Composite fronto-orbital reconstruction using a subscapular chimeric flap.

Composite defects of the fronto-orbital region represent a reconstructive challenge. Total autogenous reconstruction requires a thin pliable skin flap along with a bony component that can be osteotomized predictably. The thoracodorsal artery perforator/scapular bone chimeric flap provides a reliable single-stage method to cover difficult composite forehead defects where local options are unsuitable or have been exhausted. We present a patient with a traumatic fronto-orbital defect that has been successfully reconstructed using this flap. The report of this case illustrates well the versatility of the subscapular system as a donor site for difficult composite posttraumatic defects where tissue components need to be inset in a complex three-dimensional fashion.

Advantages of perforator flaps in reconstruction of complex defects of the head and neck.

Microsurgical transfer of vascularized tissue during the past three decades has allowed highly complicated postoncologic defects in the head and neck region to be reconstructed. Recently, perforator flaps have been used to reduce postoperative pain, shorten hospital stay, and lessen donor-site complications. These flaps are offsprings of previously known musculocutaneous and fasciocutaneous flaps and are harvested with preservation of the underlying muscular and fascial structures. The vascularized skin and soft-tissue envelope is supplied by perforating branches from the parent vessel. Less is known about the performance of these flaps in the head and neck region. During a 4-year period, 22 patients at our institution underwent reconstruction of the head and neck region with deep inferior epigastric perforator (DIEP) or thoracodorsal artery perforator (TDAP) flaps. All but one of the flaps survived. Advantages noted include: (1) longer vascular pedicles, (2) less postoperative pain, (3) less donor-site deformity, (4) improved aesthetic outcome, (5)potential for a neurosensory flap, (6) potential for an osteocutaneous flap, and (7) ease of postoperative radiologic follow-up. The DIEP flap can be harvested concurrent with oncologic resection, with the patient in the supine position. The TDAP flap is dissected with the patient in the decubitus position, creating an additional step to change operative position, and separates extirpative and reconstructive stages.

The thoracodorsal artery perforator flap: clinical experience and anatomic study with emphasis on harvest techniques.

The thoracodorsal artery perforator flap is a relatively new flap that has yet to find its niche in reconstructive surgery. At the authors' institution it has been used for limb salvage, head and neck reconstruction, and trunk reconstruction in cases related to trauma, burns, and malignancy. The authors have found the flap to be advantageous for cranial base reconstruction and for resurfacing the face and oral cavity. The flap has been used successfully for reconstruction of traumatic upper and lower extremity defects, and it can be used as a pedicled flap or as a free tissue transfer. The perforating branches of the thoracodorsal artery offer a robust blood supply to a skin-soft-tissue paddle of 10 to 12 cm x 25 cm, overlying the latissimus dorsi muscle. The average pedicle length is 20 cm (range, 16 to 23 cm), which allows for a safe anastomosis outside the zone of injury in traumatized extremities; the flap can be made sensate by neurorrhaphy with sensory branches of the intercostal nerves. Vascularized bone can be transferred with this flap by taking advantage of the inherent vascular anatomy of the subscapular artery. A total of 30 pedicled and free flap transfers were performed at the authors' institution with an overall complication rate of 23 percent and an overall flap survival rate of 97 percent. Major complications, such as vascular thrombosis, return to the operating room, fistula formation, recurrence of tumor, and flap loss, occurred in 17 percent of the patients. Despite these drawbacks, the authors have found the thoracodorsal artery perforator flap to be a safe and extremely versatile flap that offers significant advantages in acute and delayed reconstruction cases.

Bilateral breast reconstruction with the deep inferior epigastric perforator (DIEP) flap: an experience with 280 flaps.

Bilateral prophylactic mastectomy can reduce the incidence of breast cancer by 87 to 93% in high-risk individuals and is an appealing option for many patients if reconstruction can be provided with acceptable morbidity and outstanding esthetic results. Autogenous breast reconstruction techniques have evolved over the last 20 years to meet this goal. Familiarity with the deep inferior epigastric perforator (DIEP) flap led us to carry out simultaneous bilateral breast reconstruction with acceptable morbidity and superior esthetic outcome in 3 patient groups: (1) after bilateral prophylactic mastectomy, (2) after therapeutic and contralateral prophylactic mastectomy, and (3) after explantation of bilateral implant failures. A retrospective review of our experience with 280 flaps in 140 patients was performed. Average operating times, including time for implant removal or mastectomy and reconstruction, was 7.3 hours. Average hospitalization was 3.9 days. Significant perioperative complications occurred in 9 patients (6.4%); all returned to the operating room. This included 7 microvascular complications, 1 hematoma, 1 seroma, and 1 DVT. Less significant complications were divided into early and late. The early complications included 1.8% partial flap necrosis, 4.2% abdominal apron necrosis greater than 5 cm2, 2.9% seromas that required intervention, and 5.7% partial breast flap dehiscence. Late complications included 12.5% fat necrosis of any size and 2.1% hernia formation. Smoking, obesity, age, history of chest wall radiation, and flap size were evaluated as risk factors for increased morbidity.

Breast reconstruction with gluteal artery perforator (GAP) flaps: a critical analysis of 142 cases.

Fujino was the first to introduce gluteal tissue as a free flap for breast reconstruction. The use of the musculocutaneous flap from the buttock in breast reconstruction has been championed by Shaw. Despite the initial enthusiasm for this area as a donor site, few other large series exist on the subject. Two decades of experience with this region as a donor site led to recognition of advantages and drawbacks. Furthermore, use of both the superior and inferior gluteal musculocutaneous flap was associated with certain important donor site complications and the use of vein grafts to allow for microvascular anastomosis. The evolution of free tissue transfer has progressed to the level of the perforator flap. This reconstructive technique allows elevation of tissue from any region consisting only of fat and skin. This minimizes donor site morbidity by allowing preservation of the underlying muscle and coverage of important structures in the region such as nerves. The superior and inferior gluteal perforator flaps have been used at our institution for breast reconstruction since 1993. The superior gluteal artery perforator (S-GAP) flap is our preferred method of breast reconstruction when the abdomen is not available or preferable. We report the result of this flap over the past 9 years and point out important surgical refinements, advantages, disadvantages, and lessons learned during this time.