Mengqing Zang

Reconstruction of extensive upper extremity defects using pre-expanded oblique perforator-based paraumbilical flaps

The pedicled paraumbilical flap is a reliable tissue transfer for hand and forearm reconstruction. However, its size, pedicle length and/or thickness limit its application in resurfacing of extensive defects of the upper limb. To conquer those limitations, this flap was pre-expanded for 10-24 weeks prior to transfer in 25 patients and used as a pedicle flap to cover upper extremity defects. Extensive defects of upper limb were reconstructed by the pre-expanded paraumbilical flaps. The flaps ranged in size from 10 cm × 8 cm to 30 cm × 14 cm. The donor sites were closed directly in all cases. All flaps survived, but two had partial flap necrosis due to venous congestion or infection. With pre-transfer expansion, a large, well-perfused abdominal pedicle flap can be raised and transferred based on the paraumbilical perforators. This pre-expanded flap might be useful in the patients who have the extensive upper limb defects and sufficient time to allow tissue expansion.

Propeller medial arm flap: a plan "B" for reconstruction of radiation ulcer of the chest wall.

1. Hasegawa M, Torii S, Katoh H, et al. The distally based superficial sural artery flap. Plast Reconstr Surg 1994;93: 1012e20. 2. Baumeister SP, Spierer R, Erdmann D, et al. A relalistic complication analysis of 70 sural artery flaps in a multimorbid patient group. Plast Reconstr Surg 2003;112:129e40. 3. Erdmann D, Sudin BM, Moquin KJ, et al. Delay in unipedicle TRAM flap reconstruction of the breast: a review of 76 consecutive cases. Plast Reconstr Surg 2003;110:762e7. 4. Foran M, Schreiber J, Christy M, et al. The modified reverse sural artery flap lower extremity reconstruction. J Trauma 2008;64:139e43. 5. Tsai J, Laio HT, Wang PF, et al. Increasing the success of reverse sural flap from proximal part of posterior calf for traumatic foot and ankle reconstruction: patient selection and surgical refinement. Microsurgery 2013;33:342e9.

Nearly total unilateral buttock reconstruction with a proximally pedicled anterolateral thigh flap: a case report.

The anterolateral thigh flap has been used to reconstruct defects of lower trunk, perineum and upper thigh. We used a proximally based pedicled anterolateral thigh flap to repair an extensive gluteal defect ranging from the greater trochanter to the posterior midline and preserve the buttock contour. We conclude that the maximal lateral reach of the flap can extend to the posterior midline.

Distally based anterolateral thigh flap pedicled on the oblique branch of the lateral circumflex femoral artery

Background: A distally based anterolateral thigh (dALT) flap is an alternative option for reconstructing defects around the knee. This article presents our clinical experience with the use of the dALT flaps based on the oblique branch of the lateral circumflex femoral artery (LCFA) to reconstruct defects in the genicular and popliteal regions. Methods: Between 2008 and 2016, seven patients (4 males and 3 females, between 3–58 years old, mean =34 years) underwent reconstruction of defects around the knee using a dALT flap based on the LCFA oblique branch. Defect etiologies included malignant neoplasm (3 cases) and post-burn scar contracture (4 cases). Results: Reconstruction was successfully performed in all patients. The average flap size was 16.3 cm long (range, 9–24 cm) and 7.3 cm wide (range, 6–8 cm), while the mean pedicle length was 17.7 cm (range, 12–22 cm). The oblique branches originated from the LCFA descending branch in 6 patients and the transverse branch in one patient. One patient had a severely hypoplastic LCFA descending branch and thus the flap was based on the rectus femoris branch. In another patient, the pedicled dALT flap was converted to a free flap because the oblique branch originated from the transverse branch. All flaps survived without any major complications. Conclusions: Our experience demonstrated that we can reliably raise a dALT flap based on the oblique branch when it arises from the LCFA descending branch and sends cutaneous perforators to the anterolateral thigh region.

Distally based anteromedial thigh flaps pedicled on the rectus femoris branch of the lateral circumflex femoral artery for reconstruction of soft-tissue defect of the knee

BACKGROUND Anteromedial thigh flaps are far less clinically appealing than their anterolateral counterparts, and are occasionally considered as an alternative to the anterolateral thigh flap. Herein, we report the study of soft-tissue defects reconstruction in the knee using a distally based anteromedial thigh flap pedicled on the rectus femoris branch of the descending branch of the lateral circumflex femoral artery. PATIENTS AND METHODS Between July 2008 and September 2016, a distally based anteromedial thigh flap was used to reconstruct soft-tissue defects of the knee in 5 patients (3 males, 2 females; age range at surgery 4-55 years old). The perforating vessels supplying anteromedial thigh were derived from the rectus femoris branch of the lateral circumflex femoral artery. The rectus femoris branch shared a common trunk with the descending branches of the lateral circumflex femoral artery. Defect etiologies included malignant neoplasms in 2 cases and post-burn scar contracture in the remaining 3 cases. RESULTS The average flap size was 19.6 × 9.2 cm (range: 15-24 × 6-12 cm). There was no flap loss. Postoperative muscle weakness occurred in one case. The average follow-up time was 17.8 months (range: 5-36 months). No recurrence of tumor or scar contracture was noted. CONCLUSIONS Distally based anteromedial thigh flaps pedicled on the rectus femoris branch of the descending branch of the lateral circumflex femoral artery may serve as an alternative option to the distally based anterolateral thigh flap for soft-tissue defect reconstruction of the knee.

