Plast Reconstr Surg. 2006 Mar;117(3):963-7.Links
Simple reconstruction with titanium mesh and radial forearm flap after globe-sparing total maxillectomy: a 5-year follow-up study.
Hashikawa K, Tahara S, Ishida H, Yokoo S, Sanno T, Terashi H, Nibu K.
Department of Plastic Surgery, KobeUniversityGraduateSchool of Medicine, Kobe, Japan.
BACKGROUND: Reconstruction of eye globe-sparing total maxillectomy defects is one of the major challenges to reconstructive surgeons. In 1994, the authors developed an uncomplicated and easy reconstructive method, where a titanium mesh is applied for the support of orbital contents, a radial forearm free flap for covering the mesh and the cheek lining, and an obturator prosthesis for palatal and dental rehabilitation. METHODS: Five patients who underwent primary reconstruction with the authors' method after globe-sparing maxillectomy with loss of the orbital floor from 1994 to 1999 and who were followed up for more than 5 years were retrospectively reviewed for (1) the presence of diplopia, (2) the shape of the reconstructed orbital floor assessed by coronal section magnetic resonance imaging, and (3) the presence of infection/exposure of the titanium mesh. RESULTS: Only one of the five patients developed slight diplopia. Coronal magnetic resonance imaging showed that the orbital floor restored with titanium mesh had in all cases maintained a proper shape and position for more than 5 years. No infection or exposure of the titanium mesh had developed in any of the cases, despite exposure to irradiation of not less than 30 Gy. All the patients had well-retentive obturator prostheses. CONCLUSION: This long-term follow-up study demonstrated that the authors' method attained a long-lasting successful outcome functionally and is the method of choice for reconstruction after globe-sparing total maxillectomy.
PMID: 16525293 [PubMed - indexed for MEDLINE]
J Coll Physicians Surg Pak. 2004 Jan;14(1):29-34.Links
Management of oromandibular cancers.
Rashid M, Ahmad T, Sarwar SU, Ansari TN, Ahmed B, Ahmed S, Gul AA, Aslam R, Rashid D.
Department of Plastic and Reconstructive Surgery, Combined MilitaryHospital, Rawalpindi.
OBJECTIVE: To emphasize the role and importance of multidisciplinary approach in the management of oral cavity cancers involving the mandible. DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: The Departments of Plastic and Reconstructive Surgery, ENT / Head and Neck Surgery and Radiation Oncology, Combined MilitaryHospital, Rawalpindi. Duration spans over a period of six years. SUBJECTS AND METHODS: A total of 63 patients who had biopsy-proven oromandibular tumors, after thorough assessment / staging in Joint Head and Neck Oncology Clinic, underwent resection and reconstruction for malignant oral cavity tumors involving the mandible were included in the study. All the resected tumor specimen were sent for histopathology. All the post-resection defects were properly classified and reconstructed by the plastic surgery team. Postoperatively, all the patients underwent adjuvant full dose radiotherapy at the Department of Radiation Oncology. Complications were recorded and managed accordingly. At one year follow-up all the available patients were assessed for functional and aesthetic restoration and recurrences. RESULTS: Out of 63 patients there were 40 males and 23 females (ratio 1.7 : 1) with an average age of 50 years. Tumor-free resection margins could be achieved in 56 patients. In 88% cases tumor was a Squamous cell carcinoma. Radical neck dissections were carried on in 27 patients. Radial forearm free flap was used in 27 patients, pectoralis major myocutaneous flap in 19, free fibula osteocutaneous flap in 10, rectus-abdominis myocutaneous free flap with Implant was used in 3 patients to reconstruct the post-resection defects. There was only one total flap loss and 3 partial flap losses. Implant exposure was encountered in 4 instances with 3 major and 5 minor fistulae. At one year follow-up, 56 patients were available. Thirty-seven patients had intelligible speech, 15 patients were taking normal diet and in 33 patients there was a satisfactory mandibular contour restoration. Seven patients had recurrences, 2 were not traceable and 5 patients had died by that time. CONCLUSION: A multidisciplinary collaboration is the key to effectively manage this group of extremely debilitating malignancies.
PMID: 14764258 [PubMed - indexed for MEDLINE]
Plast Reconstr Surg. 1990 Feb;85(2):258-66.Links
The radial forearm flap: reconstructive applications and donor-site defects in 35 consecutive patients.
Swanson E, Boyd JB, Manktelow RT.
Department of Surgery, Toronto GeneralHospital.
