Hoon-Bum Lee

Simultaneous reconstruction of the Achilles tendon and soft-tissue defect using only a latissimus dorsi muscle free flap.

The combined loss of the Achilles tendon and the overlying soft tissue in the young ambulant patient with expectations of a normal life is a challenging problem. These patients need not only soft tissue but also dynamic and functional reconstruction. Four cases of major defects of the Achilles tendon and overlying soft tissue after trauma are presented. In each case, the tendon and the overlying soft tissues were reconstructed using only a latissimus dorsi muscle free flap and overlying split-thickness skin graft. In conventional methods, evolved in the reconstruction of the Achilles tendon and soft tissue, the size of the defect was a limit. However, this technique can be used to reconstruct an extensive defect, including distal calf muscle to the plantar metatarsal area. In one case, the flap was harvested in a myocutaneous unit, and the skin portion was deepithelialized for the coverage and enough padding on the bony exposure area in reverse position. The purpose of the present study was to reevaluate the potential of denervated muscle flap for a force-bearing conduit as an alternative reconstructive method of the Achilles tendon. The denervated latissimus dorsi muscle in this study eventually experienced the process of atrophy and fibrosis but maintained its original length. Although there remained some atrophic muscle fibers, a fibrosis of the muscle fibers formed a tendon-like fibrous band, and so the action of the posterior calf muscle could be transmitted through the tendon-like fibrotic change of the denervated latissimus dorsi muscle. The advantages of this technique are that (1) it is a single procedure, (2) it is adaptable to a wide range of defect sizes, (3) it allows faster wound healing supported by well-vascularized tissues, (4) it produces satisfactory function of the ankle joint and a padding effect, and (5) it produces good contour of the posterior calf to the sole and an acceptable donor-site morbidity.A two-part investigation was undertaken to determine whether a four- or a five-flap Z-plasty gives the greatest increase in length (deepening) over the same radius of a web. In part A, flaps were designed on a model of a webspace made from a plastic frame and Speedo fabric; four types of flaps, three different central limb lengths, and three trials for each length gave a total of 36 observations. In part B, flaps were designed on the natural axillary webs of the pig; three Yorkshire pigs with one type of flap per axillary web gave a total of 12 observations. In part A, the stereometric elongation (percent deepening) produced by the five-flap Z-plasty was similar to that of a single 60-degree Z-plasty (4-cm central limb; five-flap versus a single Z procedure, 72.5 ± 4.3 versus 75.0 ± 2.5 percent). The 90-degree four-flap procedure gave a 1.59 times greater deepening than the five-flap procedure (4-cm central limb; 90-degree four flap technique, 114.2 ± 1.4 percent). The 120-degree four-flap technique gave 2.0 and 1.26 times greater deepening than the five-flap and 90-degree four-flap procedures, respectively (4-cm central limb; 120-degree four-flap technique, 144.2 ± 1.4 percent). In part B, the 90-degree four-flap Z-plasty again produced a significantly greater lengthening (1.57 times) than the five-flap procedure (132.7 ± 6.4 versus 84.0 ± 4.0 percent; p < 0.05), and the percentage of elongation of the 120-degree four-flap procedure was 1.27 times greater than that of the 90-degree four-flap technique (167.3 ± 7.0 versus 131.3 ± 2.3 percent; p < 0.05). In conclusion, the four-flap Z-plasty produced greater webspace deepening than that of the five-flap Z-plasty. The 120-degree four-flap procedure gave the greatest percentage of elongation, but it was more difficult to design and close than the 90-degree four-flap Z-plasty.

Orbital floor and infraorbital rim reconstruction after total maxillectomy using a vascularized calvarial bone flap.

A number of techniques have been introduced to support the orbital floor after maxillectomy without orbital exenteration. These methods include skin graft or muscular sling, but they have resulted in severe complications, such as enophthalmos, global ptosis, diplopia, and facial deformity. Currently, advanced microvascular reconstruction using bone and soft tissue is performed by many surgeons. This usually results in the filling of the postmaxillectomy defect, but the lack of support for the orbital rim and floor by the bone flap may still cause the complications mentioned above. Vascularized calvarial bone flap was chosen in this study for reconstruction of the orbital floor and infraorbital rim to function as a buttress, to reconstruct recipient sites of poor vascular bed after radiation therapy, and to withstand further postoperative radiation. By providing a solid floor and rim, these complications can be prevented with satisfactory function and aesthetically acceptable results. From September of 1995 to July of 1998, we performed vascularized bone flap for the reconstruction of the orbital floor and infraorbital rim in four cases after total maxillectomy involving the orbital floor. With a follow-up period from 19 to 35 months (mean, 27 months), we obtained significant improvement of functional and aesthetically acceptable results without global ptosis, enophthalmos, diplopia, or severe facial contour deformity.

Pulp Reconstruction of Fingers with Very Small Sensate Medial Plantar Free Flap

&NA; The essence in dealing with the pulp deficit accompanying fingertip injuries lies in functional restitution of the inherent skin texture and characteristics unique to that area and sufficient preservation of digital length, along with successful restoration of fine tactile sensation indispensable to delicate and skillful maneuvers. Among various techniques used to meet such demands, the very small sensate medial plantar free flap can be considered an excellent method in view of the skin texture that allows firm grasping, durability to friction rub, a cushion effect, and adequate sensation. Six cases of finger pulp reconstruction with the very small sensate medial plantar free flap are presented. At follow‐up examination (an average follow‐up of 24.3 months), the patients were evaluated clinically and neurologically. The operative procedures, advantages, and results in clinical cases are presented. Satisfactory results were obtained with sufficient preservation of digital length and good sensory recovery. No functional deficit was found at the donor site.

