Bernard S. Alpert

The muscle flap in the treatment of chronic lower extremity osteomyelitis: results in patients over 5 years after treatment.

Preliminary reports have indicated that debridement of the bony sequestrum followed by muscle-flap coverage allows successful treatment of chronic osteomyelitis. To determine the long-term effectiveness of this procedure, 34 consecutive patients with chronic osteomyelitis of the distal lower extremity treated with debridement, a 10− to 14-day course of culture-specific antibiotics, and immediate muscle-flap coverage were evaluated. Patients were treated from 1979 through 1984, and long-term (>5 years) follow-up was available for 27 (79 percent). Twenty-three (85 percent) of these patients underwent microvascular muscle transplantation (gracilis or latissi-mus dorsi), and four underwent local muscle flaps (gas-trocnemius or soleus) for immediate wound coverage. Twenty-four patients (89 percent) healed and were without recurrence over long-term (>5 years, mean 7.4 years) follow-up. Of the three with recurrence, two were cured (>5 years follow-up) after additional muscle-flap procedures. Thus the overall success rate was 96 percent, with a minimum 5-year follow-up. Guidelines for muscle-flap selection and treatment techniques in current use are presented. Debridement and immediate muscle-flap coverage provide effective, single-stage treatment of chronic osteomyelitic wounds and allow antibiotics to be restricted to short-term use. Furthermore, muscle flaps covered with skin grafts provide durable coverage while allowing subsequent ancillary procedures (i.e., bone grafts) to be performed under the flaps.

The serratus anterior free-muscle flap: experience with 100 consecutive cases.

We report free serratus transplantation in 100 consecutive patients, 10 in combination with the latissimus muscle and 2 with rib. Transplantation was performed for extremity soft-tissue coverage, contour correction, and facial reanimation. Twenty-two patients received serratus transplantation as part of complex reconstruction requiring multiple microvascular transplants. Overall success was 99 percent, with a single flap failure. Four patients suffered partial flap loss. Emergent reexploration for suspected vascular occlusion was infrequent, required in six flaps (6.0 percent), with an 83 percent salvage rate. Significant complications occurred in 18 percent of recipient sites and 12 percent of donor sites, with eight patients developing seroma/hematoma. No scapular winging was noted, and all patients retained full shoulder range of motion. The serratus muscle flap is a highly reliable flap characterized by a consistently long pedicle, excellent malleability, and multipennate anatomy permitting coverage of complex three-dimensional wounds and consistent performance as a functional transplant. Underlying rib can be included as a myo-osseous flap to expand the versatility of this flap.

Use of the temporoparietal free fascial flap in the upper extremity.

Reconstruction of hand coverage has been limited to flaps with the drawbacks of bulkiness and donor-site morbidity. In contrast, the temporoparietal fascia is a thin, pliable, well-vascularized sheet of tissue available in abundant quantity. It leaves an inconspicuous donor site within the hair-bearing scalp. In addition, microvascular transfer is facilitated by the consistent, reliable, and largecaliber axial superficial temporal vascular supply. The branches of the superficial temporal system provide flexibility in designing axial-pattern flaps. Secondary reconstructive surgery can be safely performed beneath the flap. The intrinsic vascularity of the flap may be useful in revascularizing scarred or irradiated areas. There is also the potential to transfer cranial bone as a composite temporoparietal osteofascial free flap to the hand. There has been partial flap necrosis and permanent alopecia at the donor site in only 1 of 12 patients. We recommend this flap based on our experience in these 12 patients.

Scalp reconstruction by microvascular free tissue transfer

We report on a series of patients with scalp defects who have been treated with a variety of free flaps, spanning the era of microvascular free tissue transfer from its incipient stages to the present. Between 1971 and 1987, 18 patients underwent scalp reconstruction with 21 free flaps: 11 latissimus dorsi, 3 scalp transfers between identical twins, 3 groin, one combined latissimus dorsi and serratus anterior, two serratus anterior, and one omentum. These flaps were used to cover scalp defects resulting from burns, trauma, radiation, and tumors in patients ranging from 7 to 79 years of age. Follow-up has ranged from 3 weeks to 7 years. All of our flaps survived and covered complex defects, many of which had failed more conservative attempts at cover. One patient received radiation therapy to his flap without unfavorable sequelae. This experience began with a pioneering omental flap and includes cutaneous and muscle flaps. The latissimus dorsi is our first choice for free flap reconstruction of extensive, complicated scalp wounds because of its large size, predictable blood supply, ease of harvesting, and provision of excellent vascularity to compromised beds.

