Shugo Soeda

Inferior epigastric artery skin flaps without rectus abdominis muscle

The rectus abdominis musculocutaneous flap has many advantages, but its disadvantages are also well-known. These are the possibility of abdominal herniation and, in certain situations, its bulk. To overcome these problems, an inferior epigastric artery skin flap without rectus abdominis muscle, pedicled on the muscle perforators and the proximal inferior deep epigastric artery, have been used in two patients. A large flap without muscle can survive on a single muscle perforator.

Free anterolateral thigh flaps for reconstruction of head and neck defects.

The anterolateral thigh flap is a septocutaneous artery flap based on the septocutaneous or muscle perforators of the lateral circumflex femoral system. Little has been reported about the variations in its vascular anatomy and its application for head and neck reconstruction. We report 22 cases in which this flap was used for the reconstruction of head and neck defects. Based on our clinical and cadevaric experiences, the derivation of the vascular pedicle of this flap has four variations by which the septocutaneous perforators are derived from the descending branch of the lateral circumflex femoral system and/or from the transverse branch of that system, or for which there are no septocutaneous perforators but there are muscle perforators originating from the lateral circumflex femoral system. Clinically, the vascular variations and the locations of perforators of this system can be determined preoperatively with stereoangiograms or simple angiograms and Doppler audiommetry. The anterolateral thigh fasciocutaneous flap is suitable for reconstruction of defects in an oral floor with tongue and esophageal deficits, scalp defects with dural defects, and for large full thickness defects of the lip. The advantages of this flap are safe elevation, a long and wide vascular pedicle, skin that is generally thin, and good pliability. Even if the skin is thick, a thinner flap can be created by sacrificing a large amount of fatty tissue. Furthermore, the skin territory is very wide and long. The donor defect can often be closed directly with its scar being less noticeable. The disadvantage of this flap is that the anatomy of the pedicle vessles has irregular derivation from the main vessels. This can be overcome, however, by employing preoperative stereoangiograms. (Plast. Reconstr. Surg. 92: 421, 1993.)

The gluteal perforator-based flap for repair of sacral pressure sores

A gluteal perforator-based flap employing the gluteus maximus muscle perforators located around the sacrum is described. A cadaveric study disclosed the existence of several significant perforators all around the gluteal region. Among these, the parasacral perforators originating from the internal pudendal artery and lateral sacral artery have proven useful for the repair of sacral pressure sores. A total of eight decubitus in seven patients were treated with gluteal perforator-based flaps. There were no postoperative complications, such as flap necrosis and wound infection, with the exception of fistula formation in one case. This flap requires no transection or sacrifice of the gluteus maximus muscle, and elevation time for the flap is short. However, the perforators are located at various sites and thus require some careful dissection.

The anterolateral thigh flap; variations in its vascular pedicle

The anterolateral thigh flap is based on the septocutaneous perforators of the lateral circumflex femoral artery. Little has been written about anomalies of its vascular pedicle. We report two variants of the pedicle vessel in eight patients in whom this flap was used, and absence of the perforators in five other cases in whom it was attempted. The anterolateral thigh flap has the advantages of thin and pliable skin, long and large pedicle, inconspicuous donor scar and the technical possibility of combination with fascia, sensory nerve and iliac bone. If the perforators are absent, a tensor fasciae latae musculocutaneous flap or anteromedial thigh flap is available with only minor changes of the flap outline.

Free thin paraumbilical perforator-based flaps.

A free paraumbilical perforator-based flap fed by a muscle perforator from the inferior deep epigastric artery and with no muscle was used in 13 patients. Among them, a free thin paraumbilical perforator-based flap with a thin layer of fat, to protect the subdermal plexus of the vessels, was used in seven patients. The dominant pedicle perforator of this thin flap is usually located around the umbilicus and a large flap can be obtained. Its critical length-to-breadth ratio is considered to be 4:3. The advantages of this flap are a long and large vascular pedicle, rare postoperative abdominal herniation, little bulkiness of the flap, and a relatively large skin territory. The disadvantages are technical difficulties in dissection of the perforator and anatomical variation in the location of the perforator. We believe this flap largely overcomes the problems of the conventional rectus abdominis musculocutaneous flap.Koshima I, Moriguchi T, Soeda S, Tanaka H, Umeda N: Free thin paraumbilical perforator-based flaps. Ann Plast Surg 1992;29:12–17

Flaps nourished by arterial inflow through the venous system: an experimental investigation.

Using the abdominal skin flap of rats, we showed that the arterial inflow through the venous system nourished the distal part of a flap and also worked as a pedicle of an island flap and a free flap. The position of the arteriovenous anastomosis and the draining vein seems important. This study implies that delay produces arterial inflow as a consequence.

Free rectus femoris muscle transfer for one-stage reconstruction of established facial paralysis.

The free vascularized rectus femoris muscle graft with a long motor nerve was used for reconstruction of unilateral established facial paralysis in one stage. The pedicle vessels were anastomosed to the recipient vessels in the ipsilateral face, and the motor nerve of the muscle, which was led through the upper lip, was sutured to the contralateral facial nerve. The advantages of this one-stage reconstruction as compared with surgery involving second-stage reconstruction are that the reconstruction can be completed in one stage and that the period required for muscle refunctioning after surgery is short. The vascular supply of the rectus femoris muscle can emanate mainly from the lateral circumflex femoral artery. In our cadaveric study, five types of variation were found for origination of a nutrient artery of the muscle. The most common type was one in which the artery derived from the descending branch of the lateral circumflex femoral artery (39 percent). The motor nerve of the rectus femoris muscle is derived from the femoral nerve under the inguinal ligament and runs downward through the intermuscular space between the sartorius muscle and the iliopsoas muscle before entering the posteromedial part of the upper third of the rectus muscle. The advantages of using the rectus muscle are as follows: (1) safety and simplicity exist with one main large arterial supply for arterial anastomosis; (2) the length of the femoral nerve (more than 20 cm) is adequate for reaching the contralateral facial nerve for suturing; (3) a simultaneous operation by two teams is possible with the patient in the supine position; (4) the force and distance of contraction are appropriate to reanimate the face; (5) the rectus muscle can be separated as a segment with appropriate lengths, size, and power for replacing lost muscles in the face; (6) the tendinous fascia in both ends provides a reliable point for anchoring sutures, which provides firmer attachment; and (7) no loss of donor leg function occurs.

The Free or Pedicled Anteromedial Thigh Flap

The anteromedial thigh flap first described by Song is a septocutaneous artery flap based on the septocutaneous perforator originating from the lateral circumflex femoral vessels and long saphenous vein. The use of this flap for 3 patients who required soft tissue coverage is reported herein. The most important advantage of this flap is that it can be used not only as a skin flap but also as a vascularized fascia graft and fasciocutaneous free flap for the full-thickness defect of the abdominal wall and cranial region.

A compound radial artery forearm flap for the reconstruction of lip and chin defect

This report presents a successful case of lip and chin reconstruction by a compound radial artery forearm free flap. This was a versatile source of tissue in the absence of local tissue for reconstruction.

Vascularized free nail grafts nourished by arterial inflow from the venous system.

Three patients underwent successful transplantation of the great toenails to their index fingers using the method of vascularization from venous pedicles. We have found that this procedure is easy and reliable.