Coverage of difficult wounds around the knee joint with prefabricated, distally based sartorius muscle flaps.

The coverage of soft-tissue defects around the knee joint presents a difficult challenge to the reconstructive surgeon. Various reconstructive choices are available depending on the location, size, and depth of the defect relative to the knee joint. However, the knee joint frequently accompanies injuries to the lower leg that may limit the use of muscle flaps, especially the gastrocnemius muscle. The use of a free flap is preferred for reconstruction involving obliteration of large-cavity defects, but the isolation of recipient pedicle can be difficult because of the extent of injury zone and in cases of chronic infection around the knee. To provide muscle bulk with a reliable vascular supply, the distally based, prefabricated sartorius muscle flap was used as a last resort to reconstruct difficult wounds with chronic osteomyelitis around the knee joint in 6 patients from June 1995 to May 2001. This method is a two-stage procedure. First, the sartorius muscle is prefabricated by denervation and vascular delay. Silicone sheets are used to increase the vascularity and dimension of the flap. Second, after 3 weeks, the muscle is transposed based on a distal pedicle to reconstruct the soft-tissue defect around the knee. The prefabricated sartorius muscle can provide efficient bulk to obliterate the dead space and to cover moderate-size soft-tissue defects around the knee joint. This method can be considered to reconstruct the soft tissue around the knee joint when local muscle flaps and free flaps are not feasible.

Unilateral multilayered musculocutaneous V-Y advancement flap for the treatment of pressure sore.

&NA; We have devised a modified technique using the gluteus maximus musculocutaneous flap as multilayered sliding V‐Y advancement to cover pressure sores on the sacral area. Nine patients with relatively large (average 7 × 7 cm) sacral grade IV pressure sores underwent unilateral multilayered V‐Y advancement flap. All patients were followed for a minimum of 8 weeks. The mean postoperative follow‐up was 32.3 months, with a range of 24 to 39 months. Using this technique, the success of surgery, i.e., the percentage of sores that healed, was 100 percent in our patients. The advantages of this technique include sufficient advancement of the flap, coverage of large ulcer defects using only a unilateral musculocutaneous flap, and preservation of the contralateral gluteus maximus muscle for future use. (Plast. Reconstr. Surg. 100: 340, 1997.)

Reconstruction of composite metacarpal defects using a fibula free flap.

Vascularized bone flaps provide reliable replacement for bony deficits in the extremities and face. Vascularized bone heals faster, with less bony absorption or atrophy, and is more reliable than nonvascularized bone in settings of scar, infection, or irradiation. The free fibula flap, introduced by Taylor et al.1 in 1975, has been used extensively for skeletal reconstruction of extremities2 and mandible.3,4 We report the use of the free fibular flap to reconstruct two complex hand injuries with metacarpal and soft-tissue deficits.

Reconstruction of fingertip and stump using a composite graft from the hypothenar region

Finger amputation with bone exposure when replantation is not feasible requires a procedure for closure and padding of the stump. To preserve the length and provide adequate coverage, various flaps are used. A situation may occur in which local flaps are not sufficient and distant flaps are preferred. However, distant flaps often require a two-stage procedure, prolonged immobilization, and skin grafts. Thus, a simpler approach for fingertip or stump reconstruction while maintaining the padding effect of a flap was designed. The composite of glabrous skin and subcutaneous fat provided such padding, was performed in a single stage, and the donor site morbidity was negligible. During a 5-year period from 1996 to September 2002, 15 cases of finger stumps were reconstructed using the hypothenar composite graft. The age of the patients ranged from 1 to 63 years (average, 30 years). The average follow-up was 35 months. The donor sites were closed primarily and there were no marked complications related to this site. The graft showed relatively good contour and color match to the adjacent field, with an average two-point discrimination of 5.7 mm, indicating satisfactory reinnervation. The hypothenar composite graft for reconstruction of finger stumps can provide protective padding, maximal stump length, and minimal donor site morbidity, leading to satisfactory aesthetic and functional recovery.

De novo induction of island capsule flap by using two silastic sheets: Part 1. Generation.

A new experimental model for de novo generation of an axial pattern island flap has been designed in a rat model. The purpose of this study was to make a sufficient vascular carrier, as an island capsule flap, with only vascular pedicles and addition of collagen fibers induced by foreign-body reaction. The femoral arteriovenous bundle was isolated and sandwiched between two 2.5 x 1.5 cm Silastic sheets. Eight weeks later, as a delay procedure, femoral vessels were ligated at the distal end of the Silastic sheets and the four margins of the sheets were divided except for the vascular pedicle. This capsule flap was raised as a secondary island flap connected only by its vascular pedicle, then it was sutured back in place. Ten days after the delay procedure, the upper Silastic sheet was removed and a full-thickness skin graft was performed on the capsular island flap. Animals were killed at 80 days. A total of 40 axial pattern capsulocutaneous flaps from 20 Sprague-Dawley rats were successfully achieved. Pathologic study revealed neovascularization, and abundantly impregnated vascular structures near the pedicle were observed with randomly developed collagen fibers. The skin graft took 100 percent on this newly formed capsular flap; therefore, the capsule structure was able to survive on its own and support skin grafts. This experiment, by using an isolated femoral artery and vein as the main pedicle, led to the formation of a capsule flap through a normal foreign body reaction between two Silastic sheet implants. This new flap can be used as a reliable vascular carrier for various needs with minimal donor morbidity.