Recycling of flap pedicle in complex lower extremity reconstruction: A proof of free muscle flap neovascularization.

This article portrays the authors' clinical experience of a complex case of lower extremity reconstruction using a recycled pedicle from 10 years old free latissimus dorsi musculocutaneous flap to supply a new free anterolateral thigh flap for proximal tibia wound defect reconstruction. It provides clinical evidence that muscle neovascularization occurs and supports the dogma peripheral tissue neovascularization. This case stipulates that recycling of pedicle is feasible, when used with appropriate strategy and safety and also provides evidence for the long-term survival of greater saphenous vein grafts in lower extremity reconstruction.

Five Simple Techniques to Enable Rapid Elevation and Donor Site Closure of the Anterolateral Thigh Flap.

We describe five technical notes to facilitate rapid elevation of the anterolateral thigh flap for extremity reconstruction. We highlight the advantages of (1) a lateral approach; (2) identification of the perforator with the shortest intramuscular distance; (3) deroofing technique with cutting monopolar for pedicle dissection; (4) taking a cuff of vastus lateralis in some cases to avoid unnecessary long perforator dissection; and (5) closure of large donor sites with a modified keystone flap. Using the sequence reduces flap-raising times to 60 to 90 minutes and improves theater usage while achieving excellent outcomes.

Prefabricated Cervical Skin Flaps for Hemi-Facial Resurfacing: Elucidating the Natural History of Postoperative Edema Using Indocyanine Green.

BACKGROUND: The increases in capillary wall permeability and capillary hydrostatic pressure are considered to be the causes for the acute swelling seen in flaps; however, disruption of the circulating flap lymphatics could be another contributory factor. In this study we monitor the development of flap edema in a series of 18 prefabricated flaps and aim to delineate the natural history of this phenomenon by use of lymphography. METHODS: Postoperative swelling was monitored in a series of 18 pre-expanded prefabricated cervical skin flaps used for hemi-facial burns-scar resurfacing. Time to spontaneous resolution, presence or absence of venous congestion, and clinical outcome were recorded. In two cases, indocyanine-green (ICG) lymphography was used to monitor the dermal backflow pattern until swelling had completely resolved. Average moving velocity of ICG after injection as well as flap thickness was also recorded over the follow-up period. RESULTS: The average moving velocity of ICG in the flap lymphatics improved from 0.48 cm/min to 1.5 cm/min in the first 12 days after flap transfer. The dermal backflow pattern was stardust in the first 12 days, indicating moderate lymphedema, transforming to splash from week three, and a robust collecting lymphatic vessel occurring from the fifth month, indicating mild lymphedema and lymphatic channel recovery, respectively. CONCLUSION: Transient swelling was observed in all prefabricated flaps in our series. We postulate that this is mostly secondary to lymphatic disruption that subsides as lymphangiogenesis takes place. ICG lymphography is an inexpensive, safe, and easy-to-use imaging technology that could be used in the monitoring of postoperative lymphedema seen in prefabricated flaps.

Far-Infrared Radiation Thermotherapy Improves Tissue Fibrosis in Chronic Extremity Lymphedema.

BACKGROUND: Fibrosis can enhance the exacerbation of lymphedema, which becomes obvious in late stage II-III lymphedema. However, whether far-infrared radiation thermotherapy (FIRT) can cure lymphedema fibrosis is still lack of research. This research was to investigate the therapeutic effect of FIRT on tissue fibrosis in the treatment of Late stage II-III lymphedema. METHODS: Patients accepted only FIRT for a total of 20 sessions. The treatment session duration was 2 hours, and a stable machine temperature of 42°C was maintained throughout treatments. Clinical evaluation and laboratory evaluation were conducted before and after FIRT. Clinical outcome measures included circumference of affected extremity, skin elasticity, ultrasound, patients' subjective assessment, and quality of life (QOL). Laboratory outcome measures included serum and local lymphedema tissue fluid concentrations of fibrosis associated cytokines, tissue growth factor beta-1 (TGF-ß1), interleukin (IL)-1ß, IL-4, IL-18, and caspase-1. RESULTS: Between 2015 and 2016, clinical evaluation of 64 patients with late stage II-III lymphedema was conducted. From this group, 12 cases (18.75%) underwent simultaneous laboratory evaluation. Circumferences of affected extremities improved significantly following treatment (p < 0.001). Skin elasticity of the affected extremity improved significantly (p < 0.05). Ultrasound investigation showed reduced fiber and dense material in the affected tissue (increased gray level 6.322% ± 7.624%, p < 0.001). Patients reported a subjective improvement of their symptoms such as decreased tightness, heaviness, solidity, pain, discomfort, and numbness (p < 0.001, p < 0.001, p < 0.001, p < 0.001, p < 0.001, and p = 0.032, respectively) and improved QOL (p < 0.001). Laboratory results revealed a significant decrease in local tissue fluid concentrations of TGF-ß1 (p = 0.041) and IL-18 (p = 0.049) after course completion. CONCLUSION: FIRT provides an effective treatment for lymphedema tissue fibrosis; it reduces the concentration of fibrosis cytokines in local lymphedema tissues. Consequently, this treatment can reduce the density of fibrosed tissue in the affected extremity, increase skin elasticity, significantly improve clinical symptoms, and improve QOL of patients.

