• Archives of Reconstructive Microsurgery
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• v.11 no.2
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• pp.125-134
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• 2002

This study was designed to investigate the process of re- or neo-vascularization in the prefabricated cutaneous flap using a skeletonized arteriovenous pedicle implantation. Fourty-eight flaps were divided into six groups of eight flaps, including control group of the conventional epigastric flap. In experimental groups, skin flap was fabricated by subcutaneous implantation of a distally ligated saphenous arteriovenous pedicle in left abdomen. At 2, 4, 6, 8, and 10 weeks after, prefabricated flap was elevated as an island flap based on implanted pedicle and sutured back in place. Three days after flap repositioning, the area of flap viability was quantified, the pattern of flap vascularization was evaluated with microangiography, and the quantification of vessels was assessed histologically. There were statistically significant differences in flap viability between group 2, 3, 4, and the control (p<0.05), with increased survival area in order. But Group 5 and 6 showed higher flap viability as much as the control did. In the microangiographis study, numerous small meander vessels were newly developed in the vicinity of the implanted pedicle just only 2 weeks after pedicle implantation, but neovascularization around the tip of implanted pedicle, and its anastomosis with native vasculatures was more important for overall flap survival, which was usually developed at least 4 weeks after pedicle implantation. Histologically, vessels are evenly spread over all layers of the flap at 6 weeks after pedicle implantation. The quantification of vessels was correlated well with the improvement of flap viability (p<0.05). In conclusion, neo- and re-vascularization around the tip of implanted pedicle was an important factor for overall survival of the prefabricated flap. Therefore, skeletonized pure vascular pedicle transfer, even though it used alone without surrounding was sufficient to get higher flap viability. The optimal duration of pedicle implantation was8 weeks to obtain maximal survival.

• Journal of the Korean Burn Society
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• v.24 no.2
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• pp.64-67
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• 2021

Free flap surgery is commonly used for extensive facial burn. However, free flap surgery requires long operation time and difficult technique. Also, it requires further procedure to prepare the recipient vessels. Hence, applying pedicle flap surgery instead of free flap surgery is effective for patients with facial burn. Among a wide range of pedicle flaps, we performed lower trapezius myocutaneous pedicle flap to patients with third degree facial burn and got satisfactory results without complications. Lower trapezius myocutaneous pedicle flap has a wide arc of rotation so that it can cover middle and lower part of the face. Furthermore, it is thinner than other myocutaneous pedicle flap that can be used for facial reconstruction. Due to these advantages, lower trapezius myocutaneous pedicle can be an attractive option for the reconstruction of facial burn.

• Archives of Reconstructive Microsurgery
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• v.7 no.1
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• pp.20-27
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• 1998

Among many kinds of introduced free flaps, scapular freeflap is one of the most popularly using modalities in fasciocutaneous defect coverage with minimal donor defect and easier procedure and constant vascular patterns of the donor. Many surgeons who had experience of this flap pointed out deficit of the reliable sensation of the transplanted flap is the main shortcoming of the scapular free flap. If we can subjugate that point, scapular free flap is the most excellent procedure in such a cases as heel pad reconstruction and hand reconstruction which are relatively important to have skin with protective sensation. Author performed anatomical literature review, 10 cadaveric dissections and 12 clinical dissections. In surgical anatomical aspect, the upper six dorsal rami of the thoracic nerves have medial branches which pierce Longissimus thoracis and Multifidus muscle with small cutaneous twigs which pierce Latissimus dorsi and Trapezius muscle. Among that cutaneous twigs, several twigs distribute to the skin of the back from midline to lateral aspect which territory is identical to scapular free flap. We analysed clinical experiences of that sensory bearing scapular free flap surgical anatomy and one year follow-up studies with several results. 1) Two to three cutaneous twigs which pierced from the Trapezius muscle over the scapular free flap region. 2) Each twigs has two to four nerve fascicles with small artery. 3) The nerve distributed to the ordinary scapular free flap and large enough size and pedicle length to neurorrhapy with various recipient site nerves. 4) The inconvenience of this procedure is the vascular pedicle and nerve pedicle have opposite directions, vascular pedicle of that comes from lateral direction from subscapular vessels, but nerve pedicle comes from medial direction from trapezius muscle. Author can found constant cutaneous nerve branches which come from piercing the Trapezius. This nerves are helpful for protective sensation in transplanted scapular free flap. We can't had enough follow-up and evaluation of the nerve function of this procedure, we need continuous research works to application of this procedure. The in conveniences come from directional differences of pedicle can solve with longer harvest neural pedicle and change direction of the neural pedicle.

