrolled into this study., Results: All double anterior flaps were musculocutaneous flaps. Seven double flaps resulted in good functional and aesthetic outcomes with complete flap survival. One patient required operative exploration in the postoperative period due to thrombosis in the external jugular vein. After the salvage, one of the double flaps in the intraoral region resulted in partial failure of the superficial skin of the flap. No functional impairment at the donor sites occurred in any of the cases., Conclusion: The double anterior (anterolateral and anteromedial) thigh flap is a feasible and acceptable technique for reconstruction of an oral perforated defect involving the mandible or the maxilla through the modified lateral lip-submandibular approach. It presents a very acceptable aesthetic and functional result with the additional advantage of low morbidity at the donor site., (Copyright © 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: The anterolateral thigh myocutaneous flap is one of the most commonly used flaps in reconstructive procedures, but its application in oral and maxillofacial defects has not been fully determined. Herein, we summarize the application of 1212 anterolateral thigh myocutaneous flaps in the repair of oral and maxillofacial defects and examine their benefits in maxillofacial reconstruction of these defects., Methods: Patients were recruited from February 2002 to June 2013 in the Department of Oral and Maxillofacial Surgery of Central South University. All patients underwent reconstructive surgery employing anterolateral thigh myocutaneous flaps. Patient ages ranged from 6 to 82 years with a mean age of 51.2 years. There are 1015 flaps showing single lobe and 197 flaps showing a multi-island pedicle and one of which carries the iliac bone. The largest area among the single flaps was 28 × 12 cm(2), and the smallest was 3 × 2 cm(2)., Results: Among the 1212 transferred flaps, 1176 survived and 36 showed necrosis, a survival rate of about 97.0%. The common complications at flap donor site were poor wound healing (10.1%), localized paraesthesia (50.1%), and altered quadriceps force (11.0%). No cases presented with local serious complications, and 90% of patients achieved good functional recovery and aesthetically acceptable results after reconstruction of oral and maxillofacial defects at various locations using anterolateral thigh myocutaneous flaps. The time (23-121 min; average 51 min) for anastomosis of one vein and one artery was significantly less than that for two veins and one artery (45-153 min, average 83 min; p = 0.0003), which indicates one vein anastomosis can significantly reduce the operating time., Conclusion: The anterolateral thigh myocutaneous flaps can be easily obtained and can provide a good amount of muscle for filling dead space and fascia lata. These flaps can be prepared into a separate fat flap, multi-island fascia with iliac bone, and other composite pedicle flaps to meet the various requirements of oral and maxillofacial defects. The subcutaneous fat thickness of the anterolateral area can vary considerably and thus can be used to repair defects requiring different flap thickness. Therefore, the anterolateral thigh myocutaneous free flaps are more suitable for oral and maxillofacial defects than other flaps., (Copyright © 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Tailoring the most suitable reconstructive approach to each patient remains challenging especially in the head and neck region. To compare the applicability of the latissimus dorsi (LD) and anterolateral thigh (ALT) flap, we retrospectively analyzed patients who had reconstruction of extensive and/or bulky composite tissue defects in the head and neck area. We performed 85 free tissue transfers (44 LD and 41 ALT flaps). LD mean flap surface was 115.8 cm(2). ALT mean flap surface was 67.0 cm(2). Pedicle length ranged from 8 to 16 cm in LD and 11-16 cm in ALT flaps. The survival rate was 93% in ALT and 91% in LD flaps. Donor site morbidity occurred in 5% (ALT) and 7% (LD). A Two-team-approach was possible in 24% of the LD group, whereas all ALT flaps were raised in a Two-team-approach. Both flaps present excellent opportunities for the reconstruction of extensive and/or bulky defects. They largely meet the requirements of an ideal soft tissue flap in terms of versatility, skin texture and tissue stock. Both flaps can be raised with a double skin paddle. The advantages and disadvantages of each flap have to be weighed up against each other and both flaps should be in the repertoire of every microvascular surgeon., (© 2013 Published by Elsevier Ltd on behalf of European Association for Cranio-Maxillo-Facial Surgery.)

