The Multiple Osteotomized Free Iliac Osteocutaneous Flap for Reconstructions of Complex Maxillofacial and Oromandibular Defects

Abstract: The vascularized iliac osteocutaneous flap has been usedsuccessfully for jaw reconstruction. To obtain a better contour of thereconstructed area in large upper and lower jaw resections, thetransferred bone actually needs to be osteotomized. Single closingwedge osteotomy of the iliac flap for mandibular reconstruction hasbeen previously described. In this article, the modified multipleosteotomized perforator-based versatile free iliac osteocutaneousflap is described. Eleven cases were enrolled. Seven patients hadwide anterior mandibular resections due to oral cavity and mandibular tumors; 3 patients had a defect due to explosive injury and 1patient had complicated orbitomaxillary defect due to blast injury.Skin paddle was based on the perforators. In 8 patients, the bonysegment was divided into 3 segments by 2 osteotomies, whereas in 2patients the bony segment was divided into 4 segments by 3osteotomies. In 10 cases, the flap was used for anterior mandibulardefects, whereas in 1 case the flap was customized to fit an L-shapeddefect at the naso-orbito-maxillary region. The overall flap successrate was 100%. No resorption or morbidity related to the osteotomyof the bony segments was observed. The size of perforator skinpaddle was 6 to 8  15 to 18 cm. Physical and radiologic examinations showed proper bone healing without any additional complications. The modified multiple osteotomized free osteocutaneousiliac flap can provide a safe and versatile bony segment to be

Transaxillary-Subclavian Transfer of Pedicled Latissimus Dorsi Musculocutaneous Flap to Head and Neck Region

Abstract: Free-tissue transfer is the reconstruction of choice formost head and neck defects. However, pedicled flaps are also used,especially in high-risk patients and after failure of a free flap. Theaim of this study was to compare transaxillary-subclavian pedicledlatissimus dorsi musculocutaneous (PLDMC) flap, pectoralis majormusculocutaneous flap, and free-tissue transfer for head and neckreconstruction in American Society of Anesthesiologists grades IIand III patients.During the last 4 years, PLDMC flap with a modifiedtransaxillary-subclavian route for transfer to the neck was used in8 patients, pectoralis major musculocutaneous flap was used in 7patients, and free flaps were used in 12 patients for head and neckreconstructions. These 3 methods were compared regarding the flapdimensions, complications, flap outcome scores, hospitalizationtime, and cost of the treatment.Mean age of the patients, mean American Society of Anesthesiologists scores, mean dimensions of the flaps, and mean hospitalization time did not differ significantly among the 3 groups. Regardingthe operation time, flap complications, outcomes, and cost of totaltreatment, although statistically not significant, PLDMC group offeredthe fastest reconstruction with highest flap outcome scores andminimum cost.Free-tissue transfer is the procedure of choice especially forfunctional reconstruction of head and neck region. Occasionally,there exist cases in whom a pedicled flap could offer a safer option.The PLDMC flap transferred via the transaxillary-subclavian routemay be preferred than, with advantages including increased arc ofrotation, safer pedicle location, shorter duration of the procedure,and reduced complication rates and costs.Key Words: Head and neck reconstruction, pedicled latissimusdorsi flap, musculocutaneous flap, pectoralis major flap,transaxillary-subclavian transfer, free flap

Comparison of Free Muscle and Perforator Skin Flaps for Soft Tissue Reconstruction of the Foot and Ankle