• Archives of Plastic Surgery
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• v.47 no.1
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• pp.97-101
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• 2020

Although the success rate of deep inferior epigastric perforator (DIEP) flaps has increased, late flap failures still occur and have a low salvage rate. The present article describes a case of salvage of a case of late flap failure using the pedicle vein as a vein graft source. A 50-yearold woman underwent a bilateral DIEP free flap procedure. On postoperative day 6, she experienced flap compromise and underwent emergency flap revision. In the flap revision, flap venous drainage and the superficial inferior epigastric vein were completely obstructed. A Fogarty catheter was used to remove a thrombus from the completely obstructed pedicle vein, and this pedicle vein was used as a graft source and was ligated in retrograde fashion to the flap vein stump. After injection of urokinase into the arterial branch, venous flow to the flap was restored. At a 6-month follow-up visit in the outpatient clinic, only partial fat necrosis at the flap was noted. By dissecting various perforators in the initial operation, decisions regarding immediate revision can be made with more confidence. Additionally, the combined procedures performed in this case may be helpful even for practitioners treating cases of late flap compromise.

• Archives of Plastic Surgery
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• v.46 no.1
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• pp.84-87
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• 2019

With the recent development in microsurgery, the use of a perforator flap has been widely implemented. If the length of the ALT flap pedicle is insufficient despite adequate preoperative planning, pedicle length extension is necessary. We planned for a reverse ALT free flap using the distal vessel of the descending branch for pedicle length extension in the case of ALT perforator branch originating from the proximal portion of the descending branch. For the management of venous congestion, the distal venae comitantes were anastomosed to the proximal venous stump in an antegrade manner, successfully resolving the venous congestion. Modified reverse-flow ALT free flap, wherein the venae comitantes are anastomosed to the proximal vein stump, is a good option that allows for relatively simple pedicle extension within the same operative field when securing an adequate pedicle length is difficult because of the origin of the perforator from the proximal descending branch, unlike the initial surgical plan.

• Archives of Reconstructive Microsurgery
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• v.20 no.1
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• pp.64-67
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• 2011

Reconstruction of the distal portion of the great toe has always represented a difficult problem to surgeons. There are many methods of flap reconstruction described for foot defects, but none for tip of the great toe. We report a case of reconstruction of the great toe using a homodigital reverse pedicle island flap method. A 25-year-old man had a crushing injury at the distal phalanx of the left great toe. A homodigital reverse pedicle island flap was raised from the dorso-medial aspect of the proximal phalanx of the great toe based on the distal dorsal arcade. The flap covered the exposed distal phalanx and stump was closed without shortening. He made an uncomplicated recovery and when seen 6 months later he had a good cosmetic and functional result. A homodigital reverse pedicle island flap is described for the reconstruction of the distal part of the great toe. It involves only a single stage procedure with minimal donor site morbidity and provides a good cosmetic results.

• Archives of Plastic Surgery
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• v.47 no.5
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• pp.473-477
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• 2020

Superficial inferior epigastric artery (SIEA) flaps represent a useful option in autologous breast reconstruction. However, the short-fixed pedicle can limit flap inset options. We present a challenging flap inset successfully addressed by de-epithelialization, turnover, and counterintuitive rotation. A 47-year-old woman underwent left tertiary breast reconstruction with stacked free flaps using right deep inferior epigastric perforator and left SIEA vessels. Antegrade and retrograde anastomoses to the internal mammary (IM) vessels were preferred; additionally, the thoracodorsal vessels were unavailable due to previous latissimus dorsi breast reconstruction. Optimal shaping required repositioning of the lateral ends of the flaps superiorly, which would position the ipsilateral SIEA hemi-flap pedicle lateral to and out of reach of the IM vessels. This problem was overcome by turning the SIEA flap on its long axis, allowing the pedicle to sit medially with the lateral end of the flap positioned superiorly. The de-epithelialized SIEA flap dermis was in direct contact with the chest wall, enabling its fixation. This method of flap inset provides a valuable solution for medializing the SIEA pedicle while maintaining an aesthetically satisfactory orientation. This technique could be used in ipsilateral SIEA flap breast reconstructions that do not require a skin paddle, as with stacked flaps or following nipple-sparing mastectomy.

