Standard Fixed Enoxaparin Dosing for Venous Thromboembolism Prophylaxis Leads to Low Peak Anti-Factor Xa Levels in Both Head and Neck and Breast Free Flap Patients.

BACKGROUND: Venous thromboembolism (VTE) is a serious complication, particularly in cancer patients undergoing free flap reconstruction. Subcutaneous enoxaparin is the conventional prophylaxis for VTE prevention, and serum anti-factor Xa (afXa) levels are being increasingly used to monitor enoxaparin activity. In this study, free flap patients receiving standard enoxaparin prophylaxis were prospectively followed to investigate postoperative afXa levels and 90-day VTE and bleeding-related complications. METHODS: Patients undergoing free tissue transfer during an 8-month period were identified and prospectively followed. Patients received standard fixed enoxaparin dosing at 30 mg twice daily in head and neck (H&N) and 40 mg daily in breast reconstructions. Target peak prophylactic afXa range was 0.2 to 0.5 IU/mL. The primary outcome was the occurrence of 90-day postoperative VTE- and bleeding-related events. Independent predictors of afXa level and VTE incidence were analyzed for patients that met the inclusion criteria. RESULTS: Seventy-eight patients were prospectively followed. Four (5.1%) were diagnosed with VTE, and six (7.7%) experienced bleeding-related complications. The mean afXa levels in both VTE patients and bleeding patients were subprophylactic (0.13 ± 0.09 and 0.11 ± 0.07 IU/mL, respectively). Forty-six patients (21 breast, 25 H&N) had valid postoperative peak steady-state afXa levels. Among these, 15 (33%) patients achieved the target prophylactic range: 5 (33%) H&N and 10 (67%) breast patients. The mean afXa level for H&N patients was significantly lower than for breast patients (p = 0.0021). Patient total body weight was the sole negative predictor of afXa level (R 2 = 0.47, p < 0.0001). CONCLUSION: Standard fixed enoxaparin dosing for postoperative VTE prophylaxis does not achieve target afXa levels for the majority of our free flap patients. H&N patients appear to be a particularly high-risk group that may require a more personalized and aggressive approach. Total body weight is the sole negative predictor of afXa level, supporting a role for weight-based enoxaparin dosing.

Individually tailored approach to reconstruction of complex defects using versatility of the lateral circumflex femoral artery system-based pedicled flaps.

Lateral circumflex femoral artery (LCFA) system is one of the most versatile donor sites in the body. We present our experience with pedicled flaps from the LCFA system, including different components for a wide variety of etiologies and locations. Twenty-three consecutive pedicled flaps were performed on 22 patients (10 females and 12 males; age 4-71 years) between 2007 and 2015 by a single surgeon. Flap size, type, and composition were tailored according to the requirements of the defects, including (1) location; (2) surface area; (3) depth; (4) number of defects; (5) presence of exposed critical structures; (6) presence of exposed foreign bodies; (7) prior use of other options; (8) history of radiation; and (9) other comorbidities. Defect locations were 10 abdominal wall (including groin and pubis), 9 ischio-gluteo-trochanteric and 4 perineal. Defect sizes ranged from 6 × 6 to 30 × 35 cm. Maximum depth of wounds ranged between 7 and 18 cm. The flap sizes ranged from 9 × 6 to 38 × 20 cm. Two flaps were fasciocutaneous perforator, 4 were myocutaneous with "muscle sparing" vastus lateralis, 10 were myocutaneous with "segmental" vastus lateralis, 5 were myocutaneous "tri-muscle," 1 was "tri-muscle," and 1 was rectus femoris only. Donor sites were closed primarily in 20 cases and with split thickness skin grafting in 3 cases. All flaps survived completely without any partial loss or congestion. Pedicled flaps from the LCFA system can be tailored individually for a wide variety of etiologies and locations. Muscles can be harvested and used as "muscle sparing," "segmental," and "tri-muscle" to accommodate the requirements of the defects.

