Arthur H. Salibian

Functional oromandibular reconstruction with the microvascular composite groin flap.

Ten patients were reconstructed with the microvascular osteocutaneous groin flap for oromandibular defects with the objective of improving function. The flap was based on the superficial and deep circumflex iliac vessels for optimal positioning of the bone and contouring of the skin. Patients with major glossectomies and arch resections had intelligible speech and were able to eat a soft diet without aspirating. Cineradiographic studies to evaluate swallowing in selected patients showed that the shape of the intraoral flap and the location of the bone graft played an important role in swallowing and prevention of aspiration.

Total and subtotal glossectomy : function after microvascular reconstruction

Twelve patients with advanced carcinoma of the floor of the mouth and tongue were treated with total (five patients) or subtotal (seven patients) glossectomy, partial mandibulectomy, and immediate reconstruction with the microvascular composite groin flap. The osteomusculocutaneous groin flap was used in eleven patients, and the osteomuscular flap was used in one patient. The groin musculocutancous or muscle flap was designed to resemble the shape of the tongue for dynamic food transport, improved swallowing, and acceptable speech. Eight of the 12 patients who survived more than 1 year were evaluated for speech and swallowing. Eight patients were able to speak intelligibly, six patients could tolerate a soft/pureed diet, and two patients were limited to fluids. Cinefluorographic swallow studies using semisolid contrast material showed voluntary active intraoral transport and propulsive pharyngeal emptying without aspiration in six patients with complete flap to palate contact; the remaining two patients were unable to move the intraoral contrast material effectively for swallowing because of poor palatal contact.

Functional hemitongue reconstruction with the microvascular ulnar forearm flap.

Thirteen patients with squamous cell carcinoma of the tongue underwent full-thickness longitudinal resection of the hemitongue and immediate microvascular reconstruction using a large, contoured ulnar forearm flap. Six of the 13 patients had a composite resection for which an additional vascularized iliac crest graft was used to reconstruct the mandible and to provide support to the overlying contoured flap. To increase tongue mobility, the skin flap was designed for independent reconstruction of the hemitongue and the floor of mouth. Twelve patients were evaluated for swallowing and speech, including dietary assessment, cineradiography, and voice spectrographic analysis. Contrast cineradiography was performed to determine oral tongue mobility during the first phase of swallow. Nine patients with a narrow reconstructed tongue root and a large surface area in the floor of the mouth had good tongue mobility, allowing them to transfer food dynamically from the mouth into the pharynx for swallowing. The remaining three patients, who had a wide tongue root and an ill-defined floor of the mouth, had decreased tongue mobility and poor oral transport. The functional outcome of swallowing and speech strongly correlated with the shape of the root of the tongue, the proximity of the reconstructed tongue to the palate, and the surface area of the floor of the mouth.

Staged transfer of a free microvascular latissimus dorsi myocutaneous flap using saphenous vein grafts.

The use of long vein grafts in the axilla adds a new dimension to the versatility of the latissimus dorsi myocutaneous flap. When suitable recipient vessels are not available for a microvascular anastomosis, long vein grafts can be used in the axilla to double the arc of rotation of the flap, allowing it to cover the buttocks, lower torso, and scalp (Fig. 8). A case is presented in which the latissimus dorsi myocutaneous flap was transferred in stages to cover a large radiation ulcer of the right buttock.

Microvascular reconstruction of the mandible

Five microvascular reconstructions of the mandible were performed in the past 2 years. One dorsalis pedis osteocutaneous flap was used to reconstruct the alveolar ridge and four groin osteocutaneous flaps were used for various defects of the mandible. Free microvascular bone grafts were found useful in previously irradiated fields, in anterior arch reconstruction, and in patients with massive soft tissue and bone loss.

Reconstruction of the base of the tongue with the microvascular ulnar forearm flap : A functional assessment

Ten patients with infiltrating carcinomas of the base of the tongue/tonsillar region underwent 30 to 100 percent resection of the base of the tongue and lateral pharyngeal wall. The surgical defect was reconstructed (9 primary, 1 secondary) with a large microvascular ulnar forearm flap that was selectively contoured to provide bulk for the base of the tongue and a thin lining for the pharyngeal wall. Seven patients were evaluated for swallowing and speech 6 weeks to 2 years following the reconstruction. Cineradiographic studies showed excellent base of the tongue and flap mobility allowing glossopharyngeal closure in all patients and complete pharyngeal evacuation in four patients. Four patients who were in good health preoperatively were able to eat a regular diet postoperatively, and the remaining three patients were able to handle soft food. Functional recovery after major tongue base surgery is contingent upon a three-dimensional microvascular reconstruction using a thin forearm flap.