Rectus femoris branch: An alternative blood supply for a distally based anterolateral thigh flap

Successful raising of a distally based anterolateral thigh (dALT) flap mainly depends on a well-developed lateral circumflex femoral artery (LCFA) descending branch and an intact vascular connection between the descending branch and the vascular network of the knee. However, in some clinical scenarios, the descending branch is hypoplastic or the vascular connection of the knee is compromised. We present six cases of using dALT flaps in soft tissue defect reconstruction of the knee with either of the above-mentioned conditions. In these cases, the flaps relied on the reverse blood flow through the rectus femoris branch and showed complete survival postoperatively. We believe that the reverse flow from the rectus femoris branch could be an alternative blood supply for the dALT flap in the presence of hypoplasia of the LCFA descending branch or compromise of the vascular connection between the descending branch and the articular geniculate network.

Pre-expanded Paraumbilical Perforator Flap

The paraumbilical perforator flap is the first and the most famous perforator flap. Pre-expansion increases the flap dimension and reduces the flap thickness and donor site morbidities, making the paraumbilical perforator flap a more effective option for upper extremity reconstruction. Pre-expanded pedicled paraumbilical perforator flaps can achieve excellent function and aesthetic outcomes in patients with extensive scar contracture and giant melanocytic nevi in the upper extremity. Although this technique requires multiple procures, each operation is relatively simple and has a low complication rate, when properly planned and performed.

Pre-expanded Brachial Artery Perforator Flap

The medial upper arm flap is a time-honored yet ignored technique. It may be revitalized by combining the techniques of tissue expansion and perforator flap surgery. Pre-expansion increases flap dimension, remodels flap vasculature, and reduces donor site morbidities, making the medial arm flap a more effective option for various defect reconstructions. A pre-expanded brachial artery perforator flap achieves excellent functional and aesthetic outcomes in patients with soft tissue defects on the head and neck, axilla, chest wall, and upper extremity. Although this technique requires multiple procedures, each operation is relatively simple and has a low complication rate when properly performed.

Classification and Application of the Distally-Based Thigh Flap Based on the Lateral Circumflex Femoral Artery System

Background The lateral circumflex femoral artery system with its anatomical variations is a common source vessel for numerous thigh flaps. However, the anatomic variations of the distally based thigh flaps have not been well classified. Methods Between July 2008 and July 2016, 19 patients (13 men and 6 women; age range, 3–58 years; mean, 27.5 years) underwent reconstruction of defects around the knee using distally based thigh flaps. Defect etiologies included malignant neoplasm (6 cases) and post-burn scar contracture (13 cases). The distally based thigh flaps were raised based on perforating vessels originating from the descending, oblique, rectus femoris branches of the lateral circumflex femoral artery. Results The average flap size was 17.7 × 8.4 cm (range, 9–24 cm × 6–13 cm), whereas the mean pedicle length was 16.2 cm (range, 8.5–25 cm). The flaps perforating vessels originated from the descending branch in 6 patients, the oblique branch from the descending branch in 7 patients, the rectus femoris branch in 5 patients, and the oblique branch from the transverse branch in 1 patient. All flaps were pedicle flaps except 1 based on the oblique branch from the transverse branch that was converted to a free flap. All flaps survived in its entity. Conclusions Our experience demonstrated that a distally based thigh flap can be reliably raised using perforating vessels from different branches of the lateral circumflex femoral artery.

Perforator Propeller Flap for Oncologic Reconstruction of Soft Tissue Defects in Trunk and Extremities.

BackgroundDefects after soft tissue sarcoma resection are usually managed by myocutaneous flaps or free flaps. However, harvesting muscle will cause functional morbidities, and some regions lack reliable recipient vessel. Our purpose is to use various perforator propeller flaps for oncologic reconstruction. MethodsBetween 2008 and 2014, 33 perforator propeller flaps were performed in 24 patients to reconstruct the defects after tumor resection in trunk and extremities. Fifteen patients underwent tumor resection previously. Thirteen patients underwent adjuvant radiotherapy or chemotherapy. Flaps based on perforators adjacent to the lesions were raised and rotated in propeller fashion to repair the defects. ResultsTwenty-seven flaps were based on perforators of known source vessels, and 6 were harvested in freestyle fashion. The defects were repaired with 2 flaps in 4 patients and 3 flaps in 2 patients. The mean skin paddle dimension was 8.36 cm in width and 20.42 cm in length. The mean degree of flap rotation was 158.79°. Complications include partial necrosis of 6 flaps in 5 cases and venous congestion of 1 flap. In these 6 patients, 3 underwent adjuvant radiotherapy. The donor sites were primarily closed in 21 patients and skin grafted in 3 patients. No functional loss related to flap harvesting was recognized. ConclusionsThe perforator propeller flaps can be used to manage the medium defects in extremities and large defects in torso after soft tissue sarcoma resection. They avoid the sacrifice of the underlying muscle and eliminate the concerns of the unavailability of recipient vessels. The perforator propeller flaps provide flexible options for versatile oncologic reconstruction in trunk and extremities. However, the impact of radiotherapy on the viability of the flaps for local reconstruction needs further investigation.