A Single Superior Gluteal Artery Perforator Flap in Reconstruction of Large Midline Sacral Defects: A Method for Practical Harvest and Safe Closure.

BACKGROUND: Large midline sacral defects are reconstructive challenges. Superior gluteal artery perforator (SGAP) flap provides enough tissue and versatility to cover large defects; however, a single flap may be insufficient. We present a technique to cover large defects using single SGAP flaps. METHODS: Large sacral defects (>100 cm2) reconstructed with single SGAP flaps were included. Angle of transposition (45°-60°) was determined based on the tissue laxity and mobility of gluteal area. Perforator identification, intramuscular dissection, or skeletonization was not performed. Outcomes were measured as achieving durable reconstruction, flap viability, and complications. RESULTS: There were 17 patients (12 male, 5 females; aged 25-72 years) with different etiologies. The mean flap surface area (136.1 ± 45.6 cm2, between 9 × 8 and 26 × 10 cm) was smaller than the mean defect surface area (211.1 ± 87.2 cm2, between 10 × 10 and 28 × 14 cm) (P < 0.001). All flaps survived with no partial or complete flap loss. Minor dehiscence in 4 patients (2 at donor site and 2 at recipient site) healed with dressing changes or using negative-pressure vacuum therapy. All patients had durable outcomes without any recurrence. CONCLUSION: Single unilateral SGAP flaps can be used to completely cover midline large sacral defects. It is important to design the flaps to have a joint side with the defect in the proximal part and use the intrinsic mobility of gluteal soft tissues for the closure. Flaps can be (1) planned to be smaller than the defects, (2) harvested with no intramuscular perforator dissection or pedicle skeletonization, and (3) transposed with an angle less than 60°.

Flap Closure of Spinal Defects in High-Risk Patients: A 10-Year Institutional Experience.

BACKGROUND: Complication rates after spinal surgery are high, in part because of surgical advancements that have made procedures available to a broader range of medically complicated patients. The high rates of infection, hematoma, and dehiscence resulting in open wounds after spinal surgery often warrant plastic surgery involvement. In this study, we aim to examine the effects of preoperative and operative risk factors on complication rates, reoperation rates, and hospital length of stay after flap reconstruction of spinal defects. METHODS: A retrospective review was performed of 373 patients who required flap reconstruction for spinal wound closure at our institution between 2003 and 2013. Data regarding demographics, comorbidities, operative variables, and postreconstructive course were collected. RESULTS: Of the 373 patients, 97.3% had at least 1 comorbid condition associated with poor wound healing, 91.2% had a significant wound condition at the time of reconstruction, and 81.8% had a history of 2 or more spinal surgeries. After reconstruction, average hospital stay was 14 days, with 35% of patients developing complications and 30% requiring reoperation. Risk factors including elevated body mass index, diabetes, tobacco use, steroid use, low prealbumin level, therapeutic anticoagulation, infection, history of spine surgery, multilevel spinal reconstruction, and spinal hardware were associated with complications, reoperations, and prolonged length of stay. CONCLUSIONS: Local muscle flap coverage is an effective strategy for the reconstruction of spinal defects in medically complex patients. To reduce the inherently high risks associated with paraspinous reconstruction in this challenging population, special consideration should be given to preoperative and operative variables associated with poor outcomes. Early coordination between spine and plastic surgeons should be considered in patients at high-risk of wound complications.

Total aesthetic reconstruction of postburn bilateral breast loss using transverse myocutaneous gracilis free flaps: A case report and literature review.

