Free Flap Transplantation in Open Tibial Fracture with Vessel Injury in the Elderly

Two aged patients who had open tibial fractures with arterial injury caused by high energy accidents underwent emergency arterial reconstruction using a greater saphenous vein and soft tissue repair using free flaps. In the patients, soft tissue necrosis developed and tibias were exposed at postoperative third week. Follow-up angiography through the superficial femoral artery showed occlusion of the anterior tibial artery. The anterior tibial artery was reconstructed using the contralateral greater saphenous vein graft and the latissimus dorsi myocutaneous and rectus abdominis muscle free flaps were transplanted for repair of necrotic soft tissue. The reconstructed arteries showed good perfusion to the new free flaps until union of the tibias occurred. The patients were followed-up for 21 years and 17 years postoperatively, respectively. In management of open comminuted fracture of the tibia, injury of the arterial system must be ruled out by angiography in addition to evaluation of the degree of soft tissue injury.

Anatomical Review of Rectus Abdominis Muscle Free Flap for the Oral and Maxillofacial Reconstruction

Reconstruction of the Cone-shaped Defect in the Temporal Area with Rectus Abdominis Free Flap

Defect on the temporal area caused by, surgical ablation of a tumor or an infection should be reconstructed immediately to prevent potentially life-threatening complications such as meningitis and cerebrospinal fluid leakage. The defect on the temporal area usually presents as a typical 'cone-shape'. Successful reconstruction requires sufficient volume of well-vascularized soft tissue to cover the exposed bone and dura. From 1994 through 2003, the authors applied rectus abdominis free flap for the reconstruction of the temporal defect from 1994 through 2003. There were 10 patients with a mean age of 52.1 years. Of these 10 patients, external auditory canal cancer was present in four patients, temporal bone cancer in two, parotid gland cancer in one and three patients were reconstructed after debridement of infection(destructive chronic otitis media). All the free flaps survived, and flap-related complications did not occur. Compared to a local flap, the rectus abdominis free flap can provide sufficient volume of well-vascularized tissue to cover the large defect and can be well-tolerated during an adjuvant radiation therapy. The long and flat muscle can be easily molded to fit in to the 'cone-shape' temporal defect without dead space. It is also preferred because of the low donor site morbidity, a large skin island and an excellent vascular pedicle. Two-team approach without position change is possible. In conclusion, the authors think that rectus abdominis free flap should be considered as one of the most useful method for the reconstruction of a cone-shaped temporal defect.

One-Stage Reanimation of Paralyzed Lips Using Rectus Abdominis Muscle Neurovascular Free Flap

Facial paralysis is a devastating problem, since such a patient can neither make facial expressions nor enjoy an active social relationship. If it persists for a long time, facial muscles will have irreversible changes and deformities. The goal in the treatment of facial paralysis is to achieve a normal appearance at rest and reconstruct a natural, symmetrical smile. One of the most distressing figures in a facial palsy patient is oral deformity. There have been numerous corrective methods of reanimating the paralyzed lips. Recently the one-stage muscle transplantation, innervated by the contralateral facial nerve, has been introduced to solve this distressing problem. From March 1998 to December 1998, 3 patients(2 males and 1 female), who ranged in age from 17 to 33 years, underwent one-stage reanimation surgery of paralyzed lips using rectus abdominis muscle neurovascular free flap. All patients had unilateral facial paralysis caused by tumor resection. The rectus abdominis muscle with long intercostal nerve and pedicle vessels(deep inferior epigastric vessels) was elevated and transferred to the preoperatively designed subcutaneous pocket. The upper end of the muscle was fixed to the zygoma and parotid fascia, and the lower end was fixed to the mouth corner, upper and lower lip. The intercostal nerve was repaired to the non-paralyzed buccal branch of the facial nerve through the subcutaneous tunnel of the upper lip, and the vascular pedicle of the muscle flap was anastomosed to the paralyzed side of the facial vessels. The onset of muscle function was reported in all the patients. Five months after the surgery, nerve conduction study and EMG showed compound motor action potential(CMAP) and motor unit action potential(MUAP) of the transferred muscle respectively. Nine months after the surgery, we observed volitional muscle contraction. The power of contraction increased constantly for 2 years after the surgery.