Claudio Angrigiani

A new vascularized bone graft for scaphoid nonunion

Nonunion and avascular necrosis after scaphoid fractures continue to be problem sequelae because of unrecognized injuries, inadequate immobilization techniques, or insufficient treatment time. Screw fixation and inlay bone grafting techniques remain the options of choice, with successful union reported in approximately 90% of patients. However, prolonged immobilization with plaster up to 4 to 6 months is required with conventional techniques. With the use of standard latex injection techniques with vascular filling of vessels to less than 0.1 mm diameter in ten fresh cadaver dissections, we discovered a consistent vascularized bone graft source from the distal dorsoradial radius. We have used this vascularized bone graft source with good results in eleven patients with long-standing nonunion of the scaphoid. It is technically easy and seemingly offers the advantages of a decreased period of immobilization and a higher union rate.

Latissimus dorsi musculocutaneous flap without muscle

The possibility of raising the cutaneous island of the latissimus dorsi musculocutaneous flap without muscle based on only one cutaneous perforator is presented in this paper. An anatomic study performed in 40 fresh cadaver specimens injected with colored latex demonstrated that the vertical intramuscular branch of the thoracodorsal artery gives off two to three cutaneous branches (perforators) that are consistently present. The largest one, measuring approximately 0.4 to 0.6 mm in diameter, provides the blood supply to a 25 x 15 cm cutaneous island. The incorporation of the proximal trunk of the thoracodorsal artery lengthens the pedicle, facilitating the anastomosis or the arc of rotation (in the case of island flaps) but does not increase the amount of tissue transferable. Five clinical cases were done with this technique without tissue necrosis or flap loss.

Posterior interosseous reverse forearm flap : experience with 80 consecutive cases

The results of an anatomic investigation performed in 40 fresh cadaver specimens and 80 consecutive clinical cases of the posterior interosseous reverse forearm flap are reported. It was observed that there is a choke anastomosis between the recurrent dorsal branch of the anterior interosseous artery and the posterior interosseous artery at the level of the middle third of the posterior forearm. Ink injections through a catheter placed in the distal part of the anterior interosseous artery stained the distal and middle thirds of the posterior forearm, but the proximal third remained unstained; this secondary territory cannot be captured through the choke anastomosis between the anterior interosseous artery and the posterior interosseous artery. Intravital fluorescein injection into the distal arterior interosseous artery revealed (under ultraviolet light) that the distal third of the posterior forearm is irrigated by direct flow through the recurrent branch of the arterior interosseous artery (the traditionally called distal anastomosis of the interosseous arteries). Therefore, we can assume that the blood flow is not reversed when the so-called posterior interosseous reverse forearm flap is raised. From this point of view, this flap could be renamed as the recurrent dorsal anterior interosseous direct flap; however, the classical name is maintained for practical purposes. From the venous standpoint, the cutaneous area included in this flap belongs to an oscillating type of venous territory and is connected to the deep system through an interconnecting venous perforator that accompanies a medial cutaneous arterial branch located at 1 to 2 cm distal to the middle point of the forearm.(ABSTRACT TRUNCATED AT 250 WORDS)

Aesthetic microsurgical reconstruction of anterior neck burn deformities.

Eighty-six patients with anterior neck burn sequelae underwent scar resection up to the limits of the aesthetic unit of the neck and immediate resurfacing with a scapular-parascapular free flap (the extended scapular flap). The flap was raised in all patients above the deep fascia as a thin skin-subcutaneous tissue flap, providing an initially acceptable aesthetic result. The flap was anastomosed to the facial artery and vein. The donor area was closed directly, or a 4- to 5-cm-wide skin graft was used which could be completely removed in a secondary procedure if the patient requested it. There were four failures early in the series but no losses in the last 70 patients. In order to improve the final aesthetic result, 45 patients underwent complementary defatting procedures (average of three) and Z-plasties initiated 30 days after the initial surgery at intervals of 1 month. Analysis revealed 96 percent good aesthetic results (as determined by the cervicomental angle obtained and the subjective opinion of the patients). There were no recurrences of scar contractures, and good function of the neck was regained in the majority of the patients. Anterior neck burn sequelae thus can be safely treated with en block resection and resurfacing using this flap.

Total face reconstruction with one free flap

&NA; A bilateral extended scapular (scapular‐parascapular) free flap was used in five patients with severe facial burn sequelae for complete resurfacing of the face with the exception of the nose, which was reconstructed in a separate operative procedure. All the flaps survived. Four were utilized for complete face resurfacing and one for neck and partial face resurfacing. The results were classified subjectively according to both patient and surgeon opinion. Good to fair results were obtained. The authors believe that this method might be further explored to obtain better results in these difficult cases.

The adductor flap: a new method for transferring posterior and medial thigh skin.