Reconstruction of breast burns are challenging, as it includes both functional and aesthetic components. Transverse myocutaneous gracilis (TMG) flap has been used for postmastectomy breast reconstruction in the absence of abdominal donor site availability. Use of this flap for the breast burns is limited. A 32-year-old female sustained 54% second and third degree burns resulting with bilateral total breast loss. Anterior and posterior thorax, upper and mid abdomen, neck, shoulders, and bilateral upper extremities were also involved. Inner medial thighs had an ample amount of tissue and had never been used as donor sites. The left TMG (28 × 12 cm, 1,413 g) was used for right, and the right TMG (30 × 14 cm, 1,635 g) was used for the left breast, 3 months apart. The contracture on the chest wall was completely excised. Venous anastomosis to the venae commitantes was performed using a 2.5 mm coupler, followed by an end-to-end arterial anastomosis to the internal mammary artery. Flaps were inset in a fashion so that the inferior part became the inframammary fold, and the anterior and posterior wings were joined in the upper pole, creating a conical shape. Minimal wound dehiscence in the postoperative course healed with dressing changes and both flaps survived completely. Nipple reconstruction and areolar tattooing was performed. The patient was very happy with the outcome at seventh year follow-up. TMG may be a valuable option even in bilateral cases of microsurgical autologous free tissue transfer for total aesthetic reconstruction of postburn breast loss.

Analysis of Selection of Recipient Vein, Number of Outflows, Style and Technique in Head and Neck Venous Anastomosis and a Proposed Algorithm.

Surgeons have preferential ways of performing venous anastomosis in head and neck microsurgery. However, controversies exist regarding the superiority of each method. This study aims to determine the effects of these variables on the rates of thrombosis and flap failure, and propose an algorithm to be used as a facilitator in the decision-making process. A total of 208 microsurgical reconstructions on 199 patients from a single surgeon's data were evaluated. Selection of recipient vein (superficial vs. deep), style of anastomosis (end-to-end vs. end-to-side), number of outflows (one vs. two) and technique of anastomosis (hand-sewn vs. coupler) were compared. Selection was done according to the pre- and intraoperative plan, as well as, surgeon's clinical judgement. Outcomes were determined as rates of venous thrombosis and flap failure. Five patients (2.4%) had venous problems, leading to two partial and three total flap failures. Selection of the recipient vein, style and number of outflows did not affect the outcomes, whereas coupler use decreased the rates of venous thrombosis and flap failure (p=0.008). Although it is difficult to set dogmatic criteria to achieve consistent outcomes, coupler use in this study prevented flap failure. An algorithmic approach was proposed with the results of the data and literature to increase the success in microsurgical anastomosis. Surgeons should use algorithms and sound judgement with adherence to microsurgical principles to obtain the best results for each patient.

Reconstruction of burn contractures of the anterior neck with pre-expanded free anterolateral thigh flaps.

Burn contractures of the anterior neck result in severe functional and aesthetic deformities. The release of wide contractures leads to defects that cannot be closed with local flaps. In these cases, tissue expansion of local tissues may be a solution. However, when local tissues are also burned or inadequate, microsurgical free tissue transfer may be necessary. In order to increase the surface are of the transferred flap, pre-expansion of the donor site can be combined with the procedure. Five patients with burn contractures of the anterior neck were treated using pre-expanded free anterolateral thigh (ALT) perforator flaps. The anterolateral thigh was dissected on top of the fascia lata in an avascular plane. The borders of the dissection were kept 2 cm lateral to the pre-identified perforators. A 1000cc rectangular tissue expander was placed. The time of expansion ranged from 4-11 months with a final over expanded volume of 1200cc. The defect sizes ranged from 10 × 21 cm to 20 × 27 cm. There were either one or two perforators included in the flaps. All flaps survived completely with good functional and aesthetic outcomes. Donor areas were closed primarily in one patient and with various amounts of skin grafts in five patients. Overall, pre-expansion decreased the amount of total skin grafted area in the donor site. Pre-expanded ALT perforator flap can be a good option in extensive burns with wide contractures where the regional donor areas are also affected. This technique has several advantages: 1) large flaps can be safely harvested, 2) the expanded skin thins out making it more aesthetically appropriate to resurface superficial defects, 3) expansion period of the thigh is well tolerated by the patients, 4) two teams can work simultaneously, decreasing the operating time, 5) the donor area can be closed either primarily or with minimal skin graft application, and 6) there is no functional loss in the donor area and the donor scar stays under the clothes.

