Guido Matton

The donor site morbidity of free DIEP flaps and free TRAM flaps for breast reconstruction

This study was undertaken to demonstrate that the deep inferior epigastric perforator (DIEP) flap can provide the well-known advantages of autologous breast reconstruction with lower abdominal tissue while avoiding the abdominal wall complications of the transverse rectus abdominis myocutaneous (TRAM) flap. Eighteen unilateral free DIEP flap breast reconstruction patients were assessed 12-30 months (mean 17.8 months) after surgery. Clinical examination, physical exercises and isokinetic dynamometry were performed preoperatively and two months and one year postoperatively. Intraoperative segmental nerve stimulation, visual evaluation and postoperative CT scans were also used to quantify the damage to the rectus muscle. The 18 patients were then compared with 20 free TRAM flap patients and 20 non-operated controls. Two DIEP flap patients presented with abdominal asymmetry. A limited decrease of trunk flexing strength was noticed but rotatory function was intact. Ten of the TRAM flap patients had umbilical or abdominal asymmetry, bulging or hernias. TRAM flap patients showed a statistically significant reduction in strength to flex and to rotate the upper trunk compared to both the one year postoperative DIEP flap group and the control group. The answers to a questionnaire revealed impairment of activities of daily living for some TRAM flap patients while the activities of all DIEP flap patients were unaffected. Our data demonstrate that the free DIEP flap can limit the surgical damage to the rectus abdominis and oblique muscles to an absolute minimum. We believe it is worthwhile to spend extra operative time, the main disadvantage of this technique, to limit late postoperative weakness of the lower abdominal wall.

Doppler flowmetry in the planning of perforator flaps

Perforator flaps have become the first choice in free flap reconstruction of contour defects or skin and fat replacement in our department. The Deep Inferior Epigastric Perforator (DIEP), the Superior Gluteal Artery Perforator (S-GAP) and the Thoracodorsal Artery Perforator (TAP) flaps are now routinely used. By evaluating the vascular anatomy of these flaps preoperatively, we intend to improve our surgical strategy so that these operative procedures can proceed in a faster and safer way. In this study, the results of the colour Duplex scanning in 50 consecutive DIEP flap patients are reviewed and evaluated for their sensitivity and positive predictive value. Also the preoperative information from unidirectional Doppler flowmetry in 30 S-GAP flaps and 11 TAP flaps is evaluated for its reliability. Due to the variable vascular anatomy of the lower abdominal wall and the dorso-lateral thoracic wall we now prefer using the colour Duplex scanning for planning the DIEP and TAP flaps. The more constant course of the branches of the superior gluteal artery allows us to use the easier and cheaper unidirectional Doppler flowmetry for planning the S-GAP flap.

The "Gent" consensus on perforator flap terminology: preliminary definitions.

Due to its increasing popularity, more and more articles on the use of perforator flaps have been reported in the literature during the past few years. Because the area of perforator flaps is new and rapidly evolving, there are no definitions and standard rules on terminology and nomenclature, which creates confusion when surgeons try to communicate and compare surgical techniques. This article attempts to represent the opinion of a group of pioneers in the field of perforator flap surgery. This consensus was reached after a terminology consensus meeting held during the Fifth International Course on Perforator Flaps in Gent, Belgium, on September 29, 2001. It stipulates not only the definitions of perforator vessels and perforator flaps but also the correct nomenclature for different perforator flaps. The authors believe that this consensus is a foundation that will stimulate further discussion and encourage further refinements in the future.

The versatility of the pudendal thigh fasciocutaneous flap used as an island flap.

The pudendal thigh flap is a sensate fasciocutaneous flap based on the terminal branches of the superficial perineal artery, which is a continuation of the internal pudendal artery. Several authors have reported using this axial patterned flap in a bilateral fashion to reconstruct the vagina, mostly in patients with vaginal atresia. The technique is simple, safe, and reliable, and no stents or dilators are required. The reconstructed vagina has a natural angle and is sensate. The donor site in the groin can be closed primarily with an inconspicuous scar. The distinct advantages of this flap widen its indications to several other pathologies. In this article, the authors report on the bilateral use of the flap to reconstruct a vagina in patients with congenital atresia (n = 8) and after oncological resection (n = 5). Furthermore, the versatility of this island flap is also demonstrated by its use in a unilateral fashion in patients with recurrent or complex rectovaginal fistulas (n = 4) and in two patients with a defect of the posterior urethra in a heavily scarred perineum. All 31 pudendal thigh flaps survived completely. Some wound dehiscence was observed in two patients. Two other patients required a minor correction at the introitus of the vagina. The functional outcome was excellent in all patients, despite the presence of some hair growth in the flaps. This article discusses the expanding indications of this versatile flap and the refinements in operative technique. (Plast. Reconstr. Surg. 107: 719, 2001.)

The use of pedicled perforator flaps for reconstruction of lumbosacral defects.