Far-infrared ray for treating chronic lower extremity lymphedema with dermatolymphangioadenitis: a postoperative complication of gynecological tumor resection.

PURPOSE: Lower extremity lymphedema is regarded as a relatively common postoperative complication and is often accompanied with dermatolymphangioadenitis (DLA). This study combines clinical assessment and laboratory investigation to explore therapeutic effects of far-infrared radiation (FIR) therapy for chronic lower extremity lymphedema accompanied with DLA, occurring after gynecological tumor resection. METHODS: Patients who met inclusion and exclusion criteria would be enrolled. They received regular sessions using the FIR therapy machine over the 4-week treatment course. Clinical and laboratory outcome measures were carried out before and after treatment. Clinical outcome measures included DLA seizure frequency (episodes/year), patients' subjective feedback for lymphedema-related symptoms and quality of life (QOL). Laboratory outcome measures included bacterial cultures and concentrations of inflammatory cytokines: IL-1ß, IL-2, IL-4, IL-10, IL-12, IL-18, TNF-α, TNF-ß, caspase-1 and INF-γ, detected in serum and local lymphedema tissue fluid samples using protein microarray and ELISA. RESULTS: Between 2012 and 2016, a total of 120 female patients were screened for study enrollment. Sixty-four recruited patients underwent clinical evaluation both before FIR radiation therapy and 1 year after a single course of FIR radiation therapy. Eleven patients (17.2%), randomly chosen from the study group, underwent additional laboratory analysis of blood and local lymphedema tissue fluid samples. The frequency of DLA decreased following treatment (p < 0.001). Fifty patients (78%) did not experience a single episode of DLA recurrence in the year subsequent to treatment. The efficiency rate calculated using DLA frequencies was greater than 50% for 63 (98%) patients following treatment. Patients reported a subjective decrease in lymphedema-related symptoms (p < 0.05). Patients' QOL scores were higher after treatment (p < 0.001). Laboratory analysis showed an elevation in serum concentration of IL-1ß after FIR therapy (p < 0.05) and reduced local tissue fluid concentrations of inflammatory cytokines IL-2, IL-10 and IL-18 (p < 0.05). Bacterial culture results before and after treatment were both negative. CONCLUSION: FIR radiation therapy provides an effective treatment modality for patients with chronic lymphedema accompanied with DLA that develops secondarily to treatment of gynecological malignancies, whose therapeutic effects may be due to reduced immune dysfunction within local lymphedema tissues.

A reappraisal of the surgical planning of the superficial circumflex iliac artery perforator flap.

OBJECTIVE: The popularity of the superficial circumflex iliac artery perforator (SCIP) flap has been limited by factors such as variable vascular anatomy and short arterial pedicle. This article aimed to delineate flap design and harvest strategies based around either the proximal or distal perforators of the superficial circumflex iliac artery (SCIA) and propose a set of strategies that can help deal with the limitations of the flap. METHOD: From August 2011 to June 2015, the SCIP flap was used in 80 patients for soft tissue defects at our institution. We utilized vessel imaging navigation to get a detailed overview of the vascular anatomy preoperatively. Flaps were designed on the basis of either the proximal or distal perforators of the SCIA. Backup strategies and surgical maneuvers were suggested to solve the problems that emerged during surgery. RESULTS: In total, 51 flaps were raised on the basis of the proximal perforators of the superficial branch of the SCIA, whereas 25 cases were based on the distal perforators from the deep branch, and in four cases, the pedicle was switched to the superficial inferior epigastric artery. In eight cases, the arterial pedicle lengthen technique was applied with a maximum length of 10 cm. All donor sites were closed directly with inconspicuous scars. CONCLUSION: These surgical strategies simplified the intraoperative decision-making and overcame the shortcomings of the SCIP flap. We believe that the SCIP flap has a great potential to become a new workhorse flap in the field of reconstructive surgery.