Total aesthetic subunit reconstruction of the burned anterior abdomen using pre-expanded pedicled anterolateral thigh flap-A case report.

Combination of tissue expansion and perforator flaps broadened the reconstructive options in burn cases with wide scar contractures. We report a case of total aesthetic subunit reconstruction of the anterior abdominal skin using a pre-expanded pedicled anterolateral thigh (ALT) perforator flap in a patient with postburn contractures. Seventeen-year-old girl had a history of scalding burn to the anterior abdomen, resulting in tight contractures inhibiting her mobility. After an expansion period of 6 months, the flap of 27 × 30 cm was elevated at the suprafascial plane and tunneled to the anterior abdomen. The flap was used to resurface the defect from xyphoid process down to the mons pubis and bilaterally at linea semilunaris. Postoperative course was uneventful. A good quality aesthetic and functional reconstruction was achieved at the 10-year follow-up. Pre-expanded pedicled ALT flaps may be considered as an option in extensive scarring requiring large amounts of tissue.

Intramuscular Lipoma within a Free Myocutaneous Flap: Systematic Review and Management.

Lipomas are a common finding often of little clinical significance, but they can pose a challenge to the microsurgeon if discovered during flap harvesting, especially if found within the muscle along the pedicle or perforators. Here the authors report a case in which a well-circumscribed intramuscular lipoma was discovered within the muscle of a free myocutaneous right anterolateral thigh (ALT) vastus lateralis free flap. To the authors' knowledge, the management of lipoma during flap harvesting has not been previously discussed in the literature. A systematic review was performed, and an approach for the management of myocutaneous flaps containing a lipoma was described. Underappreciated considerations including lipoma location, growth pattern, and proximity to pedicle and perforators must be taken into account when evaluating a lipoma during flap harvest.

Primary Closure of Wide Fasciotomy and Surgical Wounds Using Rubber Band-Assisted External Tissue Expansion: A Simple, Safe, and Cost-effective Technique.

BACKGROUND: Although decompressive fasciotomy is a limb-saving procedure in the setting of acute compartment syndrome, it leaves a large wound defect with tissue edema and skin retraction that can preclude primary closure. Numerous techniques have been described to address the challenge of closing fasciotomy wounds. This study reports our experience with fasciotomy closure using rubber bands (RBs) for external tissue expansion. METHODS: Patients were informed about RB closure and split-thickness skin graft options. Only patients who opted for RB closure and had wounds that could not be approximated using the pinch test underwent the procedure. Starting from the apex and progressively advancing, the RBs were applied to the skin edges at 3 to 4 mm intervals using staples. The RBs were advanced by twisting back-and-forth to create a criss-cross pattern. One week after application, fasciotomy wounds were closed primarily or underwent further RB application, based on clinical assessment of adequacy of skin advancement, compartment tension, and perfusion. Review of a prospectively maintained database was performed, including demographics, comorbidities, etiology, wound and operative details, hospital stay, and complications. RESULTS: Seventeen consecutive patients with 25 wounds (22 fasciotomy and 3 other surgical wounds) were treated using the RB technique. Average wound length and width measured 15.7 cm (range, 5-32 cm) and 5.2 cm (range, 1-12 cm), respectively. Locations of wounds included forearm (n = 12, 48.0%), leg (n = 7, 28.0%), hand (n = 4, 16.0%), elbow (n = 1, 4.0%), and hip (n = 1, 4.0%). Eighteen of 25 wounds (72.0%) were closed primarily after 1 RB application. Additional RB application was required for 5 wounds to achieve primary closure. Between stages, patients were discharged home if they did not have other conditions requiring in-hospital stay. No complications were observed, and no revision surgeries were required. Patient satisfaction was 100%, and all indicated that they would choose the RB technique over skin grafting. CONCLUSIONS: The modified RB technique is a simple, safe, and cost-effective alternative for treating fasciotomy and other surgical defects resulting in high patient satisfaction and good cosmetic outcome, without the need for split-thickness skin graft or flap coverage.

