M. S. Noordhoff

Four types of venous flaps for wound coverage : a clinical appraisal

Venous flaps were used for coverage of hand wounds over exposed bones, joints, and tendons in 28 patients. Four types of operations were performed. Among them type IV was the best. It included the advantages of perfusion in types I and III, but excluded their disadvantages. The viability of venous flaps was confirmed. Clinical observation showed that a venous flap is not merely a composite graft. The presence of a vascular network in the flap helps to ensure initial survival before the establishment of neovascularization between the venous flap and the recipient site. Partial loss of a flap was observed in two cases and complete failure was seen in one case. Viability versus flap size and modality of perfusion are analyzed. With total venous perfusion, small venous flaps usually survive better than large ones. For large venous flaps, arterialized venous perfusion is better than total venous perfusion. Venous flaps are useful for wound coverage of fingers and hand, but they do not replace cross-finger flaps or other conventional flaps when these simpler flaps are available.

Reconstruction of the entire esophagus with chain flaps in a patient with severe corrosive injury

A method of reconstructing the entire esophagus by a chain of free forearm flaps connecting pharynx to jejunum is presented. This was indicated because all other means of reconstruction were not possible. It solved a difficult problem with good result, and the patient was satisfied.

Microvascular free muscle flaps for chronic empyema with bronchopleural fistula when the major local muscles have been divided--one-stage operation with primary wound closure.

It should be emphasized that most cases of chest empyema can be successfully treated with conventional thoracic surgery procedures. For chronic empyema with a bronchopleural fistula complicated by previous division of major local muscles following repeated thoracotomies, free muscle flaps are employed. Five such cases treated with this method resulted in successful closure of the airway fistula, as well as complete obliteration of the empyema cavity in a single operation. This method is very effective in eradicating infection and achieves prompt wound healing, decreased morbidity, and gradual improvement of pulmonary function after surgery. Analysis of roentgen ray and computed tomographic scans before and after surgery shows lung expansion when the transferred muscles atrophy. The results are satisfactory. The method described here is not the only solution to this problem, but it is a new approach that has advantages not seen in conventional methods. It is indicated only in patients who have been operated on many times and who have no remaining available local muscles.

Microvascular free posterior interosseous flap and a comparison with the pedicled posterior interosseous flap

The posterior interosseous flap has been used as a pedicled flap for coverage of hand wounds. However, the pedicled flap is associated with partial or even complete loss when there is venous congestion. This happens because it depends on retrograde venous drainage. Another pitfall of the pedicled posterior interosseous flap is the undetected damage to the communicating vessels between the anterior and posterior interosseous arteries before surgery. This would result in failure if the flap is used as a distally based flap. Thirty-four patients had been reconstructed with the microvascular free posterior interosseous flap. The free flap has a large draining vein. Flap survival rate was 97%. There was no venous congestion and no partial loss of the flap. It is thin, sensate, and reliable. The free posterior interosseous flap is indicated for coverage of the following wounds: (1) first web space and thumb, (2) radial side of the index and ulnar side of the small finger if a cross-finger flap cannot be used, and (3) defects at the dorsum of multiple fingers. It can also be used as a free fascial flap. The free posterior interosseous flap provides a reliable option for coverage of hand wounds. Previously, another 14 patients with hand wounds had been reconstructed with a pedicled posterior interosseous flap. The results of pedicled and free posterior interosseous flaps are compared.

Patch esophagoplasty with free forearm flap for focal stricture of the pharyngoesophageal junction and the cervical esophagus.

Focal stricture of the cervical esophagus can be caused by corrosive injury or irradiation or following esophageal reconstruction. For severe stricture that cannot be relieved by bougie dilatation, surgical correction should be done. Among the operations performed, the myocutaneous flap is considered the first choice. Patch esophagoplasty with a free flap is indicated in the following situations: (1) when the patient is a young woman, (2) when the patient is obese, and (3) following irradiation that renders myocutaneous flaps unreliable. For correction of focal stricture of the cervical esophagus, six patients underwent esophagoplasty with a patch of free forearm flap. In comparison with other methods, this approach is associated with less morbidity and a better aesthetic result. The patients started oral intake at 1 month. Only one patient had minor leakage, and this healed after conservative treatment. The skin patch inserted in the esophageal wall caused no problem in motility, and the patients could eat smoothly after surgery.

