Chi Sun Yoon

Posterior interosseous artery perforator-free flap: Treating intermediate-size hand and foot defects

INTRODUCTION Ambiguous defects on the hand and foot, especially on the fingers and toes, are still challenging to treat despite achievements in reconstruction. AIM The purpose of this study was to evaluate the use of the posterior interosseous artery perforator flap for resurfacing intermediate-sized defects and provide adequate coverage over tendons and bones. METHOD Between October 2008 and March 2013, a total of 19 patients with soft-tissue defects on the hand or foot were treated. Flap elevation, anatomy, and clinical progress were evaluated. RESULT All flaps survived and covered the defects, which ranged in area from 12 to 45 cm(2). The freestyle approach was used to harvest the flaps. The average length of the pedicle was 2.5 cm, and the pedicle was harvested without affecting the source vessel. The average diameter of the artery was 0.8 mm, and the average thickness of the flap was 3.5 mm. Anastomosis was performed either end-to-end on the perforator, or end-to-side on deep vessels. No subsequent thinning or surgical flap correction was necessary. Ambulation was allowed at 3 days postsurgery. The donor site was closed primarily to leave an acceptable donor site. DISCUSSION A posterior interosseous artery perforator-free flap is a suitable choice for intermediate-size defects that are too large to cover using a local flap or too small for a first-line perforator flap. Up to 45 cm(2) of adequate coverage can be provided using a thin posterior interosseous artery perforator-free flap that does not require additional debulking. The disadvantages of a short pedicle can be overcome using perforator-to-perforator supermicrosurgery.

Reconstruction of Moderate-Sized Distal Limb Defects using a Superthin Superficial Circumflex Iliac Artery Perforator Flap

BACKGROUND When using groin flaps the scars can be easily covered. However, disadvantages including short pedicle lengths, anatomical variations in the vessels, and flap bulkiness, have prevented their widespread use. We examined the use of superficial circumflex iliac artery perforator (SCIP) free flaps to moderate-sized defects in the distal extremities. METHODS From July 2011 to August 2014, 52 patients underwent reconstructions using SCIP free flaps for moderate-sized defects in the distal upper and lower extremities. We measured the flap sizes and the thicknesses and pedicle lengths. RESULTS The mean flap size was 75 cm(2). The flaps were up to 7 cm wide as all donor sites underwent primary closure. The mean flap thickness was 5 mm, and mean pedicle length was 4.5 cm. Two cases showed total necrosis, and two cases showed partial losses in the flap margins. Among the two cases with partial necrosis, one case was managed using conservative treatment without surgery, whereas the other case underwent secondary skin-graft surgery. CONCLUSION We reconstructed moderate-sized defects in the distal upper and lower extremities using SCIP flaps, and observed that SCIP flaps have several advantages. After applying thin flaps to the defects, the contour of the flap site appeared symmetrical and natural when compared with the uninjured contralateral side of the distal limb, and no debulking surgery was required. No complications were observed at donor sites, and the surgical scars were well concealed by underwear.

Overcoming the Obstacles of the Ilizarov Device in Extremity Reconstruction: Usefulness of the Perforator as the Recipient Vessel.

BACKGROUND When patients using the Ilizarov device need a free-flap procedure for their thigh and leg, it is difficult to isolate the major vessels as the recipient vessel due to the limited working space around the Ilizarov rings and pins. The usefulness of a perforator as the recipient vessel to allow minimally invasive surgery was investigated in this study. METHODS Between October 2011 and December 2013, 77 patients using the Ilizarov device needed free flap reconstruction using an anterolateral thigh perforator flap or superficial circumflex iliac artery perforator flap. The perforator was used as a recipient vessel in 50 cases, with which end-to-end anastomosis was performed using a perforator-to-perforator approach, and major vessels were used as a recipient vessel in 27 cases (n = 20, anterior tibial vessel; n = 7, posterior vessel). RESULTS When the perforator was used as the recipient vessel, total loss developed in one case and marginal necrosis in four cases. When the major vessel was used as the recipient vessel, whole necrosis developed in one case and marginal necrosis in two cases. The procedure increased the freedom of hand movement, decreased the recipient vessel dissection time, and reduced the recipient dissection scar. CONCLUSIONS The use of perforators as recipients overcomes the obstacles associated with the Ilizarov device and allows convenient and rapid reconstruction, with similar success as microsurgery using major vessels. Further studies are needed to address the limitations of this approach, which include perfusion physiology and the viable limit of the flap dimension.