Submental Artery Flap with Sentinel Lymph Node Biopsy in the Reconstruction of Oral Cancer.

BACKGROUND: Microvascular free flaps form the gold standard for reconstruction of defects after intraoral cancer surgery, but not all patients are suitable candidates for microsurgery. The submental artery flap is an alternative to free tissue transfer especially in patients who do not tolerate extensive operations due to major comorbidities. However, in metastatic neck disease, this option has not been recommended due to theoretical intraoral transfer of cancer cells. The aim of this study was to consider the indications and benefits of the submental artery perforator flap in patients with intraoral cancer. METHODS: Ten patients with early (N = 2) or locally advanced (N = 8) intraoral cancer, who were not candidates for free tissue transfer because of major comorbidities, were managed with tumor resection and coverage of the defect with the submental artery flap. The minimum follow-up time for all patients was 6 years. RESULTS: The average defect size was 5 × 9 cm. Two patients developed major complications and one of them had a flap loss. Sentinel lymph node biopsy was used in three cases to rule out positive neck disease close to the flap pedicle. During the follow-up time 6 out of 10 patients had a local recurrence and there were no appearances of metastatic neck disease. CONCLUSION: The submental artery flap is an alternative option to intraoral microvascular reconstruction in patients with major comorbidities. Sentinel lymph node biopsy can be used as an adjunct to enhance oncological safety.

Versatility of the Perforator-Based Adipose, Adipofascial, and Fasciocutaneous Flaps in Reconstruction of Distal Leg and Foot Defects.

Reconstruction of the distal leg, ankle, and foot is challenging, and local perforator flaps have emerged as valuable options. The aim of the present study was to evaluate the outcomes of local perforator flaps in the distal lower extremity. A total of 14 local perforator flaps were used in 12 patients (9 males [75%] and 3 females [25%], aged 19 to 83 years). The etiologies included 7 motor vehicle accidents (50%), 2 acute burns (14.29%), 2 chronic wounds (14.29%), 1 postburn contracture (7.14%), 1 gunshot wound (7.14%), and 1 malignancy (7.14%). The defects were localized to the mid-leg in 3 cases (21.43%), ankle in 4 (28.57%), calcaneus in 4 (28.57%), and foot in 3 (21.43%). A peroneal artery perforator flap (11 sites [78.57%]) or a posterior tibial artery perforator flap (3 sites [21.43%]) was used. Of the 14 flaps, 8 (57.14%) were fasciocutaneous, 4 (28.57%) were adipofascial, and 2 (14.29%) were adipose. The flap transfers were rotational in 9 cases (64.29%), flipped in 2 (14.29%), propeller in 2 (14.29%), and transcrural in 1 (7.14%). The flap dimensions ranged from 8 cm × 5 cm to 22 cm × 5 cm. Finally, 12 flaps (85.71%) remained viable, 1 (7.14%) had partially sloughed, and 1 (7.14%) had completely died owing to a hypercoagulable state. Overall, 13 flaps (92.86%) had good outcomes after a median follow-up period of 19 (range 12 to 37) months. Perforator flaps in the lower extremity are versatile in terms of size, design, composition, and axis of rotation. They are reliable and safe when used to reconstruct local defects.

Delay by Staged Elevation of Flaps and Importance of Inclusion of the Perforator Artery.