Free latissimus dorsi muscle flap with split-thickness skin graft cover: a report of 16 cases.

Use of the latissimus dorsi free muscle flap was split-thickness skin graft for coverage of large defects has advantages over the musculocutaneous flap. The flap is less bulky, and contouring at the recipient site is facilitated. The donor site is less conspicuous. This method has been useful in treating large scalp and lower-extremity wounds even when there has been chronic infection.

Replacement of damaged arteries and veins with vein grafts when replanting crushed, amputated fingers.

SUMMARY Two cases are presented in which multiple vein grafts were used to revascularize several digits in hands injured by severe crushes. One case had partial amputations of 4 digits, and the other had 4 complete amputations. After debriding the damaged parts of the vessels, we interposed vein grafts in both the arterial and venous circulations to the digits. Seven of 8 revascularized digits survived. In crushing injuries, it is essential to debride the vessels proximally and distally to where the intima has not been injured. To bridge the gaps, vein grafts can be used successfully where other methods are undesirable or impossible.

Mutilating multidigital injuries: Use of a free microvascular flap from a nonreplantable part

In severe hand injuries, all usable parts should be salvaged from amputated nonreplantable areas. A case is presented in which a free flap taken from an amputated finger was used to reconstruct a severely injured but viable remaining digit. This was done as part of the primary reconstructive effort and provided a well vascularized protective cover for the surviving injured digit.

Improved salvage of complicated microvascular transplants monitored with quantitative fluorometry.

Quantitative fluorometry has been used to monitor circulation in transplanted toes and cutaneous flaps in our unit since 1982. Analysis of 177 uncomplicated transplants monitored by quantitative fluorometry shows that this technique has low false indication rates for arterial occlusion (0.6 percent of patients) and venous occlusion (6.2 percent of patients). None of these patients was reexplored because of a false monitor reading, and except for single abnormal sequences, monitoring appropriately indicated intact circulation throughout the postoperative period. Quantitative fluorometry has correctly indicated vascular complications in 21 (91.3 percent) of 23 transplants over an 8-year period. The salvage rate (85.7 percent) of the fluorescein-monitored reexplored transplants was significantly higher than the salvage rates of similar reexplored transplants not monitored with fluorescein and of reexplored muscle flaps (which cannot be monitored with the fluorometer used at this unit). These clinical data indicate that quantitative fluorometry is a valid and useful postoperative monitor for transplanted toes and cutaneous flaps.

Microsurgical tissue transfer in patients more than 70 years of age.

Between 1982 and 1989, three women and seven men older than 70 years of age underwent elective free-tissue transfer. Nonhealing wounds of 1 scalp, 2 upper extremities, and 7 lower extremities were covered with 3 serratus anterior, 3 latissimus dorsi, 2 gracilis, and 2 lateral arm flaps. Major coincidental medical problems included hypertension, congestive heart failure, chronic obstructive pulmonary disease, coronary artery disease, diabetes mellitus, metastatic lung cancer, tachyarrhythmias, syncope, elevated liver function tests, and previous arterial bypass in the affected lower extremity. One flap failed and 2 others were compromised by venous thromboses but salvaged by reoperation. There were no major anesthetic complications. This series demonstrates that elective free-tissue transfers can be safely performed in patients older than 70 years of age.

Serratus anterior muscle transplantation for treatment of soft tissue defects in the hand

The inferior three slips of the serratus anterior muscle have been used as a free tissue transfer in 18 patients for the reconstruction of dorsal and palmar defects in the hand. Mean follow-up was 2.8 years. There were 12/18 flaps for palmar coverage and 6/18 for dorsal coverage. All flaps survived. On the basis of this experience we conclude that this flap has three attributes making it suitable for palmar and dorsal metacarpal resurfacing: (1) low donor site morbidity, (2) the three separate slips are easily divisible for contouring, and (3) durability and adhesion provide a stable resurfacing for grasp.