Extended Scope of the Use of the Peroneal Perforator Flap in Lower Limb Reconstruction

BACKGROUND The advantages of the peroneal perforator flap include a short harvesting time, thinness, and pliability. Due to the presence of a short pedicle and small vessel diameter, without peroneal vessel sacrifice, this flap is commonly used for distal limb reconstruction, but is rarely used for knee and proximal and middle lower leg reconstruction. We describe our experience with the application of a versatile peroneal perforator free flap for knee and proximal and middle lower leg reconstruction through supermicrosurgery. METHODS Between October 2010 and August 2014, 22 patients with small-to-medium-sized defects on their knee and proximal and middle lower leg underwent reconstruction surgery using a peroneal perforator free flap. End-to-end anastomosis using a supermicrosurgery technique is often necessary, given the extremely small perforator vessel caliber (often less than 1.0 mm). RESULTS The flap sizes ranged from 5 × 3 to 14 × 5.5 cm. The mean duration required for recipient perforator dissection was 30 minute, mean pedicle length was 4.5 cm, and mean duration required for flap harvesting was 31 minutes. Overall, 20 patients showed no complications; 1 case each showed total and partial necrosis. CONCLUSION The use of a peroneal perforator free flap for knee and proximal and middle lower leg reconstruction, via supermicrosurgery, for small- and medium-sized defects had several advantages, including the short duration required for flap harvesting and securing the recipient vessel, and the avoidance of damage to a main artery. Moreover, the thinness and pliability of the flap ensured the absence of contour deformity and tissue defect mismatches.

Modification of the Elevation Plane and Defatting Technique to Create a Thin Thoracodorsal Artery Perforator Flap.

BACKGROUND Perforator flaps have been used extensively in the field of reconstruction, and the thoracodorsal artery perforator (TDAP) flap is very popular. However, the perforator flap can be relatively bulky in some cases, depending on the defects location. Thus, several methods have been developed to address this bulkiness, including modification of the flap elevation, application of an ultrathin flap using microdissection, and the defatting technique. However, these methods have various disadvantages, so we developed an adjustable thin TDAP flap using modification of the flap elevation and defatting technique. METHODS Between January 2012 and February 2015, 13 patients underwent reconstruction of defects of their upper and lower extremities using TDAP flaps. We measured all the flap dimensions, except for thickness, because it was adjusted for the target defect. RESULTS The mean flap size was 94 cm(2) (range: 48-210 cm(2)), and all flaps were ≤10 cm wide to facilitate primary donor-site closure. Two subjects with a history of diabetes exhibited partial flap loss, so we performed secondary skin graft surgery. CONCLUSIONS The TDAP flap elevation was modified at the superficial fascia plane, and the defatting technique was used to adjust the flap volume. This technique provided more natural contours and minimized the need for secondary debulking.

Sudden Cardiac Death with Myocardial Infarction after Free-flap Lower Extremity Reconstruction

To the Editor: Free‐flap reconstructions involve factors that can increase the risk of myocardial infarction (MI; e.g., the intraoperative use of a vasoactive agent, body temperature maintenance, and postoperative administration of fluid therapy and/or antithrombotic drugs).[1] MI has been observed after free‐flap head and neck reconstruction[2] although it has not been reported after free‐flap lower extremity reconstruction. Thus, we report a rare case of sudden death from MI after free‐flap foot reconstruction.

Modified lumbar artery perforator flaps for gluteal pressure sore reconstruction

Gluteal perforator flaps (GPFs) are the most useful for gluteal region pressure sore reconstruction. However, application is difficult if the surrounding area has scar tissue from previous operations or trauma, especially with recurrent sores. We describe the use of modified lumbar artery perforator flaps when GPFs cannot be used.

