The anatomical basis for improving the reliability of the supraclavicular flap.

INTRODUCTION: The supraclavicular flap has re-emerged as a feasible option for head and neck reconstruction where a thin, pliable donor tissue is required or where free flap techniques may impose too great a surgical risk in frail patients. Whilst our understanding of the vasculature of this flap has improved immensely, the microvasculature and in particular the venous drainage of the distal half of the supraclavicular flap remain relatively unclear. The present study aims to detail the arterial supply and venous drainage of the supraclavicular flap, particularly relating to the interperforator anastomoses. METHODS: The arterial and venous systems of the supraclavicular flap were injected with a radiopaque medium in eighteen fresh cadavers (twenty three and twelve flaps, respectively). Dissected supraclavicular flaps were subjected to plain X-ray imaging plus CT angiography to visualise the arterial and venous systems and relations to surrounding muscle and fascia. Further, the nature of any true or choke anastomoses was described. RESULTS: The arterial supply of the supraclavicular flap is a combination of axial pattern proximally and random pattern distally, demarcated by the origin of deltoid muscle. The venous system must undergo significant shunting into high pressure vessels once the preferred natural venous pathways are ligated whilst the flap is raised. A vast number of anastomoses, both arterial and venous exist over the body of deltoid and are critical to distal flap tissue survival. CONCLUSION: The vascularity of the supraclavicular flap is complex and relies upon relatively small, superficial vessels. This technique is a prototypical example of the angiosome concept at work and thus relies heavily on our understanding of the location and nature of the anastomoses along its course. We conclude that the supraclavicular flap remains a reliable method for reconstructing head and neck defects so long as the constraints of a complicated suprafascial vascular system are respected.

Developments in image-guided deep circumflex iliac artery flap harvest: a step-by-step guide and literature review.

PURPOSE: The deep circumflex iliac artery (DCIA) flap has evolved significantly over time in the intricacies of flap design and breadth of surgical application. This has been facilitated by advances in preoperative imaging and planning, in particular, computed tomographic angiography. Studies have highlighted that advanced imaging modalities and other technologies such as image-guided stereolithographic biomodeling can substantially improve flap planning, flap harvest, and operative outcomes. PATIENTS AND METHODS: The present report comprises a combined literature review and clinical cohort study of 20 consecutive patients to assess the modern technologies applied to DCIA flap planning and harvest. We have also described a step-by-step guide for the implementation of these techniques into clinical practice. RESULTS: The protocol for a single, standardized technique of computed tomographic angiography scanning is presented and was applied to a range of techniques in the preoperative planning of DCIA flaps. These include 1) bony and vascular imaging analysis of both donor and recipient sites, 2) stereolithographic "biomodeling" of both donor and recipient bony and vascular anatomy, and 3) the use of preoperative "virtual surgery" with image-guided stereotactic navigation. The application and role of each technique was explored. CONCLUSIONS: Modern imaging and stereolithographic techniques are innovations that can substantially improve surgical outcomes in DCIA flap surgery, such as has been highlighted in our clinical experience and in published studies. Notably, few outcome studies have been reported, and the need for larger case series and comparative studies is apparent.

Achieving adequate margins in ameloblastoma resection: the role for intra-operative specimen imaging. Clinical report and systematic review.

BACKGROUND: Ameloblastoma is a locally aggressive odontogenic neoplasm. With local recurrence rates reaching 90%, only completeness of excision can facilitate cure. Surgical clearance has widely been based on pre-operative imaging to guide operative excision margins, however use of intra-operative specimen x-ray or frozen-section has been sought to improve clearance rates, and advanced imaging technologies in this role have been proposed. This manuscript aims to quantify the evidence for evaluating intra-operative resection margins and present the current standard in this role. METHOD: The current study comprises the first reported comparison of imaging modalities for assessing ameloblastoma margins. A case is presented in which margins are assessed with each of clinical assessment based on preoperative imaging, intra-operative specimen x-ray, intra-operative specimen computed tomography (CT) and definitive histology. Each modality is compared quantitatively. These results are compared to the literature through means of systematic review of current evidence. RESULTS: A comparative study highlights the role for CT imaging over plain radiography. With no other comparative studies and a paucity of high level evidence establishing a role for intra-operative margin assessment in ameloblastoma in the literature, only level 4 evidence supporting the use of frozen section and specimen x-ray, and only one level 4 study assesses intra-operative CT. CONCLUSION: The current study suggests that intra-operative specimen CT offers an improvement over existing techniques in this role. While establishing a gold-standard will require higher level comparative studies, the use of intra-operative CT can facilitate accurate single-stage resection.

Total scalp reconstruction with bilateral anterolateral thigh flaps.

Large scalp defects can require complicated options for reconstruction, often only achieved with free flaps. In some cases, even a single free flap may not suffice. We review the literature for options in the coverage of all reported large scalp defects, and report a unique case in which total scalp reconstruction was required. In this case, two anterolateral thigh (ALT) flaps were used to resurface a large scalp and defect, covering a total of 743 cm(2). The defect occurred after resection and radiotherapy for desmoplastic melanoma, with several failed skin grafts and local flaps and osteoradionecrosis involving both inner and outer tables of the skull. The reconstruction was achieved as a single-stage reconstruction and involved wide resection of cranium and overlying soft-tissues and reconstruction with calcium phosphate bone graft substitute, titanium mesh, and two large ALT flaps. The reconstruction was successfully achieved, with minor postoperative complications including tip necrosis of one of the flaps and wound breakdown at one of the donor sites. This is the first reported case of two large ALT flaps for scalp resurfacing and may be the largest reported scalp defect to be completely resurfaced by free flaps. The use of bilateral ALT flaps can be a viable option for the reconstruction of large and/or complicated scalp defects.

Trauma centre experience: flap reconstruction of traumatic lower limb injuries.

BACKGROUND: Decision-making in the management of combined major skeletal and soft tissue trauma to the lower limb is a complex process made more difficult by the uncertainty surrounding outcomes. The aim of this study was to review and present our experience with flap reconstruction of traumatic lower limb defects, with particular reference to in-hospital complications and outcomes related to timing, choice of flap and pre-existing complications. METHODS: Retrospective review of all lower limb flap reconstructions carried out by the Plastic and Reconstructive Surgery Unit at the Alfred Hospital from 1 July 2001 to 20 October 2005 (51-month period) was carried out. RESULTS: Sixty-four patients had 83 flap reconstructions (35 free and 48 local) of 70 separate lower limb injuries. Internal skeletal fixation was followed by earlier soft tissue coverage and lower deep metal infection rates. Twenty-seven flaps (32.5%) developed soft tissue infections, and 16 fixation devices (25.8%) were complicated by deep metal infection. There were six (12.5%) local flap partial necrosis and four (11.4%) free flap failures. Limbs in which flaps were carried out after day 5 were more likely to develop deep metal infection (P = 0.04) and suffer free flap failure or local flap partial necrosis (P = 0.02). Three patients underwent secondary amputation during their initial admission. CONCLUSIONS: The current study presented our experience with flap reconstruction of complex lower limb injuries at a major trauma centre. Thorough wound debridement, internal fixation and early soft tissue coverage (within 5 days of injury) were associated with lower infection rates and optimal outcomes.