Background: Today, virtually planned surgery and computer-aided designed/computer-aided manufactured (CAD/CAM) tools to reconstruct bony structures are being increasingly applied to maxillofacial surgery. However, the criteria for or against the usage of the CAD/CAM technique are disputable, since no evidence-based studies are available. Theoretically, the CAD/CAM technique should be applied to complex cases. In this case report, we present our experiences and discuss the criteria for application., Case Report: Three cases are reported in which subjects received an osseous reconstruction using CAD/CAM techniques. In the first case, resection of the mandibular body and ramus was carried out, and reconstruction with a vascularised iliac bone transplant was performed. During surgery, a repositioning of the ipsilateral condyle was necessary. The second case comprised a wide mandibular reconstruction together with a repositioning of the condyles and the soft tissue chin using a two-segment osteomyocutaneous fibula flap. In the third case, a two-flap technique consisting of a double-barrelled osseous fibula flap and a radial forearm flap was applied to cover a wide palatine defect., Conclusion: Our experience suggests that the CAD/CAM technique provides an accurate and useful treatment not only in complex cases, but also in simpler ones, to achieve an anatomically correct shape of the bone transplant and to reposition adjacent structures.

Prelamination, permitting improvement not esthetics only, but also function of the damaged region, to create necessary, by contents and configuration, vascularized complexes of tissues, is applied for effective treatment of complex defects in tissues. In experiment on laboratory animals for prelamination of vascularized flaps were applied separate and combined placement of mucosal and cartilaginous autotransplants. Results of the investigation witness possibility and efficacy of creation of content--component complexes of tissues, owing necessary characteristics for their further application in the clinic during performance of reconstructive interventions.

Background: Lower lip reconstruction following cancer resection includes a variety of clinical and microsurgical options., Objective: We have developed a myocutaneous flap for full thickness reconstruction with a functioning muscle., Technique: In all patients, the submandibular artery was outlined using computerized tomographic angiography and Doppler. The flap was designed after resection. The first lobe was designed to fill the defect and was outlined 90° from the defect margin, with the submandibular artery in the center of the flap. A second lobe was then outlined 90° from the first lobe. The flap was raised along with the platysma muscle and artery, with the first lobe rotated to the lip and the second lobe inset into the first lobe site, permitting neck closure without skin redundancy., Results: From January to May 2012, 17 patients were treated with this flap, and all flaps survived. All of the patients had oral continence at sixteen months, and electromyography documented platysma function., Conclusion: The flap provides single-stage lower lip reconstruction with functional muscle., (Copyright © 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Cheek or head cancer and its treatments are difficult for head and neck surgeons. Large tumor resection can leave extensive defects in the facial region. Technique difficulties are always possible to cover existing defects. We are presenting a different platysma myocutaneous flap with Z-plasty.

Background: The transverse myocutaneous gracilis flap provides adequate autologous tissue for breast reconstruction from the high thigh region, but flap harvest may affect the patient's activities of daily living, sexuality, and quality of life. The authors evaluated the reconstruction outcome, postoperative donor-site complications, and quality-of-life outcomes., Methods: All patients who underwent transverse myocutaneous gracilis breast reconstruction performed by the senior author (M.H.) since 2007 were included in the study. Patient files were reviewed, and a questionnaire was used to assess patient satisfaction., Results: Forty-nine transverse myocutaneous gracilis flaps were performed in 36 patients for breast reconstruction. Total flap necrosis occurred in two flaps (4 percent). Additional fat grafting was required in 61 percent of flaps, and donor-site complications occurred in 59 percent of patients. Wound dehiscence and infection were the most commonly encountered donor-site complications. However, by harvesting less skin and gracilis muscle, there was a statistically significant (p<0.001) lower complication rate in the last 16 patients. Twenty-two patients with at least 6 months of follow-up were included in the questionnaire study. Eighteen returned questionnaires. Most patients were happy to very happy with their result and could go about their activities of daily living. There was no statistically significant correlation between the independent variables (e.g., age, body mass index, and radiotherapy) and the dependent variables (e.g., breast satisfaction, sexuality, and donor-site morbidity). There was a statistically significant difference regarding donor-site satisfaction when comparing patients with and without donor-site complications (p=0.01)., Conclusions: Although fat grafting was often required, patients were happy with the result of their transverse myocutaneous gracilis breast reconstruction. Donor-site complications correspondence inversely to patient satisfaction., Clinical Question/level of Evidence: Therapeutic, IV.