Thirty-five consecutive patients treated with the radial forearm flap were reviewed. This flap was used in head and neck reconstruction in 25 patients, soft-tissue cover of an extremity in 9 patients, and as a new technique for penile reconstruction in 1 patient. Osteocutaneous flaps were used for mandibular reconstruction in 13 patients. In 6 patients innervated flaps were used to provide sensation on the dorsum of the hand or on the weight-bearing surface of the foot. There was only one total flap failure and no partial failures. Recipient-site complications were few, with prompt healing and very acceptable appearance. Donor-site complications included partial loss of the skin graft with tendon exposure in 10 patients (33 percent), an unsatisfactory appearance in 5 patients (17 percent), and one case of radial fracture (8 percent). On functional testing, there was no significant loss of strength or joint mobility in the donor extremity in 19/20 patients. The authors recommend measures to reduce donor-site morbidity and conclude that, with an acceptable donor site, this flap is valuable in a variety of reconstructive applications.
PMID: 2300632 [PubMed - indexed for MEDLINE]
Ann Thorac Surg. 2008 Apr;85(4):1473-82.Links
Operative treatment of coronary atherosclerosis.
Barner HB.
Division of Cardiothoracic Surgery, St. LouisUniversity, St. Louis, Missouri63108, USA.
The evolution of percutaneous intervention has reduced the prevalence of coronary bypass surgery in a patient population that is older, with more comorbidity and advanced coronary disease. Despite this less favorable group, perioperative mortality has continued to decline as the operation improves. The latter includes off-pump coronary grafting, smaller incisions, better intraoperative myocardial preservation, improving management of cardiopulmonary bypass, perioperative glucose control, and increasing use of arterial conduits as the radial artery comes of age and the gastroepiploic artery is reborn as a free graft. This brief review of the basics of coronary artery bypass is part experience with an effort to be fair-minded and balanced and to include that which is new and promising. It is imperative that we continue to innovate and distill the best from the old so that we can provide the optimal intervention for coronary artery disease.
PMID: 18355565 [PubMed - indexed for MEDLINE]
Br J Plast Surg. 1984 Apr;37(2):149-59.Links
Comment in:
Br J Plast Surg. 2003 Dec;56(8):837-9.
The free thigh flap: a new free flap concept based on the septocutaneous artery.
Song YG, Chen GZ, Song YL.
Based on the septocutaneous artery flap concept, the thigh, which is the commonest conventional donor site for split-skin grafts, can also become a donor area for skin flaps. The thigh flap, with its large and long neuro-vascular pedicle, can be used either as a free flap or as an island flap as an alternative to the lower abdominal flap, groin flap, tensor fasciae latae myocutaneous flap, sartorius myocutaneous flap or the gracilis myocutaneous flap. The anatomical basis, operative technique and characteristics of the thigh flap are discussed.
PMID: 6713155 [PubMed - indexed for MEDLINE]
Plast Reconstr Surg. 1996 Apr;97(5):985-92.Links
Consideration of a thin flap as an entity and clinical applications of the thin anterolateral thigh flap.
Kimura N, Satoh K.
Department of Plastic and Reconstructive Surgery at the ChibaEmergency Medical Center, USA.
A defatted (thinned) anterolateral thigh flap was designed to reconstruct skin defects requiring thin flap coverage. We used this flap as a free flap for five cases of skin defects, and the outcomes of the reconstructions were all successful. The vascular pedicle of this flap, the cutaneous perforator of the lateral circumflex femoral artery, is about 8 cm long and 2 mm in diameter, and it is ideal for microvascular anastomosis. Thinning is performed in about 3 to 4 mm of thickness almost uniformly except for the vascular pedicle. It was ascertained as one of the useful donor sites of the free thin flap. The virtue of the thin anterolateral thigh flap is its uniform thinness compared with other thin flaps reported previously--the thin groin flap and the thin rectus abdominis musculocutaneous flap. We considered thin flaps as an entity, and they are classified into three types.
PMID: 8619002 [PubMed - indexed for MEDLINE]
Plast Reconstr Surg. 2006 Mar;117(3):1004-8.Links
Comment in:
Plast Reconstr Surg. 2007 Jun;119(7):2327-8; author reply 2328.
Thin anterolateral thigh perforator flap using a modified perforator microdissection technique and its clinical application for foot resurfacing.
Yang WG, Chiang YC, Wei FC, Feng GM, Chen KT.
Department of Plastic and Reconstructive Surgery, ChangGungMemorialHospital, ChiaYi, Taiwan.