Patch esophagoplasty with musculocutaneous flaps as treatment of complications after esophageal reconstruction

A musculocutaneous flap is a simple and effective treatment for the complications which can follow esophageal reconstruction at the cervical portion, such as stricture, fistula, and infection of costal cartilages. After the strictured segment is opened or resected, the resultant esophageal defect can be replaced with the skin patch of a musculocutaneous flap. Then the muscle component of the musculocutaneous flap can be used to form a seal around the previously infected lesion site, an area with the potential for recurrent infection and leakage in subsequent operations. Seven patients were treated this way with satisfactory results.

Posterior tibial artery flap for reconstruction of the esophagus.

Three patients presented who needed reconstruction of the entire esophagus. Because the stomach and colon were not available in these patients, a posterior tibial artery flap was employed for reconstruction. In the first stage, the long and wide skin flap was elaborated into a skin tube to create the major portion of esophagus in the subcutaneous tunnel. In the second stage, the lower end of the skin tube was joined to the jejunum in Roux-en-Y fashion. This method resulted in smooth passage of food and early rehabilitation for these patients. However, this procedure has the disadvantage of a scar over the leg. In addition, this procedure has the following limitations: (1) a well-vascularized leg is necessary, and (2) a hairless leg is necessary. Although this would not be a procedure of first choice, it remains a worthwhile backup procedure in esophageal reconstruction.

Finger reconstruction with triple toe transfer from the same foot for a patient with a special job and previous foot trauma.

After the loss of four fingers at the metacarpal level, triple toe transfer from the same foot was performed in the dominant hand of an art worker who needed three ulnar digits to work with the intact thumb. The toes of the left foot could not be used because of a previous injury. Long-term follow-up at 3 years showed good results in terms of function. He regained dexterity for calligraphy, notably the brush calligraphy and painting that are important in his job. The donor site was treated very carefully to prevent complications. There was minimal donor site morbidity. He still can walk very well and runs fast. Gait analysis of the donor foot is presented. This was a unique situation, and satisfactory results were obtained through the cooperation of the patient as well as detailed analysis before surgery.

Transposed replantation of fingers at forearm bones in severe segmental injuries across the hand and wrist.

There are situations in which amputated hands or fingers cannot be replanted directly back to their original positions. When there is severe segmental injury across the hand and wrist but one or several fingers are still healthy, the fingers can be selected to be replanted at the forearm bones to restore pinch function. This is different from the toe to antebrachial stump transplantation presented by Dr. Vilkki. From the results in four patients, the following conclusions are drawn: (1) When the fingers are replanted at the forearm bone(s), only pinch function can be obtained. There is no opposition. (2) Grip function is weak because the intrinsics are lost and only a few fingers are replanted. The forearm bones are often shortened, as are the flexors. (3) Of particular importance is the creation of a large web space between the radial digit and ulnar digit(s), because fingers are longer than toes. (4) The sensory recovery is not so good as in ordinary finger replantation. However, this is a salvage procedure. Regardless of these facts, the patients are still satisfied with the results out of such severe injuries. With good pinch function, not only are they independent in daily life, but they also can do a lot of work. It is a worthwhile procedure. A functional prosthesis can be added distally after this replantation.

Appraisal of Free Skin Flaps in the Reconstruction of Hypopharynx and Cervical Esophagus

Regardless of the advances in surgery there are still some handicaps in the reconstruction of hypopharynx and esophagus, such as insufficiency or stricture of the anastomotic site and disturbances in swallowing. Recent development in microsurgery provides a new approach to these problems.