Skin flaps from the medial aspect of the thigh have traditionally been based on the gracilis musculocutaneous unit. This article presents anatomic studies and clinical experience with a new flap from the medial and posterior aspects of the thigh based on the proximal musculocutaneous perforator of the adductor magnus muscle and its venae comitantes. This cutaneous artery represents the termination of the first medial branch of the profunda femoris artery and is consistently large enough in caliber to support much larger skin flaps than the gracilis musculocutaneous flap. In all 20 cadaver dissections, the proximal cutaneous perforator of the adductor magnus muscle was present and measured between 0.8 and 1.1 mm in diameter, making it one of the largest skin perforators in the entire body. Based on this anatomic observation, skin flaps as large as 30 × 23 cm from the medial and posterior aspects of the thigh were successfully transferred. Adductor flaps were used in 25 patients. On one patient the flap was lost, in one the flap demonstrated partial survival, and in 23 patients the flaps survived completely. The flap was designed as a pedicle island flap in 14 patients and as a free flap in 11. When isolating the vascular pedicle for free tissue transfer, the cutaneous artery is dissected from the surrounding adductor magnus muscle and no muscle is included in the flap. Using this maneuver, a pedicle length of approximately 8 cm is isolated. In addition to ample length, the artery has a diameter of approximately 2 mm at its origin from the profunda femoris artery. The adductor flap provides an alternative method for flap design in the posteromedial thigh. Because of the large pedicle and the vast cutaneous territory that it reliably supplies, the authors believe that the adductor flap is the most versatile and dependable method for transferring flaps from the posteromedial thigh region. (Plast. Reconstr. Surg. 107: 1725, 2001.)

Blood supply of the Le Fort I maxillary segment: an anatomic study.

&NA; The vascular supply of the Le Fort I osteotomy segment was studied by utilizing standard latex injection techniques. Anatomic dissections in 10 fresh cadavers demonstrated interruption of the descending palatine arteries with preservation of the ascending palatine branch of the facial artery and the anterior branch of the ascending pharyngeal artery within the attached posterior palatal soft‐tissue pedicle in all specimens following Le Fort I maxillary osteotomy. These ascending arterial branches entered the soft palate at a position approximately 1 cm posterior to the pterygomaxillary junction, which was disrupted during the Le Fort I maxillary osteotomy. Separate ink injections of total maxillary osteotomy segments confirmed vascular perfusion of the ipsilateral hemimaxillary segment by the ascending palatine artery. Thus vascular supply of the mobilized Le Fort I maxillary segment is by means of the ascending palatine branch of the facial artery and the anterior branch of the ascending pharyngeal artery in addition to the rich mucosal alveolar anastomotic network overlying the maxilla. (Plast. Reconstr. Surg. 100: 843, 1997.)

The inframammary extended circumflex scapular flap : An aesthetic improvement of the parascapular flap

&NA; Parascapular free flaps traditionally have been designed obliquely across the back, corresponding to the descending branch of the circumflex scapular artery. The donor site of this workhorse flap has the drawback of a widened and frequently hypertrophic scar. In searching for aesthetic improvements in the donor site, we have progressively rotated the axis of this flap in an anterior direction. The end result of this modification is the flap we report here: the inframammary extended circumflex scapular flap. This flap has a longitudinal axis of rotation lying curvilinearly from the inframammary fold to the circumflex scapular artery within the triangular anatomic space. We have used this flap in 20 patients over the past 2 years. The vast majority of these cases were deepithelialized flaps with customized extensions of dorsal thoracic fascia to correct facial asymmetry. We feel that the inframammary extended circumflex scapular artery flap donor‐site scar is well hidden within the inframammary fold, and that the unavoidable widening and hypertrophy of parascapular and scapular flap donor‐site scars were minimized compared with traditional flap designs.

The dorsal scapular island flap: an alternative for head, neck, and chest reconstruction.

&NA; The back has become an increasingly popular donor site for flaps because it can provide thin, pliable tissue, with minimal bulk, and the scar can be easily hidden under clothing. The authors performed a cadaveric and clinical study to evaluate the anatomy of the dorsal scapular vessels and their vascular contribution to the skin, fascia, and muscles of the back. On the basis of anatomical studies in 28 cadavers and clinical experience with 32 cases, it was concluded that the dorsal scapular vessels provide a reliable blood supply to the skin of the medial back, making it a versatile flap to use as an island flap. A flap raised on the dorsal scapular vessels can be harvested with a long pedicle and can be rotated to reach as far as the anterior regions of the head, neck, and chest wall. Delaying and expanding the flap may help to facilitate venous drainage. The authors recommend the use of this versatile island pedicle flap as an alternative to microvascular free‐tissue transfer for the reconstruction of defects in the head, neck, and anterior chest. (Plast. Reconstr. Surg. 111: 67, 2003.)

A new musculocutaneous island flap from the distal thigh for recurrent ischial and perineal pressure sores

In the paraplegic patient who has had previous surgeries for pressure sores, local tissue is frequently unavailable for further use. The posterolateral aspect of the thigh, however, is almost always available and provides an excellent reconstructive alternative for this difficult problem. In 1983, Baek described the skin territory supplied by the third perforator of the profunda femoris artery. A musculocutaneous flap can be raised consisting of the same skin territory and a portion of the biceps femoris muscle (short head) through which the third perforator courses. In addition, the distal part of the vastus lateralis muscle, which is supplied by a muscular branch of the same perforator, can be included in the flap. The flap is elevated as an island based on the profunda femoris artery and accompanying venae comitantes. A substantial soft-tissue mass can be transposed easily to the perineum. Standard latex injection techniques were used in 12 fresh cadaver dissections prior to use of this flap in 16 clinical cases. Selective india ink injections into the third perforator of the profunda femoris artery in 6 cadavers confirmed the perfusion of the overlying skin territory. Recurrent ischial and perineal wounds were closed successfully with this musculocutaneous flap in all 16 clinical cases. (Plast. Reconstr. Surg. 96: 935, 1995.)