BACKGROUND: A thin skin flap is often required for optimal resurfacing of particular areas of the body. An anterolateral thigh perforator flap can be thinned to an extent to which it is vascularized by the subdermal plexus only. This study presents a novel flap thinning technique and its application for resurfacing the dorsum of the foot. METHODS: From July of 2002 to October of 2003, 18 patients underwent resurfacing of the dorsum of the foot with thin anterolateral thigh flaps. The main perforators were strategically located in the flap center to keep the peripheral area within the vascular territory. The flaps were larger than needed, initially elevated subfascially, and then thinned to the suitable thickness while the pedicle was still attached. The dissection of perforators in the adipose layer close to the dermis entry was carried out microscopically. Flap sizes ranged from 3 x 3 to 16 x 8 cm. RESULTS: Seventeen flaps survived completely and one had distal superficial necrosis of 1 x 2 cm. No debulking procedures were necessary. Average follow-up was 12 months. CONCLUSIONS: A thin flap vascularized through subdermal plexus is reliable. Microsurgical dissection of the perforator is a recommended technique. The thin anterolateral thigh perforator flap provides ideal reconstruction in resurfacing the dorsum of the foot.
PMID: 16525300 [PubMed - indexed for MEDLINE]
Plast Reconstr Surg. 1993 Sep;92(3):411-20.Links
Free combined composite flaps using the lateral circumflex femoral system for repair of massive defects of the head and neck regions: an introduction to the chimeric flap principle.
Koshima I, Yamamoto H, Hosoda M, Moriguchi T, Orita Y, Nagayama H.
Department of Plastic and Reconstructive Surgery, KawasakiMedicalSchool, Okayama, Japan.
Chimeric composite flaps combined using microanastomoses consist of two or more flaps or tissues, each with an isolated pedicle and a single vascular source. Free combined chimeric flaps using the lateral circumflex femoral system were used to treat massive composite defects of the head and neck in 10 cases. A combined anterolateral thigh flap and vascularized iliac bone graft based on the lateral circumflex femoral system and the deep circumflex iliac system was the most commonly used combination. An anteromedial thigh flap and a paraumbilical perforator-based flap were also combined with this principal combination. The advantages of this chimeric flap over other osteocutaneous flaps are: (1) The flap is relatively thin and the pedicle vessels are up to 10 cm longer and are wider than those of other flaps for easier harvesting of the flap. (2) It is unnecessary to reposition the patient. (3) The vascular pedicle to the skin can be separated from that of the bone. (4) The donor site is not close to the recipient site. (5) The donor scar is in an unexposed area. (6) The skin territory of this flap is extremely wide. (7) A combined anterolateral and anteromedial thigh flap and vascularized iliac bone graft can be easily obtained as an extended combined osteocutaneous flap. (8) Other neighboring skin flaps, such as a groin flap, a paraumbilical perforator-based flap, or a medial thigh flap, can be combined with this chimeric flap because several major muscle branches to be anastomosed derive from the lateral circumflex femoral system. Chimeric composite flaps using the lateral circumflex femoral system are considered suitable for the repair of massive composite defects of the head and neck.
PMID: 8341739 [PubMed - indexed for MEDLINE]
Plast Reconstr Surg. 2005 Jan;115(1):142-7.Links
The use of anterolateral thigh perforator flaps in chronic osteomyelitis of the lower extremity.
Hong JP, Shin HW, Kim JJ, Wei FC, Chung YK.
Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea.
From April of 2000 to May of 2003, 28 consecutive patients with chronic osteomyelitis of the lower extremity underwent surgical debridement and reconstruction with anterolateral thigh perforator flaps (six cases were combined with vastus lateralis muscle flaps). All wounds were open for a minimum period of 6 weeks (average, 24.7 months; range, 6 weeks to 52 months). The average patient age was 42.8 years (range, 18 to 71 years), there were 21 male and seven female patients, and the average follow-up period was 18.2 months (range, 5 to 41 months). The cause of injury was an open fracture in 10 cases, secondary wound complications after reduction in eight cases, and diabetic foot in 10 cases. The surface defects ranged from 50 to 153 cm. The wounds were debrided an average of 2.5 times and then reconstructed with flap and treated with antibiotics for 6 weeks. Antibiotic beads were used in six cases and secondary bone graft procedures were performed in seven cases 3 months after the flap coverage. All 28 flaps were successful without any signs of recurrences or persistent osteomyelitis, but partial wound dehiscence was observed during early rehabilitation in two cases suspected of delayed healing caused by diabetes. These wounds healed spontaneously. All patients achieved acceptable gait function after rehabilitation. No debulking procedure was necessary in any case. Although the muscle flap is known to provide superior vascular supply, the type of flap used for coverage seems to be less critical in the final outcome, provided that total debridement and obliteration of dead spaces are achieved. A well-vascularized anterolateral thigh perforator flap was successfully used to combat infection and bring stability to wounds with chronic osteomyelitis.
