J. Brian Boyd

The extended deep inferior epigastric flap: a clinical technique.

A versatile flap based on the deep inferior epigastric artery is presented. Its application for local and free-flap transfer is discussed and presented in two clinical cases. The possible inclusion of bone as an osteocutaneous flap is outlined. The flap can be raised with ease and speed, and the donor site is repaired as a linear scar. Since the latissimus dorsi flap with its pedicle based in the axilla has become the workhorse for the upper torso, this extended flap may become its distal counterpart with its pedicle based on the groin.

The Supraclavicular Artery Island Flap (SCAIF) for Head and Neck Reconstruction: Surgical Technique and Refinements

Objective We have found the supraclavicular artery island flap (SCAIF) to be a reliable, first-line tool for the reconstruction of complex head and neck defects. Here, we review our technique of flap elevation and summarize the current literature citing important contributions in the evolution of this flap. Data Sources Medline literature review of supraclavicular artery island flap or shoulder flap in head and neck reconstruction with particular emphasis on developments within the past 5 years. Review Methods Literature review of technique, indications, anatomy, modification, and outcomes of the supraclavicular artery island flap. Conclusion The supraclavicular artery island flap is an important and reliable option in head and neck reconstruction. We use the flap routinely in our practice as a first-line technique when fasciocutaneous soft-tissue reconstruction is required, and we provide a detailed summary of the flap elevation and inset. Implications for Practice The supraclavicular artery island flap is a safe, reliable, technically simple, sensate, thin, pliable fasciocutaneous regional flap option that has low morbidity. It provides sensate, single-stage reconstruction for a variety of head and neck defects and should be considered as a first-line option in head and neck reconstruction.

Supraclavicular Artery Island Flap (SCAIF) vs Free Fasciocutaneous Flaps for Head and Neck Reconstruction

Objective At our institution, the supraclavicular artery island flap (SCAIF) has become a reliable option for fasciocutaneous coverage of complex head and neck (H&N) defects. We directly compare the outcomes of reconstructions performed with SCAIFs and free fasciocutaneous flaps (FFFs), which have not been reported previously. Study Design Retrospective chart review. Setting Tertiary academic medical center. Subjects and Methods Retrospective review of consecutive single-surgeon H&N reconstructions using fasciocutaneous flaps over 5 years. Reconstructions were divided into 2 groups: SCAIFs and FFFs. Patient demographics, surgical parameters, and outcomes were compared statistically between groups. Results Thirty-four flaps were used in H&N reconstruction (18 SCAIFs and 16 FFFs). There was no difference in patient demographics, distribution of defects, or follow-up (SCAIF 9.2 vs FFF 15.13 months, P = .65) between the 2 groups. The SCAIFs were larger than the FFFs (164.6 ± 60 vs 111 ± 68 cm2, P < .05) and had shorter total operative times (588 ± 131 vs 816 ± 149 minutes, P < .05). Intensive care unit (ICU) length of stay was shorter for the SCAIF vs the FFF group (1.8 vs 5.6 days, P < .05). Overall morbidity was not significantly different (SCAIF 39% vs FFF 44%, P = NS). Conclusion The SCAIF is a technically simpler and equally reliable sensate fasciocutaneous flap for H&N reconstruction with comparable outcomes, shorter operative time, less ICU stay, and no need for postoperative monitoring when compared with using FFFs. It should be considered a first-choice reconstructive option for complex H&N defects.

Quality of innervation in sensate medial plantar flaps for heel reconstruction.

Background: Reconstruction of the heel represents a difficult challenge for surgeons, given the demand for thick, durable skin capable of withstanding both pressure and shear. The authors describe the use of a sensate medial plantar flap for heel reconstruction in three patients and document the long-term retention of sensation compared with the contralateral uninjured heel and corresponding donor site. Methods: A medial plantar flap was harvested to include the branch of the medial plantar nerve to the instep to preserve innervation. Sharp pain, light and deep pressure, vibration, cold temperature, and static and dynamic two-point discrimination were examined between 6 months and 1 year after surgery. Results: Sharp pain, vibration, and deep pressure sensation were present equally in the medial plantar flap, contralateral heel, and contralateral instep. Cold perception, light pressure, and static two-point and dynamic two-point discrimination were significantly less in the normal contralateral heel when compared with the heel reconstructed by the innervated flap. There were no significant differences in sensation between the medial plantar flap and the contralateral instep. Conclusions: The medial plantar flap is capable of providing durable, sensate coverage of plantar hindfoot defects with minimal donor-site morbidity. Furthermore, that sensation remains identical to that of the instep donor site and superior to that of the normal heel pad.

Free Flap Survival Following Failure of the Vascular Pedicle.

BackgroundControversy exists regarding whether or not, or, if so, how quickly free flaps can achieve neovascularization from the surrounding tissue bed and independence from the vascular pedicle. In this paper, we document the survival of free flaps despite early vascular pedicle thrombosis and review the literature regarding the period of time believed to be required for flap autonomy to occur. DesignCase series SettingHarbor–UCLA Medical Center PatientsWe report 3 cases in which pedicle failures occurred within 2 weeks of free flap transfer. The first patient suffered repeated leaks from the vascular anastomosis with hematoma formation occurring on postoperative days 4, 6, and 17, ultimately requiring ligation of the pedicle. The second patient developed a salivary leak and accumulation of saliva around the pedicle, which was found thrombosed on postoperative day 11. The third patient lost Doppler signals from the pedicle on postoperative day 7 and 8, each occasion necessitating a return to the operating room for anastomotic revision. However, on postoperative day 9, the signal was lost yet again and no further revisions were attempted. ResultsTwo of the 3 flaps survived completely and the third was noted to have near complete survival. ConclusionMicrovascular free flaps can survive despite complete pedicle failure as early as 10 days after surgery. The mechanism behind this may involve the process of neovascularization. We conclude that early free flap pedicle failure does not necessarily equate to complete flap loss.