Keystone-Designed Perforator Island Flaps for the Coverage of Traumatic Pretibial Defects in Patients With Comorbidities

Reconstruction of pretibial skin and soft-tissue defects remains a challenge because this area has less underlying tissues and limited tissue mobility. Here, we present a retrospective review of our experience with pretibial reconstruction using the keystone-designed perforator island flap (KDPIF) in patients with comorbidities. All defects resulted from nononcological causes. We describe the expanding versatility of KDPIF reconstruction for pretibial defects and suggest a simple algorithmic approach. The medical records of 9 patients who underwent reconstruction with a KDPIF to cover a pretibial defect between May 2016 and June 2017 were reviewed. Clinical and operative data were collected. All 9 KDPIFs fully survived. The defect size varied from 3 × 2 cm2 to 8 × 6 cm2. The flap size varied from 5 × 3 to 20 × 10 cm2. The mean operative time was 90.4 minutes (range = 37-127 minutes). No postoperative complications occurred. The cosmetic results were favorable, and all patients were satisfied with the final outcomes. Thus, the KDPIF is a good reconstruction modality with few complications and provides an alternative to free flaps for pretibial defect reconstruction in patients with comorbidities.

Keystone-designed buried de-epithelialized flap: A novel technique for obliterating small to moderately sized dead spaces

Abstract Effective obliteration of dead space after reconstructive surgery facilitates a good cosmetic outcome and prevention of delayed wound healing and recurrent infection. We evaluated the efficacy of a keystone-designed buried de-epithelialized (KBD) flap for the obliteration of small to moderately sized surgical dead spaces. We reviewed the medical records of patients who received a KBD flap following removal of a mass or debridement of necrotic tissue from September 2015 to February 2016. The diagnosis, site, dead space dimensions, flap width, drain data, complications, and follow-up duration were recorded. Twenty-eight KBD flaps were evaluated, including 9 cases of fat necrosis, 7 cases of epidermal cyst, and 12 cases of lipoma. Dead space dimensions ranged from 2 × 1.5 × 1 cm to 10 × 5 × 3 cm, with a mean depth of 2.01 cm. Flap sizes ranged from 2.5 × 1 cm to 11 × 3 cm, with a mean flap width of 2.01 cm. No postoperative complications, such as seroma or hematoma, occurred. The cosmetic results were favorable, and all patients were satisfied with their final outcomes. The KBD flap is useful for the obliteration of small to moderately sized surgical dead spaces both spatially and physiologically and shows excellent cosmetic outcomes.

Popliteal fossa reconstruction with a medial sural artery perforator free flap using the medial sural vessel as the recipient

Abstract Background: Reconstruction of the popliteal fossa using a free flap is challenging. Therefore, to facilitate easier free flap reconstruction of the popliteal fossa, we use a medial sural artery perforator (MSAP) free flap with a medial sural vessel as the recipient vessel, as it provides several advantages based on many reports. Methods: This report describes the authors’ experience and outcomes with this technique. Between October 2010 and January 2015, 10 patients with medium-sized defects in their popliteal fossa underwent MSAP free flap reconstruction using the medial sural vessel as the recipient vessel. The flap size and thickness were evaluated, as well as the pedicle length, for each case. Results: The skin flap sizes ranged from 60–112 cm2. The average flap thickness was 6 mm (range = 4–8 mm), and the average pedicle length was 7.5 cm (range = 6–9 cm). Full flap survival was observed in nine cases, and flap tip necrosis was observed in one case during a mean follow-up of 15 months (range = 3–36 months). MSAP free flap reconstruction was performed for moderate-sized defects in the popliteal fossa, using the medial sural vessel as the recipient vessel. Conclusion: The obvious advantages of this technique included simple vascular anastomosis (minimal size discrepancy), no intraoperative position changes, and good aesthetic outcomes (replacing like with like).