Wolfgang Michlits

Reconstruction of Soft Tissue Defects Overlying the Achilles Tendon Using the Super Extended Abductor Hallucis Muscle Flap

BACKGROUND Soft tissue defects overlying the Achilles tendon often occur after traumatic ruptures of the Achilles tendon or because of pressure ulcers in patients suffering from circulatory problems. Ideally, reconstruction should be achieved in as few stages as possible. Currently, there are different methods used to treat these defects. Here, we examined whether reconstruction of this region could benefit from the super extended abductor hallucis muscle flap. METHODS In 12 cadaver feet, the vascular supply and mobilization radius of the abductor hallucis muscle were studied to clarify the possible clinical utilization of this flap. A technique for Achilles defect reconstruction using this flap, along with the functional and cosmetic results in six patients are presented. RESULTS Our anatomic findings agree with those available in the literature and the adaptation in pedicle preparation allowed an increase in rotation of the flap for successful coverage of defects overlying the Achilles tendon. Using the super extended abductor hallucis muscle flap, the functionality and the anatomic shape were successfully reconstructed. Six weeks after surgery all patients were fully mobile, unless they suffered from Achilles tendon ruptures then they were mobile after 12 weeks. CONCLUSIONS The super extended abductor hallucis muscle flap might represent an alternative to established methods because of ease of handling and a shorter anesthesia compared with a free flap procedure.

Valvular Density Alone Cannot Account for Sites of Chronic Venous Insufficiency and Ulceration in the Lower Extremity

Objective: Class 6 chronic venous stasis is associated with abnormal venous hemodynamics and ulceration. Ulcers primarily occur over bones and tendon prominences but very rarely over muscular compartments. We hypothesized that the anatomical distribution of venous stasis ulcers in the lower extremity is related to a lower density of venous valves.

Perineal reconstruction after rectal and anal disease using the local fascio-cutaneous-infragluteal flap: A new and reliable technique

BACKGROUND Significant morbidity can result from perineal wounds, particularly if the tissue has been partially devitalized after radiotherapy and extensive resection for cancer or chronic inflammation which may occur in Crohns disease. Many different types of flaps have been used to improve healing of perineal tissue defects. The purpose of this study was to evaluate the morbidity and outcomes of reconstruction using the local fasciocutaneous infragluteal (FCI) flap. METHODS Fourteen consecutive patients undergoing local FCI flap reconstruction for perineal wounds and defects were included in the study. In 5 female patients, the defect included the dorsal wall of the vagina, which was reconstructed in 1 step. Ten patients underwent operations for anal or low rectal cancer, 3 suffered from Crohns disease and extensive local fistula formation, and 1 young girl presented with a defect after resection of a perineal synovial sarcoma. Eleven of these patients underwent preoperative chemotherapy and either pre- or intra-operative radiotherapy. RESULTS Complete healing of perineal wounds occurred in 13 of the 14 patients. There were 4 flap-related complications, including 3 patients with delayed wound healing and wound dehiscence and 1 patient with partial flap necrosis. The last patient required a second local flap for wound closure. In 2 patients, a second FCI flap was necessary because of a second tumor and a local tumor recurrence. Ambulation and normal mobility were possible after the flap procedure in all patients without restriction of activity. Four patients died during the follow-up period (median, 42.5 months) from tumor metastasis. CONCLUSION Local FCI flap for reconstruction of large perineal defects achieves good wound healing with only moderate morbidity in most patients after extensive resection owing to cancer or Crohns disease.

Pectus excavatum and free fasciocutaneous infragluteal flap: a new technique for the correction of congenital asymptomatic chest wall deformities in adults.

Background: Pectus excavatum is typically a cosmetic congenital chest wall deformity. In most cases, it does not affect heart and lung function; therefore, because of their high rate of complications, extensive procedures need not be performed. Various alternative techniques (e.g., reconstruction with silicone prosthesis or the transverse rectus abdominis musculocutaneous flap) were introduced in asymptomatic pectus excavatum. All of these methods have their advantages but also limitations. Thus, the authors used a free fasciocutaneous infragluteal flap for reconstruction of asymptomatic pectus excavatum in selected patients. Methods: Between 2001 and 2007, six patients suffering from asymptomatic pectus excavatum underwent correction with the free fasciocutaneous infragluteal flap. The fasciocutaneous infragluteal flap is based on a constant end artery of the inferior gluteal artery. After raising of the flap and wound closure in the buttock region, the flap was adjusted to the defect using a small skin incision in the inframammary fold, and the vessels were anastomosed. Results: There were no flap losses and no major complications. One patient suffered from a sensory change at the posterior thigh in the early postoperative period that resolved completely within 2 weeks. In four cases, flap shaping or liposuction was performed to improve the aesthetic result. In the authors’ final evaluation, all patients were very satisfied with the result and would undergo the procedure again. Conclusions: The authors have demonstrated for the first time the reconstruction of asymptomatic pectus excavatum with the free fasciocutaneous infragluteal flap. It is the authors’ opinion that, in selected patients, this flap offers an excellent alternative to established techniques for this problem.

