Hidehiko Minakawa

Role of buttress reconstruction in zygomaticomaxillary skeletal defects.

&NA; The purpose of this study was to review eight patients undergoing midfacial skeletal reconstruction following extensive resection of tumors based on the principles of restoration of three maxillary buttresses, the nasomaxillary, zygomaticomaxillary, and pterygomaxillary. The zygomaticomaxillary skeletal defects were reconstructed with a three‐dimensionally contoured piece of titanium mesh, vascularized costal cartilage, or vascularized bone flap of scapula and rib. Restoration of the zygomaticomaxillary buttress prevented the inferior deviation of the orbit and provided good zygomatic contour. Restoration of the nasomaxillary buttress prevented the superior and posterior deviation of the alar base of the nose, and restoration of the pterygomaxillary buttress prevented the superior and posterior deviation of the upper lip. Combination of the V‐shaped scapular bone and the rib flap based on the thoracodorsal vascular system, which provides simultaneous reconstruction of all three buttresses, is a very versatile technique for reconstruction of extended midfacial skeletal defects. In this series, both of the patients reconstructed with titanium mesh presented with late persistent cutaneous fistulas. We now recommend a vascularized autologous soft and bony tissue reconstruction for midfacial composite defects.

Pelvic reconstruction with a free fillet lower leg flap

The free fillet lower leg flap was applied for immediate reconstruction after hemipelvectomy including the overlying soft tissue and the internal and external iliac vessels. The flap, harvested from the amputated lower extremity, is a versatile reconstructive technique for such a large pelvic defect.

Facial Reconstruction with Free-Tissue Transfer

The article provides a retrospective review of 25 free-tissue transfers for facial reconstruction on 24 recipient sites in 21 patients. The recipient sites of the face were classified into frontal (4 patients), orbital (2 patients), nasal (2 patients), buccal (11 patients), and oral region (5 patients). The transferred flaps included 16 fasciocutaneous flaps (6 forearm flaps, 5 scapular flaps, 2 anteromedial thigh flaps, 1 lateral arm flap, 1 dorsalis pedis flap, and 1 deltopectoral flap) and 8 myocutaneous flaps (6 latissimus dorsi myocutaneous flaps, 1 serratus anterior myocutaneous flap, 1 rectus abdominis myocutaneous flap, and 1 prefabricated flap). Thinning modifications such as the expansion, reduction, or extension techniques were performed in the myocutaneous flap to avoid having a bulky flap. In our view, the flap from the trunk matches the facial skin color better than that from the extremity. Satisfactory results were attained in all cases in which a complete replacement of the facial aesthetic unit was performed.

Experience with Arteriovenous Malformations Treated with Flap Coverage

Fourteen patients with arteriovenous malformations were treated with surgical resection followed by well-vascularized tissue transfer. Free-tissue transfers were used in 12 of the patients and axial local flaps in 2 patients to reconstruct the region with arteriovenous malformations. The feeding arteries of the arteriovenous malformations were used as recipient vessels in all cases of free-tissue transfers without any trouble in microvascular anastomosis. With an average follow-up of 3 years and 2 months, 12 patients showed no clinical recurrence (86 percent). Follow-up angiography in seven patients showed complete disappearance of malformations in two patients and residual malformations not enlarged in three patients. Two patients had residual malformations that were noted to be increasing in follow-up angiograms, and they also had clinical evidence of recurrence. In these patients an intramaxillary recurrence in one and intraorbital in the other appeared at about 1 and 3 years, respectively, after surgery. This therapeutic concept can be expected to provide great remission in the treatment of arteriovenous malformations.

Functional alveolar ridge reconstruction with prefabricated iliac crest free flap and osseointegrated implants after hemimaxillectomy.

We achieved functional alveolar ridge reconstruction after hemimaxillectomy using a prefabricated iliac crest flap. The iliac crest was vascularized secondarily by a long rectus abdominis muscle flap with its inferior epigastric vessels intact to obtain an ideal anatomic location between the maxillary defect and microvascular anastomosis site. The iliac crest was tightly resurfaced with a split-thickness skin graft as well. After a bony surgical delay, the prefabricated iliac crest flap was microsurgically transferred to the face. Three osseointegrated implants were placed in the prefabricated iliac crest, and a dental prosthesis was worn with immobilization and stability. Our procedure enabled recovery of a satisfactory facial appearance and excellent masticatory function.