Heating and Compression Bandage Treatment Is Effective for Chronic Lymphedema with Dermatolymphangioadenitis-A Case-Controlled Study.

BACKGROUND: To investigate the therapeutic effect of far infrared rays and compression bandaging in the treatment of chronic lymphedema with dermatolymphangioadenitis (DLA). METHODS: Between 2005 and 2013, 106 patients with chronic lymphedema with DLA treated at the Shanghai Ninth People's Hospital were retrospectively reviewed. These patients were divided into an infrared and a bandaging group (80 patients, group 1) and bandaging only group (26 patients, group 2). Outcome measures include DLA frequency, patients' subjective feedback with regards to their symptoms, and the relationship between continuous elastic compression bandaging and relapse of DLA. RESULTS: The frequency of DLA in group 1 and group 2 were significantly reduced after treatment (p = 0.000 and 0.004, respectively). Seventy five percent (60) of patients in group 1 and 19% (5) of patients in group 2 suffered no further episodes of DLA during the follow-up period. In group 1, over 90% of patients reported a subjective improvement in their symptoms and the relapse rate was shown to be lower using elastic compression bandaging when higher pressures were applied. CONCLUSION: Heating with compression bandaging can be an effective treatment strategy to reduce DLA and improve the quality of life for those patients with chronic lymphedema associated with DLA.

Versatility of the Free Anterolateral Thigh Flap in the Reconstruction of Large Defects of the Weight-Bearing Foot: A Single-Center Experience with 20 Consecutive Cases.

Background Reconstruction of the weight-bearing surface of the foot represents a challenging task. With very little scope to borrow glabrous tissue from adjacent areas means that achieving a "like for like" reconstruction is rarely possible. In this setting, alternative approaches need to be considered. In this article we present our experience with various differing designs of the anterolateral thigh flap (ALT) in the reconstruction of 20 large defects of the weight-bearing sole. Methods Twenty patients with complex soft tissue defects of the weight-bearing sole underwent reconstruction over a 5-year period. Five cases were complicated by osteomyelitis resulting in significant calcaneal defects. The follow-up period ranged from 8 to 48 months and outcomes were assessed by two-point discrimination and protective sensation, observation of gait, and the ability of the patient to return to wearing normal footwear. Results All flaps survived with the exception of two partial skin necrosis. Sensory nerve coaptation was performed in 12/20 cases. One patient underwent second-stage total calcaneal reconstruction with a fibula osteocutaneous flap. Five large defects were reconstructed with the split skin paddle technique to allow for direct donor-site closure. No evidence of postoperative ulceration was noted in any of the patients over the follow-up period and all were satisfied regarding the functional and aesthetic results achieved. Conclusion Complex defects of the weight-bearing sole can be successfully reconstructed using the free ALT flap resulting in very favorable functional outcomes. Even when calcaneal osteomyelitis has set in, excellent outcomes can be achieved.

Bipedicled Preexpanded Forehead Flaps for Simultaneous Reconstruction of Total Nasal and Upper Lip Subunits: A Novel Approach to Complex Facial Resurfacing.

Background Reconstruction of the central facial subunits is a complex and challenging task. In cases in which both the nasal and upper lip subunits are involved, a technique that can reconstruct both aesthetic units with tissue of similar color and texture from a single donor site will be ideal. In this article we present our experience with the bipedicled preexpanded forehead flap for simultaneous nasal and upper lip resurfacing. Patients and Methods Between January 2012 and January 2015 we used this technique in the simultaneous reconstruction of total nasal and upper lip subunits in five patients. All cases were for burns scar resurfacing. Results Good aesthetic results were achieved in each of our five cases to date and no complications were encountered. All donor sites closed primarily with aesthetically pleasing well-concealed linear scars. In all cases small modifications such as philtral shaping and further flap thinning were performed under local anesthesia between 6 and 12 months postoperatively Conclusion The preexpanded forehead flap provides an unparalleled color and texture match when it comes to facial resurfacing. When both total nasal and upper lip resurfacings are required, it is possible to achieve this in a single sitting from a single donor site by using a bipedicled preexpanded forehead flap.

New double-layer design for 1-stage repair of orocutaneous and pharyngocutaneous fistulae in patients with postoperative irradiated head and neck cancer.

