David G. Dibbell

Clinical definition of independent myocutaneous vascular territories.

The use of myocutandous flaps can increase the possibilities for construction in many cases by bringing in new blood supply to avascular areas by furnishing additional bulk for filling defects or covering bone grafts or other deep repairs, and sometimes by making longer flaps viable. Also, the need for delay procedures is decreased and sometimes avoided. In this paper we define the vascular territories of 13 clinical myocutaneous flaps, and we describe possible uses of them. Three illustrative clinical cases are presented, in which repairs were done with these flaps. The future uses of these flaps challenge the imagination. Knowledge about them may significantly alter the traditional approaches to flap designs and repairs.

EXPERIMENTAL DEFINITION OF INDEPENDENT MYOCUTANEOUS VASCULAR TERRITORIES

Experimental studies were undertaken in dogs to determine whether useful island myocutaneous flaps could be based on the gracilis, sartorius, biceps femoris, trapezius, or rectus abdominis muscles. Dissection and injection studies on these muscles were also undertaken in human cadavers to determine the contributions of these muscles to the blood supply of the overlying skin. In most instances it was considerable. The use of island myocutaneous flaps seems promising in many situations. Such transfers can be done in one operation, without delay procedures, and result usually in a better blood supply with the transfer of a thicker amount of tissue. Clinical research on such flaps in patients will be described in a subsequent paper.

Abdominal wall reconstruction (the mutton chop flap)

Reconstruction of full-thickness abdominal wall defects can be a difficult surgical challenge. Reconstructing the epigastrium may be especially vexing. The use of prosthetic mesh has significant drawbacks, and the use of pedicled myofascial and myocutaneous flaps should be advantageous. We present 15 consecutive cases demonstrating highly successful reconstructions of massive abdominal wall defects using myofascial and myocutaneous flaps without prosthetic mesh. The extended rectus femoris flap, or “mutton chop” flap, which is capable of resurfacing the epigastrium, is described. Complications were minimal, and use of myofascial units, particularly the rectus femoris, should be considered as the technique of choice for reconstruction of major abdominal wall deficits.

Hypoplasia of the latissimus dorsi muscle complicating breast reconstruction in Poland's syndrome.

Polands syndrome includes anomalies of the breast, thorax, and upper extremity. Unilateral hypoplasia of the breast and pectoral muscle are seen most frequently, and the resulting problem of breast reconstruction must be addressed. The latissimus dorsi myocutaneous flap is one of the most useful reconstructive tools in this situation. A case is presented of Polands syndrome with hypoplasia of the latissimus dorsi muscle-an abnormality not generally associated with Polands syndrome. The latissimus dorsi muscle should be carefully evaluated preoperatively in such patients, to make sure it is adequate for reconstructing the absent breast and pectoral muscle.

Intraoral reconstruction with a microvascular peritoneal flap

The microvascular peritoneal flap offers a new reconstructive option for closure of intraoral defects. The flap is easy to raise, and donor-site morbidity is low. Unlike fascial flaps, in which the raw surface may take weeks to “mucosalize,” the peritoneal surface heals primarily. Finally, the rectus muscle effectively covers all forms of mandibular reconstruction, and the reliable skin paddle makes possible the closure of substantial cutaneous defects.

Successful correction of velopharyngeal stress incompetence in musicians playing wind instruments.

Two professional musicians who played wind instruments developed velopharyngeal stress incompetence which prevented them from generating the high intraoral pressures required to play their instruments. In both cases, we did a V-Y pushback with a superiorly-based pharyngeal flap. At 1 1/2 and two years postoperatively, both patients remain free of velopharyngeal incompetence and are actively engaged in their musical careers.

Retroperitoneal transposition of rectus abdominis myocutaneous flaps to the perineum and back.

Rectus abdominis myocutaneous flaps may be transposed through the retroperitoneum to reconstruct defects of the back and perineum. Cadaver dissections and clinical cases are presented to demonstrate the surgical technique and reconstructive possibilities of this flap.

Hidradenitis suppurativa polyposa.

A case of severe chronic hidradenitis suppurativa of the perineum complicated by disfiguring fibrous, polypoid lesions is presented. The patient, a 41-year-old woman, had a long history of axillary hidradenitis which subsequently involved the perineum. Draining sinuses, scars and large pendulous masses of the vulva developed over 10 years. Cutaneous scars, ridges, papules and large fibrous polyps were present. Deep clefts, sinuses, dense fibrous scars and foci of chronic inflammation were seen. Rarely, large fibrous polyps may develop in chronic hidradenitis suppurativa and may be due to chronic local lymphedema. Careful pathologic examination is necessary to exclude squamous cell carcinoma.

Successful use of muscle flaps or myocutaneous flaps in patients with sickle cell disease.

Sickle cell disease presents an unusual challenge to the reconstructive surgeon. The interaction between the underlying hemoglobinopathy and the circulatory mechanics in pedicled flaps leads to a high incidence of flap necrosis in patients with this disease. We present 3 patients with sickle cell disease in whom the use of axial flaps allowed the repair of difficult reconstructive problems in one stage, without preoperative exchange transfusions. The rationale for this approach is discussed.

Immediate reconstruction of gunshot injuries to the face.

In the past, severe traumatic injuries to the face resulting from shotgun injuries have been managed by primary wound healing followed by little or late reconstruction. This would involve a long period of convalescence by the patient, followed by years of living with his deformity. With recent demands to minimize the patients suffering and disabilities and to lessen hospitalization costs, a method of immediate reconstruction of such crippling facial injuries using a partially de-epithelialized skin flap has been devised and successfully applied to the patient presented here.