• Archives of Plastic Surgery
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• v.47 no.3
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• pp.209-216
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• 2020

Background Perforator flaps have led to a revolution in reconstructive surgery by reducing donor site morbidity. However, many surgeons have witnessed partial flap necrosis. Experimental methods to increase inflow have relied on adding a separate pedicle to the flap. The aim of our study was to experimentally determine whether increasing blood flow in the perforator pedicle itself could benefit flap survival. Methods In 30 male Lewis rats, an extended posterior thigh perforator flap was elevated and the pedicle was dissected to its origin from the femoral vessels. The rats were assigned to three groups: control (group I), acute inflow (group II) and arterial preconditioning (group III) depending on the timing of ligation of the femoral artery distal to the site of pedicle emergence. Digital planimetry was performed on postoperative day (POD) 7 and all flaps were monitored using laser Doppler flowmetry perioperatively and postoperatively in three regions (P1-proximal flap, P2-middle of the flap, P3-distal flap). Results Digital planimetry showed the highest area of survival in group II (78.12%±8.38%), followed by groups III and I. The laser Doppler results showed statistically significant higher values in group II on POD 7 for P2 and P3. At P3, only group II recorded an increase in the flow on POD 7 in comparison to POD 1. Conclusions Optimization of arterial inflow, regardless if performed acutely or as preconditioning, led to increased flap survival in a rat perforator flap model.

• Archives of Plastic Surgery
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• v.33 no.3
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• pp.276-282
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• 2006

The anterolateral thigh(ALT) flap has been known as a very versatile and reliable flap. We report our experiences with the anterolateral thigh flap for the postoncologic reconstruction of head and neck region from April 2002 to March 2005. A total of 38 subjects (M: F=30:8, mean age:53.8 years) were taken. We reviewed primary site of tumors, size and thickness of flaps, location and number of perforators, course of perforators, length of pedicle, and postoperative complications. The mean flap size, thickness and pedicle length were $11.8{\times}6.4cm$, 1.1 cm and 12.2 cm, respectively. We classified the pedicles based on the authors' criteria. Type I, pedicle with short intramuscular course, was with 29 cases(72.5%), type II, pedicle with long intramuscular course, with 6 cases(15%), type III, pedicle with septocutaneous course, with 3 cases(7.5%), and type IV, clinically unavailable pedicle, with 2 cases (5%). We experienced 1 case of partial and 1 case of total flap loss. There was 1 case of donor site wound dehiscence, which was treated by debridement and closure. According to the defect, efficient adjustment of the size and thickness of flap was possible, and favorable functional and aesthetic results have been obtained in our study. Our experience confirmed the versatility and usefulness of the anterolateral thigh flap for various reconstructions in head and neck region.

• Archives of Plastic Surgery
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• v.32 no.3
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• pp.319-326
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• 2005

This study was designed to investigate the optimal period of pedicles implantation in the prefabricated periosteofascial flap using a vascular tissue transfer. Flap prefabrication was prepared with a transposition of the central pedicles of right auricle on the calvarium of the New Zealand white rabbit. Thirty flaps were divided into five groups of six flaps, including control group (group I) of the conventional periosteofascial flap based on the right lateral border of parietal bone. The prefabricated flap was elevated as a $2{\times}2cm$ sized island flap and reposed in place in 1, 2, 3, and 4 weeks after the pedicles transfer in groups II, III, IV, and V, respectively. Five days after flap repositioning, the flap viability and vascularity were evaluated with microangiography and histological study quantitatively. The flap survival was increased in accordance with the implanted period of the pedicle. New vessels developed around the implanted pedicle in the 2nd week, and overall vascularization of the flap was accomplished in the 3rd week. The flap with 4 weeks of implantation period, however, showed the same survival rate as the control group. In conclusion, prefabricated periosteo- fascial flap can be created with a vascular tissue transfer, and the optimal duration of the pedicle implantation is more than 4 weeks to obtain adequate flap survival.