"Surgical delay" is aimed at increasing blood flow to adjacent angiosomes by opening choke vessels, to obtain larger and more reliable flaps. We hypothesized that staged elevation (delay) from distal to proximal, in addition to preservation perforator artery near the base will improve survival. Thirty-two Sprague-Dawley rats were divided into 4 groups and 3x8cm caudal McFarlane flaps were elevated. In "delay" groups the 3 × 4 cm distal part was elevated and sutured back, with complete elevation (3 × 8 cm) after 4 days. The deep circumflex iliac artery (DCIA) at the base was either preserved or transected. The groups were: group A (Delay/DCIA preserved), group B (Delay/DCIA transected), group C (No Delay/DCIA preserved), group D (No Delay/DCIA transected). The percentage of surviving flap area was measured after 7 days with digital planimetrics. Statistics were done with ANOVA and unpaired T-test. The survivals were: 98.44 ± 3.13 %(group A), 69.33 ± 5.51 %(group B), 76.50 ± 8.91 %(group C) and 52.89 ± 3.15 %(group D). Delay lead to a greater degree of survival whether the arteries were preserved (p = 0.002) or transected (p = 0.01). In groups where the DCIA was preserved, the delay lead to a greater area of survival (p = 0.002). Inclusion of arteries lead to a greater degree of survival whether delay was performed (p = 0.003) or not (p = 0.005). Necropsy showed that the DCIAs were dilated bilaterally when preserved with vascular arcades reaching all viable areas. When the DCIA was transected, the gluteal perforators were dilated bilaterally with the vascular arcades reaching all viable areas. Staged elevation is an effective method of delay in both random and rando-axial flaps. When this is combined with preserving the perforator artery, survival rates are further enhanced.

Intraoral reconstruction with "thinned" peroneal artery perforator flaps: An alternative to classic donor areas in comorbid patients.

Free fasciocutaneous flaps like the radial forearm free flap (RFFF) and the anterolateral thigh (ALT) are the most commonly used flaps in intraoral reconstruction. However, certain conditions preclude the use of either of these flaps. The aim of this report was to show applicability of "thinned" peroneal artery perforator (PAP) flaps in intraoral reconstruction. We report two cases of squamous cell carcinoma involving the tongue and floor of the mouth, where one patient had advanced scleroderma with tight forearm skin and the other with a history of Reynaud's disease precluding the use of RFFF. In addition, both patients were morbidly obese with thick adipose tissue in the thigh making ALT flap not a suitable option. Instead, a PAP flap was chosen. After the harvest, the subcutaneous tissue thickness was measured to be 2.2 and 1.8 cm, respectively. The thinning was performed by removing the deep fat lobules of the superficial fat layer down to a final thickness of 0.4 and 0.3 cm, respectively. A 2 × 2 cm area surrounding the perforators were kept untouched. Both patients had uneventful postoperative course with one patient having a small donor area dehiscence that healed with local wound care. The functional outcomes at 1 year were good. "Thinned" PAP flap is a unique and novel application that may be an alternative in intraoral reconstruction when primary choices are not available.

Aesthetic reconstruction of the postburn neck contracture with a preexpanded anterolateral thigh free flap.

INTRODUCTION: The release of wide burn contractures leads to defects that cannot be closed with local flaps. In these cases, tissue expansion of local tissues may be a solution. However, when local tissues are also burned, distant tissue transfer remains the only option. Tissue expanded anterolateral thigh (ALT) flaps can be a reasonable option. CASE: A 15-year-old boy with a cervical burn contracture had limited movement in the neck. The release of the contracture and removal of the scarred tissue resulted in a 22 × 18-cm neck defect. This was resurfaced with preexpanded anterolateral thigh perforator flap. RESULT: Three months postoperatively, the flap shrunk to the point that the underlying aesthetic anatomical landmarks such as the clavicle, sternal notch, sternocleidomastoid muscle, and thyroid cartilage were clearly visible. The reconstruction was both functionally and cosmetically excellent. CONCLUSION: Tissue expanded ALT can be a good option in wide burn contractures where local tissues are inadequate. The advantages are (1) large flaps can be prepared without any functional loss, (2) the expanded skin thins making it more cosmetically appropriate to resurface skin only defect, and (3) the donor area stays under the clothes during expansion period and is well tolerated by the patient.

Neutrophil gelatinase associated lipocalin as an indicator of acute kidney injury and inflammation in burned children.