The combined flap based on a single vascular source : A clinical experience with 32 cases

&NA; This article provides a retrospective review of 32 combined flap transfers. It consists of two or more flaps based on independent vascular branches from a single vascular source. This series included the combined flap based on the subscapular‐circumflex scapular‐thoracodorsal vascular system in 24 patients and the profunda femoris‐lateral circumflex femoral vascular system in 8 patients. Twenty‐four combined flaps were transferred as free flaps and eight as pedicled flaps. The combined flap based on the subscapular system has very good indications for massive and three‐dimensional composite defects in the head and neck region. The combined flap based on the lateral circumflex femoral‐profunda femoris system is useful for reconstruction of large defects in the groin, perineal, and lower abdominal regions. (Plast. Reconstr. Surg. 97: 1385, 1996.)

The rectus abdominis myocutaneous flap combined with vascularized costal cartilages in reconstructive craniofacial surgery.

The efficacy of osteocutaneous or vascularized bone flaps for reconstruction of massive skeletal and soft-tissue defects has been supported by recent descriptions in the literature. In this article we presented an alternative technique, which is the rectus abdominis myocutaneous flap combined with vascularized eighth and ninth costal cartilages, for reconstruction of midfacial composite defects. The vascular pedicle of the composite flap is the deep inferior epigastric artery and vein. The costal cartilages are supplied by the perichondrial vascular network through the anterior intercostal vessels connecting with the deep epigastric vascular system. Vascularized costal cartilages are considered to reduce the incidence of postoperative complications and resorption of this material. This technique is a useful tool for restoration of craniofacial contour in reconstructive head and neck surgery.

Cheek reconstruction with an expanded prefabricated musculocutaneous free flap: case report

We present a case of reconstruction of the left cheek with a prefabricated musculocutaneous flap. A pedicled serratus anterior muscle flap was transferred to the left chest, deep to skin. The muscle flap and overlying skin were expanded. The expanded, prefabricated musculocutaneous flap was then transferred as a free flap to the left cheek defect.

Reconstructive considerations after resection of malignant melanoma in the head and neck

Little has been written about reconstructive methods after resection of melanomas in the head and neck region. We investigated reconstructive methods retrospectively related to the site and size of the melanomas resected by examining the medical records of 28 patients who had malignant melanomas of the head and neck resected at our hospital from 1984 to 2001. The tumour distribution was 12 in the cheek, 6 in the conjunctiva, 2 in the upper lip, 2 in the lower lip, one each in the lower eyelid, eyebrow, scalp, nose, and auricle. Reconstructive methods were 18 skin grafts, seven local flaps, and three free flaps. Three patients who had skin grafts required secondary reconstruction using free flaps. No local recurrences were observed. Reconstructions with local flaps give better aesthetical and functional results than free flaps and skin grafts. Immediate reconstruction with a flap is safe and it does not affect observation of local recurrences.

«Boomerang» rectus abdominis musculocutaneous free flap in head and neck reconstruction

Immediate head and neck reconstruction after cancer resection using the “boomerang” rectus abdominis musculocutaneous (RAM) free flap was performed in 13 patients over the past 2 years. The skin paddle of the flap is designed as a boomerang shape based on the anatomical construction of the dominant perforators from the inferior epigastric vascular system. A versatile technique of the boomerang RAM flap provides effective use for reconstruction of the complex defects at the skull base, orbital, nasal cavity, paranasal sinuses, oropharynx, palate, buccal mucosa, tongue, floor of mouth, and neck. It also allows a reconstructive surgical team to elevate the flap simultaneously with a head and neck surgical team before the size and location of the defect are exactly determined and greatly reduces operating time. This flap will be a routine technique for immediate head and neck reconstruction after cancer resection.