Objective: To evaluate the therapeutic effect of pedicled muscular flaps combined with partial thoracotomy for treatment of pythorax-resulted wounds and defects., Methods: 35 cases with pythorax-resulted refractory infected wound and dead space, were retrospectively analyzed. The wound and dead space were eliminated with pedicled muscular flaps, including latissimus dorsi muscular flaps and serratus anterior muscle flaps in 21 patients, pectoralis major muscle flaps with rectus muscle flaps in 8 patients, latissimus dorsi muscul flaps and vertical rectus muscle flaps in other 6 patients., Results: 34 flaps survived completely except for 1 verticle rectus muscular flap with partial necrosis at distal end. Primary healing was achieved in 29 cases. The other 6 cases were discharged with drainage. Among the 6 cases, 3 cases healed spontaneously, 2 cases underwent reoperation, 1 case need long-term drainage in the fistula., Conclusion: Pedicled muscular flap, combined with partial thoracotomy can effectively treat refractory wound and dead space resulted by pythorax.

Background: Usually, several surgical methods are used, with re-suturing, free skin grafting and local flaps, for the reconstruction of wall defects after abdominoperineal resection. However, or larger defects, free flaps have been preferred because they can provide a large area of well-vascularized soft tissue, which is suitable for defect repair. We present the case of a large abdominal wall defect, which was treated with a free combined serratus anterior and latissimus dorsi myocutaneous flap, resulting in a successful outcome., Case Presentation: A 38-year-old female originally had squamous cell carcinoma of the cervix uteri, and had undergone radical hysterectomy and oophorectomy followed by radiotherapy. She had a recurrence of the cervical cancer after 13 years, and underwent pelvic exenteration. However, the mid-abdominal wound developed dehiscence and an abdominal full-thickness defect communicating with the pelvic cavity. Furthermore, the adhered colon developed necrosis, which drained stools into the pelvic cavity, resulting in chronic peritonitis. During surgery, the empty pelvic cavity was filled with a combined serratus anterior and latissimus dorsi myocutaneous flap to prevent chronic peritonitis, to create a new stoma in the skin paddle of the flap for the necrotic colon, and to separate the pelvic cavity from the drained stools. The patient could walk in the absence of abdominal hernia formation and relapse of infection., Conclusions: A combined serratus anterior and latissimus dorsi myocutaneous free flap was applied to cover the raw surface and reinforce the abdominal wall and to fashion a new colostomy, as well as successfully filling the pelvic cavity with a large muscle body and long vascular pedicle. This is the optimal method for reconstructing severe abdominal wall defects that have many complications.

Purpose: Plate exposure is the most common complication after reconstruction of oncologic resection using a titanium plate. The outcomes of covering exposed reconstructive plates with extended vertical lower trapezius island myocutaneous flaps (TIMFs) were evaluated., Patients and Methods: Twelve instances of exposure of reconstructive plates occurred in patients after segmental mandibulectomy to treat cancer of the oral cavity and oropharynx. The plates were covered with extended vertical lower TIMFs. The site of the primary tumor was the gingiva or mandible in 5 cases, the buccal mucosa in 3, the floor of the mouth in 2, and the base of the tongue in 2. The types of bone defect were hemimandibular in 1 case, central in 2, and lateral in 9. Intraoral, extraoral, and intra- and extraoral exposures occurred in 1, 7, and 4 instances, respectively. Intraorally and extraorally exposed plates were re-covered with skin paddles measuring 6 × 7 to 6 × 23 cm (average, 6.0 × 13.5 cm). Four folded extended vertical lower TIMFs were constructed to cover plates exhibiting intra- and extraoral exposure., Results: All flaps survived. Patients were followed for 12 to 36 months (median duration, 22.8 months). One patient (8.3%) exhibited external plate exposure at 20 months. Nine patients (75.0%) were alive with no evidence of disease at 12 to 36 months, and 2 (16.7%) were alive with disease at 20 to 28 months. One patient (8.3%) died of local recurrence at 23 months., Conclusions: The use of extended vertical lower TIMFs to cover intraorally, extraorally, or intra- and extraorally exposed plates is reliable., (Copyright © 2014 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Aim: Chronic pelvic sepsis is a challenging problem, which may require muscle flaps to fill the pelvic cavity. The aim of this systematic review was to determine the relative success of rectus and gracilis flaps used for this purpose., Method: A systematic review was conducted to identify papers that reported the outcome of rectus or gracilis myocutaneous flaps in the treatment of persistent perineal sinuses or chronic pelvic sepsis. Reports of muscle flaps used for reconstruction or treatment of fistula in the absence of chronic sepsis were excluded. A successful outcome was defined as complete perineal healing within 12 months of surgery., Results: The review identified 19 studies reporting the outcome of 73 rectus and 87 gracilis flaps. Their respective success was 84% and 64%. Heterogeneity of the underlying cases did not allow for direct comparison of the flaps. Full healing of the flaps was generally achieved within 3 months. Donor site morbidity was minimal., Conclusion: The surgical treatment of chronic pelvic sepsis should be tailored to the individual, but the rectus flap has a reasonable success rate with little morbidity., (Colorectal Disease © 2014 The Association of Coloproctology of Great Britain and Ireland.)