Local fasciocutaneous infragluteal (FCI) flap for vulvar and vaginal reconstruction: a new technique in cancer surgery.

Introduction Soft tissue reconstruction after vulvar, vaginal, or anal cancer resection poses a formidable task for reconstructive surgeons because of the functional, locational, and cosmetic importance of this region. Although numerous flaps have been designed for vulvar reconstruction, each has its disadvantages. Methods The authors introduce the local fasciocutaneous infragluteal (FCI) flap for vulvar and vaginal reconstruction after tumor resection, vaginal scar obliteration, and vulvar ulceration in 15 patients operated on between 1999 and 2007. The FCI flap is supplied by the cutaneous branch of the descending branch of the inferior gluteal artery. The sensory supply of this flap comes from side branches of the posterior cutaneous nerve of the thigh. A total of 17 flaps were performed in 15 patients. Results Except for one, all flaps survived. One flap necrosis occurred because of false postoperative position with compression and tension to the vascular pedicle. In the remaining patients, we found one local cancer recurrence with necessity of a second flap from the contralateral side. The patients report satisfaction with reconstruction, without one having pain at donor site and recurrent vaginal ulceration. Conclusions This article discusses the expanding indications of this versatile flap and the operative technique of the local FCI flap for reconstruction of vulvar and partial vaginal defects. It can be raised in different volume and dimension out of possible irradiated area with an inconspicuous scar.

Autologous Breast Augmentation With the Deepithelialized Fasciocutaneous Infragluteal Free Flap: A 10-year Experience

Introduction:Breast augmentation with silicone implants is frequently performed, a daily procedure in plastic surgery. Nevertheless, there are well-known risks of capsular formation and contraction leading to pain, displacement, and rupture after breast augmentation. Thus, the frequency of augmentation with autologous tissue is increasing. Most frequently used are the transverse rectus abdominis muscle flap, the deep inferior epigastric artery perforator flap, and the gracilis free flap, but in some cases, these flaps are not the first choice. Therefore, we present our experience with the free fasciocutaneous infragluteal (FCI) flap. Methods:The FCI flap is based on a constant end artery of the inferior gluteal artery and has frequently been used for various indications at our department for many years. Since 1998, 17 patients suffering from breast hypoplasia, congenital breast asymmetry, or consecutive capsular fibrosis were treated with 25 FCI flaps. Results:In this series, no complete or partial flap loss was clinically detected. The only complaint was a discomfort at the donor site in the early postoperative period. As revealed by a final questionnaire, all patients were satisfied with the result. Conclusion:Our results suggest that the FCI flap should be considered as a worthy alternative for autologous breast augmentation, especially in thin patients suffering from breast hypoplasia, congenital asymmetry, or consecutive capsular formations.

Nose reconstruction by chondrocutaneous preauricular free flaps: anatomical basis and clinical results.

Many flaps have been suggested over the years, but the ones that are used most often have two things in common—they fulfill a therapeutic need sufficiently often to make the surgeon familiar with them, and they exploit areas of availability effectively. —Ian McGregor1 Does this free flap of preauricular skin and tragal cartilage satisfy these criteria? Michlits et al. studied the vascular supply of the preauricular area by injection and anatomic dissection in 72 cadavers and with duplex sonography in 15 volunteers. They identified a tragal branch of the superior temporal artery in more than 97 percent of examinations, suggesting that a new free flap of preauricular skin and its adjacent deep tragal cartilage is available for microvascular transfer in nasal repair. In six patients, partial-thickness defects of the nose were resurfaced with this free flap. Two clinical cases are illustrated. In both, small flaps approximately 2 3 cm in size were used to resurface the nasal tip, transferring an unspecified amount of tragal cartilage (presumably a block approximately 1 cm in size). What do the results show us? We are not provided enough information to know. In case 1, the flap “matches” adjacent nasal skin fairly to moderately well, but the tip contour is poor and inadequately projected. The preauricular donor site is barely visible, but is only fair in quality. In case 2, the only postoperative photograph shows excellent projection on the lateral view. However, intraoperative photographs suggest that a postoperative frontal view would show a bulky repair. The donor site is not shown. To have real application, any facial donor site must be available and useful. Facial sites are limited in size, but can be easily and reliably transferred by traditional methods. Matching well in color and texture, the helical rim has been transferred as a composite skin graft to supply cover support and lining to repair nasal defects. Although the flap size is limited by the resulting deformity of the donor ear, the helical contour can duplicate the delicate alar rim shape. Recently, the helical root has been transferred as a free flap based on the superficial temporal vessels. As noted by Pribaz and Falco,2 it is a “substantial effort for repair of a relatively small defect,” but was recommended for partial defects of the distal nose when a patient or surgeon wishes to avoid a “central facial deformity” (a forehead scar). Unfortunately, microvascular surgery requires a unique level of technical skill and surgical support. The preauricular free flap described by Michlits et al., unlike the helical free flap described by Pribaz and Falco, provides only a small amount of surface skin and a flat cartilage strip. It cannot be used to re-create a contoured alar rim, to provide cartilage with an intrinsic nasal shape, or to provide lining. It is, however, equally at risk of vascular failure. It may be practical to distinguish between categories of “difficult” facial wounds. Some defects, complicated by massive tissue loss, poor vascularity, significant contamination, or exposed vital structures, are best addressed by microvascular transfer. To preserve life or function, large amounts of highly vascular composite tissue can be transferred in a single stage as a distant free flap. The distant tissue does not match facial skin or have a nasal shape. Thus, distant tissue is best used for the “invisible” requirements of support, platform,

Treatment of segmental bone and soft-tissue defects of the forearm with the free osteocutaneous lateral arm flap.