BACKGROUND: The development of a postoperative orocutaneous fistula (OCF) or pharyngocutaneous fistula (PCF) in the irradiated tissues of patients with head and neck cancer represents a high burden of morbidity for the patient. With high postoperative recurrence rates, these fistulae result in a reconstructive challenge for the plastic surgeon. In this study, we propose a new double-layer design to successfully repair these fistulae in a 1-stage reconstruction. METHODS: Twelve patients with an average age of 56 years (range, 45-67 years) were operated on between January 2006 and December 2012 using this double-layer single-stage technique. All patients had received postoperative radiotherapy after their initial reconstruction. A circumferential turnover flap was designed and raised from the skin surrounding the fistula to recreate inner lining using a tension-free, water-tight repair. No debridement of the fistula itself was performed. The second-layer of the reconstruction, which represents the outer lining, was achieved with either a local or a free flap. RESULTS: Fistula size ranged from 0.8 × 0.5 cm to 3 × 3.2 cm with a mean size of 2 cm(2) . The outer lining was achieved using a free flap in 5 cases and a local flap in 7 cases. All the flaps survived completely with no cases of postoperative infection, however, 1 case was complicated by mandibular plate exposure necessitating its removal. No major complication or recurrence has yet been encountered in any of our patients with a mean follow-up of 28 months (range, 12-78 months). CONCLUSION: This 1-stage double-layer design can provide a reliable and relatively straightforward means of repairing OCF and PCF in the irradiated tissues of patients with head and neck cancer. © 2015 Wiley Periodicals, Inc. Head Neck 38: E353-E359, 2016.

A Prospective Head-to-Head Comparison of Color Doppler Ultrasound and Computed Tomographic Angiography in the Preoperative Planning of Lower Extremity Perforator Flaps.

BACKGROUND: This investigation compared the application of color Doppler ultrasound and computed tomographic angiography in preoperative planning of lower extremity perforator flaps. METHOD: This study was a prospective comparative analysis of 40 patients with lower extremity defects who underwent reconstruction with perforator flaps. The position, caliber, route, and quality of the perforator vessels were detected by computed tomographic angiography and color Doppler ultrasound preoperatively. The results of the preoperative navigation with both imaging techniques were verified during the operation. RESULTS: Color Doppler ultrasound had a higher accuracy in terms of identifying (95 percent versus 90 percent) and locating (95 percent versus 82.5 percent) the perforators in the lower extremity. Color Doppler ultrasound required approximately 25 minutes for examination, whereas computed tomographic angiography required 46 seconds for the scan and approximately 22 minutes for the image analysis. There was no significant difference between the two methods. CONCLUSIONS: Preoperative radiologic vessel navigation is capable of offering valuable information such as the perforator's location, diameter, and path; and information regarding the quality of the perforators, which can shorten the operative time and improve the surgical results. The authors recommend color Doppler ultrasound for preoperative planning when harvesting perforator flaps from the lower extremity. In cases where the patient has a metal implant, allergy to the contrast agent, or renal insufficiency, color Doppler ultrasound is the only option. In time, the use of color Doppler ultrasound and computed tomographic angiography in combination will be recommended to improve the accuracy of preoperative perforator navigation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, IV.

Prelamination of the Anterolateral Thigh Flap With a Fibula Graft to Successfully Reconstruct a Mandibular Defect.

Flap prelamination is the process whereby a complex 3- dimensional construct is fashioned in a staged manner. We present a case whereby the tissues of the anterolateral thigh, nourished by perforators of the descending branch of the lateral circumflex femoral artery, were prelaminated with a fibula in the setting of salvage head and neck reconstruction. With a paucity of recipient vessels in the neck and a previous failed free fibula transfer secondary to osteoradionecrosis, a fibula was implanted into a suprafascial pocket created in the anterolateral thigh. This was allowed to pick up a blood supply from this rich vascular bed and mature over a period of 3 weeks before being transferred with the anterolateral thigh tissues as a prelaminated osteocutaneous composite free flap. A bone scan performed both before and after transfer confirmed uptake of radionucleotide by the fibula suggesting neovascularization. The composite mandibular defect was successfully reconstructed using this technique, and we believe this could represent a new strategy in the setting of salvage head and neck surgery.

Pedicled free-style perforator flaps for trunk reconstruction: a reliable method.