Background: The submental flap was first introduced 20 years ago (1993). Advances in techniques and new findings from anatomic studies expanded the indications and improved the flap characteristics. Indications, limitation, and all possible variants of this flap are discussed comprehensively in this article., Materials and Methods: A literature review was performed. We paid attention to the anatomy of submental region, and especially to submental artery and vein, muscles and lymphatics. Surgical techniques for each possible variant of this flap and examples of each situation are presented. Indications of submental flap for facial, oesophageal, pharyngeal, laryngeal, and oral cavity reconstruction were assessed., Results: Ninety studies meeting the inclusion criteria were reviewed. Classification of the submental flap based on skin paddle composition and blood supply is presented. Major modifications such as pedicled, free, and perforator flaps are discussed comprehensively and minor variants of submental flap such as bipaddled, bipedicled, expanded, deepithelialized, and interposition submental flaps are discussed, briefly. A historical look at this topic is presented to show how and by whom advances in submental flap were done., Conclusion: The submental flap has a wide arc of rotation; it is easy to rise and has low donor site morbidity. It is a safe, simple, and predictable method for reconstruction of oral cavity., (Copyright © 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Purpose: There are few studies analyzing the long-term clinical effects related to increasing the size of head and neck free tissue reconstructions. The purpose of this study was to compare long-term clinical outcomes of patients undergoing very large area (≥200 cm(2)) and large area (100 to 199 cm(2)) free tissue reconstructions of head and neck defects., Patients and Methods: Institutional review board approval was obtained before conducting this retrospective cohort study at the authors' university-based tertiary care hospitals. The authors analyzed the charts of consecutive patients with free flaps of at least 100 cm(2) treated from July 2000 to December 2011. Very large area flaps were arbitrarily defined as larger than 200 cm(2). Intraoperative variables, flap success rates, overall survival, and total hospital and intensive care unit (ICU) stays for the 2 groups were analyzed. Fisher exact tests or χ(2) tests were used for categorical variables and Student t tests were used for continuous variables. Log-rank tests were conducted to investigate whether overall survival was significantly different between the 2 groups. Statistical significance was defined as a P value less than .05., Results: The charts of 121 consecutive patients were analyzed. Thirty-eight patients (31%) had very large area flaps (277.1 ± 79.4 cm(2); range, 200 to 576 cm(2)) and 83 patients (69%) had large area flaps (140.1 ± 25.5 cm(2)). There was no difference between flap groups in presenting T4 stage disease (P = .448). Ninety-eight percent of the very large area flaps and 93% of the large area flaps survived. Total hospital stays for the very large area and large area flap groups were 12.8 ± 8.2 and 12.3 ± 8.3 days, respectively (P = not significant). In contrast, ICU stays were increased for the very large area flap group at 7.1 ± 7.5 versus 4.0 ± 4.0 days for the large area flap group (P = .022). The overall median patient survival for the very large area flap group was 7.6 months (95% confidence interval, 5.7-10.0) and that for the large area flap group was 8.4 months (95% confidence interval, 5.4-12.9; P = .376)., Conclusion: Performing very large area flaps for head and neck reconstruction did not negatively affect clinical outcome. Comparable success rates, total hospital stays, and overall survival can be safely achieved in this difficult patient population. More studies need to be conducted on resource usage., (Copyright © 2014 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Introduction: Although several techniques have been described for the repair of soft palate defects, soft palate reconstruction remains challenging. This study was performed to evaluate swallowing and speech functions in patients undergoing placement of folded reverse facial-submental artery submental island flaps (FRFF) to reconstruct soft palate defects following cancer ablation., Materials and Methods: FRFFs were designed for eight patients with soft palate defects resulting from soft palatal squamous cell carcinoma ablation. The clinical stages of tumours were I in two patients, II in four patients, and III in two patients. FRFFs were created to reconstruct soft palate defects. Swallowing and speech functions were evaluated 3 months postoperatively., Results: One minor flap failure occurred, but all flaps survived. No donor-site problem occurred. Five patients managed ingestion of a solid diet, two managed a soft diet, and one remained on a liquid diet. Six patients achieved normal speech, one achieved intelligible speech, and one retained slurred speech. The patients were followed for 8-48 months; seven patients were living with no evidence of disease, and one was living with disease., Conclusions: The FRFF is reliable for soft palate defect reconstruction following cancer ablation and can achieve satisfactory swallowing and speech functions., (Copyright © 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: Transfusion with old red blood cells (RBCs) was associated with adverse clinical outcomes. The effect of perioperative transfusion of old RBCs on postoperative complications after free muscle sparing transverse rectus abdominis myocutaneous (TRAM) flap surgery was retrospectively investigated., Methods: Two hundred sixty-one patients undergoing breast reconstruction were assigned to two groups: no transfusion and transfusion groups. Transfused patients were further divided according to the RBC storage duration (fresh, ≤14 days; old, >14 days). Postoperative complications such as vascular thrombosis, hematoma, and flap congestion were noted., Results: Patients who received old blood (n = 34), compared with those received fresh blood (n = 40) or no transfusion (n = 187), had a higher incidence of postoperative complications (44.1% vs. 20.0% or 12.8%, P < 0.05)., Conclusions: Perioperative transfusion of old RBCs can be associated with an increase in postoperative complications after free muscle sparing TRAM flap surgery., (© 2014 Wiley Periodicals, Inc.)