Microvascular Repair of Heminasal, Subtotal, and Total Nasal Defects with a Folded Radial Forearm Flap and a Full-Thickness Forehead Flap

Background: The site, size, and depth of tissue loss, irradiation, or composite injury to adjacent cheek and lip may make local tissues inadequate or unavailable for the repair of major nasal defects. Methods: In 13 patients, a single, folded, horizontal radial forearm flap was used to line the vault and columella, with an incontinuity fasciocutaneous extension to resurface the nasal floor, with or without primary dorsal support. Later, excess external forearm skin was turned over to adjust the nostril margin and alar base positions. Delayed primary cartilage grafts completed subunit support. A three-stage full-thickness forehead flap provided covering skin. Three-dimensional contouring of the midlayer framework was performed over the entire nasal surface, during an intermediate operation, before pedicle division. Results: Good to excellent aesthetic and functional results were obtained in total and subtotal defects in five operations over 8 months, including a late revision. Partial necrosis of the folded columellar lining (n = 2) and dehiscence of unilateral alar lining (n = 1) were salvaged at forehead flap transfer by hinging over excess external forearm skin (n = 2) or by folding the extension of the forehead flap for columellar lining (n = 1). Indolent cartilage infection necessitated débridement (n = 4) and partial support replacement (n = 3). No free flaps were lost or required to salvage a complication. Conclusions: The approach is reliable, efficient, and applicable to varied defects and has the ability to correct design errors and complications before pedicle division. An unscarred lining sleeve, defined three-dimensional contour, and thin conforming skin cover are restored.

Bipedicle Gastrocnemius Musculocutaneous Flap for Defects of the Distal One-Third of the Leg

A bipedicle gastrocnemius musculocutaneous flap has been designed to cover soft-tissue defects over the lower one-third of the tibia. The flap, which consists of the entire medial or lateral half of the posterior leg skin and the underlying gastrocnemius muscle, combines the advantages of the axial-pattern blood supply of a musculocutaneous flap and the dual blood supply to a bipedicle flap. The augmented circulation from the proximal end of the flap allows the distal pedicle to be narrowed and advanced anteriorly in one stage without jeopardizing the blood supply. Bipedicle gastrocnemius musculocutaneous flaps are best suited for moderate-sized defects over the anterior lower one-third of the leg. Indications for use of the flap are presented.

Inframammary approach to nipple-areola-sparing mastectomy.

Background: Different approaches have been advocated for performing nipple-areola–sparing mastectomy. The inframammary approach has been viewed as having limited applications, particularly in large breasts. The authors review their experience with nipple-areola–sparing mastectomy using the inframammary approach for different breast sizes. Methods: Between 2005 and 2012, 118 nipple-areola–sparing mastectomies with staged implant-based reconstruction were performed in 80 consecutive patients. Patients with different breast sizes underwent inframammary nipple-areola–sparing mastectomy, except those patients who had very large breasts or those who requested a breast lift. Oncologic data related to tumor size, selection criteria, and recurrences are presented. All nipple-areola–sparing mastectomies and reconstructions were performed by the same surgeons (J.K.H. and A.H.S), who operated as a team in performing the mastectomies. Results: Patients were followed up from 6 to 97 months (mean, 33.5 months). There were four recurrences (5 percent), three of which were attributed to the biological behavior of the tumor. The aesthetic outcomes of the reconstructions were analyzed based on nipple location, breast contour, and symmetry: 35 patients (44 percent) had a very good result, 28 (35 percent) had a good result, nine (11 percent) had a fair result, and eight (10 percent) had a poor result. Risk factors and complications affecting the final aesthetic outcome are discussed. Conclusions: The inframammary approach for nipple-areola–sparing mastectomy is the authors’ procedure of choice for small, medium, and large breasts. The team approach to the mastectomy facilitates the procedure, reduces skin-related complications, and results in a better aesthetic outcome. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Microvascular Gastrocnemius Muscle Transfer to the Distal Leg Using Saphenous Vein Grafts

The gastrocnemius muscle has been transferred to the distal leg by lengthening its vascular pedicle with interposition saphenous vein grafts. This procedure is presented as an alternative to free-flap transfers requiring vein grafts to the proximal leg. By increasing the arc of rotation of the gastrocnemius muscle with vein grafts, the full dimensions of the muscle can be used to cover large prepatellar, suprapatellar, and distal leg defects.