INTRODUCTION: Neutrophil gelatinase associated lipocalin (NGAL) is a novel predictor of acute kidney injury (AKI), which increases with inflammation. We aimed to assess whether serum NGAL (SNGAL) and urine NGAL (UNGAL) can predict AKI in burned children. METHODS: Patients were referred within the 12 h of burn to our center. Serum samples for SNGAL, C-reactive protein (CRP), procalcitonin (PCT) and urine for UNGAL, microalbumine (Umalb), creatinine (Ucr) were obtained at both admission and the 5th day after burn. Blood urea nitrogen (BUN) and serum creatinine (Scr) were examined daily. RESULTS: Twenty-two subjects were enrolled and six (27.2%) of them developed AKI within the 48 h of injury. Burn size and abbreviated burn severity index (ABSI) were significantly increased in patients with AKI. CRP, PCT, SNGAL and UNGAL levels at admission and day 5 were significantly higher in patients with AKI than in those without AKI and controls. Scr was not significant between AKI and non-AKI groups at hospital days 1 and 5. A SNGAL level of 315 ng/ml and a UNGAL level of 100 ng/ml were determined as predictive cut-off values of AKI at admission (sensitivity and specificity: 71.4%, 83.3% and 93.3%, 93.7%, respectively). SNGAL and UNGAL were positively correlated with CRP, PCT, ABSI and Umalb/Ucr. CONCLUSION: SNGAL and UNGAL are good early predictors of AKI in children with severe burn. NGAL might reflect the severity of burn insult and also could be used as an indicator of inflammation in burn children.

Free segmental vastus lateralis muscle flap for reconstruction of recalcitrant defects of the cleft hard palate.

INTRODUCTION: Large recalcitrant defects of the anterior palate due to clefting are difficult to close with local tissues. In some cases distant tissue transfer may be the only option. Free segmental vastus lateralis muscle with its long high-caliber pedicle and low donor-site morbidity may be a good option. PATIENT/METHOD: An 8-year-old girl with bilateral cleft lip and palate was evaluated for a defect in the anterior hard palate. She had four failed palate closures resulting in a 3.2 × 2.8 cm defect with severely scarred surrounding palatal tissues and severely hypernasal speech. A vastus lateralis muscle with a 7-cm pedicle was prepared. Only a 5 × 4 × 1 cm segment of muscle was harvested based on segmental motor innervations, thus sparing 90% of the remaining muscle. Vessels were anastomosed to the facial artery and vein through a facial tunnel. The flap was directed into the palatal defect via the right alveolar cleft and sutured in a fashion to prevent dehiscence and fistulization. RESULTS: The surface of the flap mucosalized over an 8-week period. The defect was completely closed. The speech markedly improved. There was no donor-site morbidity. CONCLUSION: Free segmental vastus lateralis muscle offers easy harvest, a two-team approach, long pedicle length, a highly vascularized flap, and no functional loss.

Periosteal ossification from the vascular pedicle of a free fibular flap.

BACKGROUND: Free fibular flap is commonly used in mandibular reconstruction. In some cases, to obtain a longer vascular pedicle, the peroneal artery and vein are stripped of the proximal fibula with its periosteum. PATIENT: A 17-year-old patient evaluated with fibromyxoma of the mandible underwent excision of the tumor and reconstruction with a 6-cm free fibular flap. To obtain a longer pedicle, the peroneal artery and vein were stripped of the proximal fibula together with the periosteum. The recovery was uneventful. In his 6-month follow-up, there was a hard palpable stick-like mass (4 × 0.5 cm) 3 cm below the mandible. In the panoramic mandibular radiography, there was a radiopaque mass and ossification in the same location. The patient had no complaints, and no further treatment was done. DISCUSSION: Periosteal ossification from the pedicle of the free fibular flap is a very rare phenomenon. However, because of the capacity of the periosteum to regenerate a new bone, it can be seen especially in younger patients. This can be prevented by a more careful dissection of the vascular pedicle from the bone and the periosteum. In cases where the primary disease is a tumor, it can be confused with recurrence. Depending on where the pedicle and the ossification are, it can give rise to symptoms or be totally asymptomatic.