Background: The use of internal mammary perforators (IMPs) as recipient vessels in autologous free flap breast reconstruction has many additional benefits compared with the internal mammary or thoracodorsal vessels. Our goals were to analyze the characteristics of these vessels and to evaluate the reliability of using them in an Asian population., Methods: Thirty-five consecutive patients were prospectively studied between November 2000 and December 2010. Twelve patients underwent muscle-sparing-2 transverse rectus abdominis musculocutaneous flap, and 23 had deep inferior epigastric perforator flap reconstructions., Results: Internal mammary perforator vessels were used in 29 patients (83%). Most (75%) of the vessels were located in the subcutaneous plane, and 85% were in the second and third intercostal spaces. There were significantly more usable IMP vessels in the immediate than in the delayed reconstructions (P = 0.049). All the flaps in the study were successful despite 1 requiring emergency re-exploration because of venous congestion., Conclusions: Most of the IMP vessels are small; however, they are still reliable and safe for use as recipient vessels in selected Asian patients. Most are located in the subcutaneous plane, which further facilitates dissection and also reduces recipient-site morbidity.

Background: Wound complications after perineal and groin obliterative procedures are a significant cause of morbidity, particularly following chemoradiation therapy. Vertical and, increasingly, oblique rectus abdominis myocutaneous flaps have been used to fill potential dead space and bring healthy, vascularized tissue into the defect. The authors compared the complications and outcomes of patients undergoing perineal or groin reconstruction with vertical or oblique rectus abdominis myocutaneous flaps. They hypothesized that the oblique flap offers outcomes similar to those of the vertical flap, without an increased risk of complications., Methods: All patients who underwent immediate reconstruction of perineal, pelvic, or groin defects using vertical (n=49) or oblique rectus abdominis myocutaneous (n=22) flaps over the past 10 years at the University of Washington Medical Center were reviewed retrospectively. Patient, disease, and obliterative procedure characteristics and donor- and recipient-site complications were compared. Statistical analysis was performed using the t test for continuous variables and Fisher's exact test for categorical variables., Results: There were no statistically significant differences in major or minor donor- or recipient-site complication rates, need for augmented fascial closure, need for additional flaps, flap loss, readmission, or reoperation rate between the two groups., Conclusions: Immediate reconstruction of perineal or groin defects with oblique rectus abdominis myocutaneous flaps results in complication rates similar to those with reconstruction using with vertical flaps. Oblique flap reconstruction is a reasonable and safe alternative, providing several distinct advantages over the vertical flap, including greater arc of rotation, thinner skin paddle, less bulk, and limited fascial harvest., Clinical Question/level of Evidence: Therapeutic, III.