PMID: 15622244 [PubMed - indexed for MEDLINE]
Plast Reconstr Surg. 2002 Jun;109(7):2219-26; discussion 2227-30.Links
Comment in:
Plast Reconstr Surg. 2003 Jun;111(7):2481.
Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps.
Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH.
Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Medical College and University, 199 Tung Hwa North Road, Taipei 10591, Taiwan.
The free anterolateral thigh flap is becoming one of the most preferred options for soft-tissue reconstruction. Between June of 1996 and August of 2000, 672 anterolateral thigh flaps were used in 660 patients at ChangGungMemorialHospital. Four hundred eighty-four anterolateral thigh flaps were used for head and neck region recontruction in 475 patients, 58 flaps were used for upper extremity reconstruction in 58 patients, 121 flaps were used for lower extremity reconstruction in 119 patients, and nine flaps were used for trunk reconstruction in nine patients. Of the 672 flaps used in total, a majority (439) were musculocutaneous perforator flaps. Sixty-five were septocutaneous vessel flaps. Of these 504 flaps, 350 were fasciocutaneous and 154 were cutaneous flaps. Of the remaining 168 flaps, 95 were musculocutaneous flaps, 63 were chimeric flaps, and the remaining ten were composite musculocutaneous perforator flaps with the tensor fasciae latae. Total flap failure occurred in 12 patients (1.79 percent of the flaps) and partial failure occurred in 17 patients (2.53 percent of the flaps). Of the 12 flaps that failed completely, five were reconstructed with second anterolateral thigh flaps, four with pedicled flaps, one with a free radial forearm flap, one with skin grafting, and one with primary closure. Of the 17 flaps that failed partially, three were reconstructed with anterolateral thigh flaps, one with a free radial forearm flap, five with pedicled flaps, and eight with primary suture, skin grafting, and conservative methods.In this large series, a consistent anatomy of the main pedicle of the anterolateral thigh flap was observed. In cutaneous and fasciocutaneous flaps, the skin vessels (musculocutaneous perforators or septocutaneous vessels) were found and followed until they reached the main pedicle, regardless of the anatomic position. There were only six cases in this series in which no skin vessels were identified during the harvesting of cutaneous or fasciocutaneous anterolateral thigh flaps. In 87.1 percent of the cutaneous or fasciocutaneous flaps, the skin vessels were found to be musculocutaneous perforators; in 12.9 percent, they were found as septocutaneous vessels. The anterolateral thigh flap is a reliable flap that supplies a large area of skin. This flap can be harvested irrespective of whether the skin vessels are septocutaneous or musculocutaneous. It is a versatile soft-tissue flap in which thickness and volume can be adjusted for the extent of the defect, and it can replace most soft-tissue free flaps in most clinical situations.
PMID: 12045540 [PubMed - indexed for MEDLINE]
Plast Reconstr Surg. 1993 Sep;92(3):421-8; discussion 429-30.Links
Free anterolateral thigh flaps for reconstruction of head and neck defects.
Koshima I, Fukuda H, Yamamoto H, Moriguchi T, Soeda S, Ohta S.
Department of Plastic and Reconstructive Surgery, KawasakiMedicalSchool, Okayama, Japan.
The anterolateral thigh flap is a septocutaneous artery flap based on the septocutaneous or muscle perforators of the lateral circumflex femoral system. Little has been reported about the variations in its vascular anatomy and its application for head and neck reconstruction. We report 22 cases in which this flap was used for the reconstruction of head and neck defects. Based on our clinical and cadevaric experiences, the derivation of the vascular pedicle of this flap has four variations by which the septocutaneous perforators are derived from the descending branch of the lateral circumflex femoral system and/or from the transverse branch of that system, or for which there are no septocutaneous perforators but there are muscle perforators originating from the lateral circumflex femoral system. Clinically, the vascular variations and the locations of perforators of this system can be determined preoperatively with stereoangiograms or simple angiograms and Doppler audiometry. The anterolateral thigh fasciocutaneous flap is suitable for reconstruction of defects in an oral floor with tongue and esophageal deficits, scalp defects with dural defects, and for large full thickness defects of the lip. The advantages of this flap are safe elevation, a long and wide vascular pedicle, skin that is generally thin, and good pliability. Even if the skin is thick, a thinner flap can be created by sacrificing a large amount of fatty tissue. Furthermore, the skin territory is very wide and long. The donor defect can often be closed directly with its scar being less noticeable. The disadvantage of this flap is that the anatomy of the pedicle vessels has irregular derivation from the main vessels. This can be overcome, however, by employing preoperative stereoangiograms.