Background: Free tissue transfer is generally required forreconstruction of soft-tissue defects of the foot and ankle regionbecause of the limited local tissue available. This type ofreconstruction may interfere with postoperative function andfootwear if a bulky flap is used. Materials and Methods: Twentynine patients had free tissue transfers to the foot and ankleregion during a period of 3 years. Sixteen had reconstructionwith free anterolateral thigh perforator flaps (ALT) and 13had reconstruction with free muscle flaps. The outcomes ofboth types of reconstructions were compared according to flapscores and complications, operative time, hospitalization, gaitand shoewear problems. Results: The patients in the ALT groupwere younger compared with those of the free muscle flapgroup (p = 0.022). The operative time and flap complicationrate was significantly higher (p = 0.007 and 0.040, respectively)in the ALT group. ALT was generally used for reconstructionof the dorsal foot, heel and plantar regions. Muscle flaps werepreferred in the ankle region, where open fractures of thetibia and fibula were frequently present, and for the patientswith increased risk of perioperative morbidity. Conclusion: FreeALT flap consisting of skin and adaptable subcutaneous tissue,both diminishes donor site morbidity and is ideally suited formost soft-tissue reconstruction of the dorsal foot, heel andplantar foot. Free muscle flaps, however, may offer relativelyless complicated tissue transfers and are preferred at the ankleregion in the presence of open tibia fractures, and in high riskpatients to decrease the perioperative morbidity.

Free Anterolateral Thigh Flap for Reconstruction of Car Tire Injuries of Children’s Feet

Background: Grade IV and V car tire injuries occurring inchildren cause extensive soft tissue defects with exposure orloss of tendons and bone on the dorsum of the foot. Freetissue transfer is indicated for reconstruction of these defectsbecause of the limited local tissue available. We describe ourmanagement of high-grade car tire foot injuries in children withfree anterolateral thigh flap (ALT). Materials and Methods: Fivepre-school children with car tire injuries (one grade IV and fourgrade V) were treated with free ALT flap in the last 4 years.The mean age was 4.8 years. In four patients, immediate flapcoverage after initial debridement was performed and delayedreconstruction was used as a secondary procedure in onepatient. Results: One of the flaps was re-explored for hematomaevacuation and salvaged. All of the flaps survived completelyand there were no donor site complications. None of the flapsrequired a debulking procedure and custom shoe wear has notbeen necessary in any of the patients. Minor gait abnormalitieswere detected in two of the patients. Conclusion: With minimaldonor site morbidity, long vascular pedicle allowing anastomosisoutside of the trauma zone, we believe free ALT flap providesthe ideal soft tissue reconstruction for high grade car tireinjuries of foot in children. ALT flap can be further thinned toadapt to the defect, contracts less than muscle flaps and containsa vascularized fascia which can be used for extensor tendonreconstruction.Level of Evidence: IV, Retrospective Case SeriesKey Words: Car Tire Injury; Foot Reconstruction; AnkleReconstruction; Free Flap; Anterolateral Thigh Flap; ThinFlap; Children Injury

A Hemodynamic Study of the Effects of Arterial Anastomoses With Interrupted Simple Versus Horizontal Mattress Sutures on Rat Epigastric Flap Perfusion

Abstract: The effects of interrupted simple versus horizontal mattress sutures and of the internal diameter of the arterial pedicle at thelevel of the anastomosis on rat epigastric flap perfusion wereinvestigated. In the first group, a microclip was applied to thefemoral artery for 30 minutes. In the second group, the artery wascut, and a classic 7- to 8-suture microarterial end-to-end anastomosis was performed. In the third group, the artery was cut, and amicroarterial end-to-end anastomosis with 3 horizontal mattresssutures at 120-degree intervals was performed. Perfusion was measured using a laser Doppler flowmeter (Periflux 2B, Perimed, Sweden) at 3 zones of the flap at 30 and 60 minutes and at 21 days afterthe procedure. Internal vascular diameters were measured histopathologically. Perfusion was better in the control group than inthe experimental groups. However, the internal vascular diameterswere greater with the classic method than with the new method, andthe perfusion did not differ statistically in the anastomosis groups. Inconclusion, even when significant narrowing develops at the anastomosis, flap viability is not affected.Key Words: microsurgery, microvascular surgery, vesselanastomosis, vascular anastomosis method, internal vasculardiameter, perfusion, rat epigastric flap, laser Doppler flowmeter