&NA; Large lumbosacral defects remain a difficult challenge in reconstructive surgery, especially in the nonparaplegic patient. Traditional options for closure include local rotation or transposition flaps and musculocutaneous flaps. These flaps, however, are not an optimal option in previously irradiated or operated areas, or in cases of large defects. Application of the perforator principle to the traditional musculocutaneous flap creates perforator flaps, which are an additional tool in the treatment of these defects in the nonparaplegic patient. A large amount of healthy, wellvascularized tissue can be transferred on one perforator without sacrificing important underlying muscles. The are of rotation is also larger than in traditional flaps. The authors present an anatomic overview of three types of pedicled perforator flaps: the superior gluteal artery perforator flap, the lumbar artery perforator flap, and the intercostal artery perforator flap. They also report 4 patients in whom a pedicled perforator flap was used to reconstruct a large lumbosacral defect. Roche NA, Van Landuyt K, Blondeel PN, Matton G, Monstrey SJ. The use of pedicled perforator flaps for reconstruction of lumbosacral defects. Ann Plast Surg 2000;45:7‐14

Allogeneic cultured keratinocytes vs. cadaveric skin to cover wide-mesh autogenous split-thickness skin grafts

Improved shock therapy has extended the limits of survival in patients with massive burns, and nowadays skin coverage has become the major problem in burn management. The use of mesh skin grafts is still the simplest technique to expand the amount of available donor skin. However, very wide-mesh skin grafts take a very long time to heal, often resulting in unaesthetic scar formation. On the other hand, allogeneic cultured keratinocytes have been reported as a natural source of growth factors and thus could be useful to improve wound healing of these wide-mesh grafts. A clinical study was performed to compare the use of cryopreserved allogeneic cultured keratinocytes vs. the traditional cadaveric skin as a double layer over widely expanded autogenous skin grafts. This procedure was performed in 18 pairs of full-thickness burn wounds (with similar depth and location) in 11 severely burned patients. Early clinical evaluation was made at 2, 3, and 4 to 5 weeks. Parameters such as epithelialization, granulation tissue formation, infection, and scar formation were evaluated. Biopsies were taken to compare the histological characteristics of the epidermis, the epidermal-dermal junction, and the dermis. Late evaluations were performed at 6 and 12 months regarding color, softness, thickness, and subjective feeling of the scar tissue. Aside from a faster (p < 0.05) epithelialization in the keratinocyte group at 2 weeks, there were no statistically different results in any of the early evaluated parameters, neither clinically nor histologically. At long-term follow-up, clinical results and scar characteristics were not significantly different in the two compared groups. It is concluded from the results of this study that, during the early phase, epithelialization was faster with allogeneic cultured keratinocytes compared with cadaveric skin. However, taking into account the substantial difference in costs, the described use of cryopreserved allogeneic cultured keratinocytes as a double layer on meshed autogenous split-thickness skin grafts can hardly be advocated.

Pilomatricoma in Children: Common but often Misdiagnosed

Abstract A pilomatricoma, also known as pilomatrixoma or calcifying epithelioma of Malherbe, is a benign skin tumor arising from the hair follicle matrix. This tumor is common in children and young adults, especially in the head and neck region. However, pilomatricomas are frequently misdiagnosed or not recognized. The history is typical of a slowly enlarging mass, irregularly contoured, it is fixed to the skin but slides freely over the underlying tissues, often with a discolouration which varies from red to purple-bluish. Ultrasound examination, MRI-scan and fine-needle aspiration can be helpful if the diagnosis is uncertain. Spontaneous regression has never been observed and malignant degeneration is very rare. Surgical excision with clear margins is the treatment of choice, otherwise recurrence may occur due to incomplete resection.

The antecubital fasciocutaneous island flap for elbow coverage.

Soft-tissue defects in the area of the periolecranon may be a source of concern to the reconstructive surgeon who aims for durable protection with a minimum of drawbacks. Lamberty and Cormack described the antecubital fasciocutaneous flap both as a local transposition and as a free flap. The island version of this flap enables a single-stage transfer of thin, pliable, sensitive skin into the region of the periolecranon Without further scarring around the defect. In general, most of the donor site can be closed primarily together with a small, full-sheet, split-thickness skin graft on the remaining skin defect on the volar surface of the distal forearm. An additional advantage of this flap is the rather straightforward dissection with minimal repercussion on the forearm contour. An anatomic overview as well as 4 patients are described to illustrate the appealing features of this fasciocutaneous flap.Van Landuyt K, De Cordier BC, Monstrey SJ, Blondeel PN, Tonnard P, Verpaele A, Matton G. The antecubital fasciocutaneous island flap for elbow coverage.

Complete survival of a free flap after early pseudoaneurysm formation and pedicle thrombosis.

A microsurgical pseudoaneurysm is a very rare complication after free flap surgery. The authors report a case of a free thoracodorsal artery perforator flap transferred to a degloving wound on the dorsum of the foot and ankle. The patient developed pedicle thrombosis caused by a septic pseudoaneurysm, which was treated by conservative means. Sufficient vascularization developed within 15 days after surgery and the flap survived completely. This is in sharp contrast to other reported cases of pseudoaneurysm formation, all of which were treated surgically and resulted in flap failure, except in one case. A critical review of the literature is presented and the factors influencing flap survival are discussed.

Gluteal thigh flap used as a fascio-cutaneous free flap.

The gluteal thigh flap is a myofascio‐cutaneous flap receiving its blood supply from a descending branch of the inferior gluteal artery. The gluteal thigh flap was first described by Hurwitz in 1980; since then numerous articles have reported on the successful use of this flap, as a transposition or a pedicled island flap, to cover wounds in the sacrogluteal and perineal regions. In contrast to its widespread use as a pedicled flap, employment of the gluteal thigh flap as a free flap is almost unreported in the literature, despite its extremely low donor morbidity and numerous articles on successful (other) free flap reconstructions based on the (same) inferior gluteal artery (e.g., in breast reconstruction). In this article we report on the successful use of the gluteal thigh flap as a purely fascio‐cutaneous free flap in limb reconstruction. The literature on the microvascular anatomy of the gluteal thigh flap is reviewed in detail, and a precise description is given of the preoperative measures and surgical manoeuvres required to increase the reliability of this free flap. From the anatomical data and the problems encountered in this case, it should be concluded that, despite the many advantages of this flap and an ultimately successful outcome, the gluteal thigh flap is not a first choice flap for microvascular transfer.