BACKGROUND: By exploring the perforating vessels that supply the soft tissues adjacent to a given defect, a perforator flap can be designed in free-style fashion. METHODS: From 2009 to 2013, 14 defects of the trunk (excluding the abdomen) were reconstructed using pedicle free-style perforator flaps at the Department of Plastic Surgery, E-Da Hospital, Taiwan. Several perforators at the periphery of the defect were detected and marked preoperatively using a handheld Doppler probe. Then, they were explored intraoperatively through the existing wound edge after wide excision of lesions. The most suitable perforator was selected by means of direct vision and chosen as the pivot point, and then the flap was designed around it, taking into consideration the axiality of the vessel and the ability to achieve direct donor-site closure. RESULTS: All of the flaps survived completely, except for one flap that partially failed because of congestion, and for which the salvage procedure was a skin graft. Full coverage of the defect with excellent contour and color matching and primary closure of the donor sites was achieved in all of the patients. CONCLUSIONS: The free-style approach to trunk reconstruction allows the surgeon to complete a robust like-for-like reconstruction while confining the scar burden to a single site. Using the handheld Doppler device and visualizing the perforators directly through the wound edge eliminates the need for preoperative imaging, and allows for the optimal flap to be designed based on vessel size and quality and minimizes donor-site morbidity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

A "green" approach to secondary reconstruction: the concept of the recycle flap and a classification.

BACKGROUND: Harvesting soft tissue from a previously transferred flap allows for flap reshaping and simultaneously raising tissue for a secondary procedure. This is done without increasing the number of donor sites and is therefore a very attractive reconstructive option. METHODS: Between March of 2011 and October of 2013, the authors performed 60 recycle flaps on 60 patients (three women and 57 men) who had undergone previous flap reconstruction (52 free and eight pedicled). The recycle flaps were raised as either random pattern or perforator flaps. Mean time between primary reconstruction and the recycle procedure was 28.3 months (range, 6 months to 20 years), and the mean age of our patients was 57 years (range, 21 to 78 years). RESULTS: Of 60 recycle flaps raised for secondary reconstruction, 58 survived completely (97 percent). Two cases of total flap necrosis were encountered resulting from pedicle damage during attempted perforator dissection within a previously irradiated flap. Twenty-nine flaps were raised as random pattern flaps, 29 were raised as pedicled perforator flaps (20 with perforator skeletonization), and two were raised as free perforator flaps. CONCLUSIONS: There are a number of ways to safely "recycle" the soft tissues used in a previous reconstruction. This provides new tissue for a secondary procedure while debulking and refining the primary flap. Raising perforator flaps from previously irradiated flaps is, however, technically challenging and carries a high risk of flap necrosis (40 percent in our series) and should be advised against. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Achieving direct closure of the anterolateral thigh flap donor site-an algorithmic approach.

BACKGROUND: Minimizing donor-site morbidity after free flap harvest is of paramount importance. In this article, we share our experience with achieving primary closure of 58 anterolateral thigh (ALT) free flap donor sites using a simple algorithm in cases where primary closure would otherwise have not been possible. METHODS: Between 2004 and 2010, 58 patients who underwent free ALT flap reconstruction were included in the study. The inclusion criteria were those who had flap width requirements that were wider than 16% of the thigh circumference and had achieved direct primary closure of the donor site by the use of our technique. RESULTS: Primary closure of the donor sites was facilitated in all cases by the use of 3 distinct techniques. This included the use of the V-Y advancement technique in 13 patients, split skin paddle technique in 7 patients, and the tubed skin paddle design in 38 patients. No episodes of postoperative wound dehiscence at the donor site were encountered; however, 2 cases were complicated by superficial wound infections that settled with a course of antibiotics. CONCLUSIONS: Direct primary closure of the ALT donor site can be facilitated by the use of our simple algorithm. Certain strategies need to be adopted at the design stage; however, the techniques used are simple and reliable, produce superior cosmetic results at the donor site, save time, and spare the patient the morbidity associated with the harvest of a skin graft.

Aesthetic subunit reconstruction facilitated with v-y island advancement flaps on the face: a case report.

SUMMARY: The reconstruction of complex facial soft-tissue defects is a challenge that is often encountered by the plastic surgeon. Careful planning and knowledge of the aesthetic subunits that border the defect are paramount to achieve optimal results. We present a case of a 56-year-old woman who underwent excision of a large disfiguring chronic xanthelasma that extended from canthus to canthus across the nasal bridge. An aesthetic outcome was achieved by use of bilateral V-Y nasolabial flaps combined with a V-Y glabella advancement, which allowed for a tension-free like-for-like subunit reconstruction.