BACKGROUND Complex defects of the forearm often require microvascular reconstruction with osteocutaneous free flaps to salvage the limb. In this review, we report our experience with the use of the free osteocutaneous lateral arm flap to reconstruct such defects in four patients. METHODS Three male patients with osseous defects of the ulna and one defect of the radius with associated soft-tissue defects were treated with a free osteocutaneous lateral arm flap between 2004 and 2007. The indications for the procedure included posttraumatic osteitis (3) and bone with soft-tissue defects after trauma (1). We evaluated the patients with respect to postoperative results by evaluating the range of motion, pain, strength, and score on the disabilities of the arm, shoulder, and hand questionnaire. Donor-site morbidity was also documented. RESULTS The average length of segmental bone defects was 5.75 cm. The average dimension of the skin paddle was 99.5 cm. The average duration of follow-up was 43.3 months. All bone flaps healed without nonunion; the fasciocutaneous flaps healed without complications. No problems related to microanastomoses were found. Functional results were very satisfactory; disabilities of the arm, shoulder, and hand questionnaire scores showed a median of 5.8 (0-10.8). All patients had returned to their preinjury occupations. CONCLUSION This analysis demonstrates that the free osteocutaneous lateral arm flap is an effective treatment for combined segmental osseous and soft-tissue defects of the forearm that are caused by osteitis and trauma.

The new distal soleus adiposal pull-through composite flap for reconstruction of defects overlying the Achilles tendon: The anatomy and clinical experience

INTRODUCTION Defects overlying the Achilles tendon are common in patients after immobilization, particularly in those with vascular disease. Conservative wound management and local or free flaps are well-known treatments. Rapid recovery is important, especially in elderly patients; therefore, we looked for an alternative local surgical technique. We introduced for the first time the distal soleus adiposal pull-through flap for covering limited defects over the Achilles tendon. METHODS In 10 cadaveric feet, the vascular supply of the sub-Achilles adiposal tissue was studied to clarify the possible clinical utilization. We introduced this novel technique in 6 clinical cases. First, debridement was carried out and the Achilles tendon was divided in the midline. Next, the underlying soleus muscle and sub-Achilles adiposal tissue were carefully dissected. After detaching the flap distally, it was pulled through the Achilles tendon and fixed into the defect. Forty-eight hours later, the flap was covered with meshed split-thickness skin graft. RESULTS Our anatomic findings showed a sufficient blood supply of the sub-Achilles adiposal tissue by perforators from the soleus muscle, even after ligation of all perforators from the posterior tibial artery and fibular artery. This novel technique allowed a successful defect reconstruction with good functional and cosmetic outcome in all our cases. Two weeks after operation, all patients were fully mobile. DISCUSSION The distal soleus adiposal pull-through flap is a reliable flap for coverage of defects overlying the Achilles tendon, especially in patients with vascular problems and/or elderly patients. The ease of handling, short operative time, and the early mobilization are of great benefit to patients. Therefore, this novel technique should be considered for limited defect reconstructions overlying the Achilles tendon.

Special techniques in the funnel chest deformity

With the triumphal march of the surgical method (MIRPE) in the correction of pectus excavatum deformities, according to Donald Nuss [6] the method originally described by Ravitch in 1949 and 1958 [9, 10] was partially dislodged into the background and minor scope was left for special applications only. However the Ravitch technique is still widely used as a standard procedure in the correction of pectus carinatum deformities (Chapter 7.1) Although a recent study consisting of a systematic review and meta-analysis methodology confirmed that the complication rate in the MIRPE technique is higher than in the Ravitch technique, and the period of requirement of postoperative analgesics seems to be lower than in the MIRPE collectives, a clear difference concerning the aesthetic outcome could not be elaborated. It seems that particularly the parameters of pain and aesthetic result, being of paramount importance for the patient self, could not be studied comparatively due to too many biasing factors and lack of long-term comparability [1, 5]. Despite that the MIRPE technique offers a method requiring far shorter surgery time and represents an overall elegant method with however pleasing results lasting for many years. The elegancy and straightforward technique in experienced hands with relatively hidden scars supported its triumphal march so far, convincing patients and surgeons as well. However, these findings are predominantly true for children and adolescents, but must be regarded differentiated in adults. For the latter collective of patients no comparative data are yet available.