Bipedicled flaps in posttraumatic lower-extremity reconstruction

BACKGROUND Complex, lower-extremity, soft-tissue defects pose a significant challenge to the reconstructive surgeon and often require the use of free flaps, which puts significant demands on the patient, the surgeon and the health-care system. Bipedicled flaps are random but receive a blood supply from two pedicles, allowing the surgeon to use local tissue with an augmented nutrient blood flow. They are simple to elevate and economical in operating time. This study describes our experience with lower-extremity wound reconstruction using the bipedicled flap as an alternative to pedicled flaps and free flaps. METHODS Ten patients with lower-extremity defects underwent bipedicled flap reconstruction. Operative times, length of stay following flap procedure and postoperative complications were documented. Data were collected in a prospective fashion. RESULTS Two patients had minimal areas of flap necrosis, both of which resolved with conservative local wound care and one patient developed a postoperative wound infection remedied with a course of oral antibiotics. We experienced one major complication involving wound dehiscence requiring an additional flap. CONCLUSIONS Bipedicled flaps provide a safe, fast and relatively easy alternative for coverage of certain complex open wounds in the lower extremities. Their use does not preclude the use of more traditional options of pedicled muscle or free flap coverage at a later time should they be required. CLINICAL QUESTIONS ADDRESSED/LEVEL OF EVIDENCE: What are alternative strategies for lower-extremity wound reconstruction. Level of Evidence V.

Comparison of Superior Gluteal Artery Musculocutaneous and Superior Gluteal Artery Perforator Flaps for Microvascular Breast Reconstruction

Background: At the authors’ institution, the superior gluteal artery musculocutaneous flap has been replaced by the superior gluteal artery perforator flap for autologous breast reconstruction. The authors present a head-to-head comparison of the two techniques. Methods: A retrospective chart review of 102 gluteal flap transfers in 80 patients compared the two methods with regard to perioperative details, complications (especially anastomotic), and the number of secondary procedures required to achieve optimal outcome. Statistical analysis was carried out, and a value of p < 0.05 was considered significant. Results: Seventy superior gluteal artery and 32 superior gluteal artery perforator flap procedures were performed over a period of 10 years. Patients in the superior gluteal artery perforator group tended to lose significantly less blood (375 cc versus 241 cc). There was no significant difference in the duration of surgery, hospital stay, or the overall complication rate. Even though the difference in the rate of anastomotic thrombosis (10 percent and 6 percent, respectively) was not statistically significant, patients in the superior gluteal artery group were prone to venous thrombosis, were more likely to require vein grafting, and had a higher rate of reoperation for anastomotic problems. There was no difference in the number of secondary operations. Conclusions: This report provides some evidence of the superiority of the superior gluteal artery perforator flap over the superior gluteal artery flap for breast reconstruction, particularly with regard to ease and reliability of the microvascular anastomosis. However, in the expert hands of its early proponents, the superior gluteal artery flap did remarkably well.

Grafts, Local and Regional Flaps

Over the last century, numerous solutions have been devised for the closure of defects where tissue is missing or which cannot be closed with the simple approximation of the wound edges. Grafts and flaps both represent tissue transfer from one location to another. Grafts differ from flaps in that they do not have their own blood supply, whereas flaps bring their own blood supply when transferred to a new location. This chapter provides a basic overview of flaps and grafts and lists several examples of each.

Introducing the Tibial-Dorsalis Pedis Osteocutaneous Shin Flap: A New Option for Oromandibular Reconstruction

Objectives: The authors investigate the possibility of incorporating a well vascularized, partial corticotomy of the anterolateral aspect of the tibia in-series with a dorsalis pedis fasciocutaneous free flap for oromandibular reconstruction. Methods: The study consisted of three components. A cadaveric perfusion study was performed to characterize the vascular territory of the anterior tibial artery in regard to the surrounding osseous and soft tissue. A two-point breaking strength of the tibia was examined with fracture strain gauge analysis to determine the threshold of tibia corticotomy that would lead to a pathological fracture. Finally, the authors performed an in-vivo prospective clinical examination of the tibial-dorsalis pedis osteocutaneous shin flap. Results: The perfusion study revealed that the anterior tibial artery provided a rich matrix of myofascial periosteal blood supply to the anterolateral cortex of the tibia that could support free osseous tibial transfer. Two-point osteotomy fracture strain gauge analysis demonstrated that the threshold of tibia corticotomy that would lead to fracture of the remaining tibia was 30%. The osteocutaneous shin flap was performed in eight patients for recurrent, radiation failure, oral cavity T4 squamous cell carcinomas. The mean follow-up was 61 months. There were no cases of flap loss, salivary fistula, nonunion, or tibia pathologic fracture. All patients achieved ambulation. Conclusions: The authors introduce the osteocutaneous tibial-dorsalis pedis free vascularized flap as a viable option for oromandibular reconstruction. Its most notable advantage is the independent mobility of the skin paddle, in combination with an osseous reconstruction of the mandibular arch that facilitates primary osseointegration or denture rehabilitation.

The Supraclavicular Artery Island Flap (SCAIF) as an Ideal Option in Head & Neck Reconstruction

Background: At our institution, the Supraclavicular Artery Island Flap (SCAIF) has become a reliable, firstchoice option for fasciocutaneous coverage of complex Head & Neck defects. No studies have compared the outcomes of reconstructions performed with SCAIFs and free flaps directly. The aim of our study was to compare outcomes between SCAIFs and free fasciocutaneous flaps (FFF) via a single surgeon’s experience at a County Hospital.