• Archives of Reconstructive Microsurgery
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• v.11 no.2
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• pp.153-161
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• 2002

Purpose : Plantar surfaces, calcaneal area, and region of Achilles insertion, which are extremely related with weight-bearing area and shoes application, must be reconstructed with glabrous and strong fibrous skin. Numerous methods of reconstructing defects of these regions have been advocated, but the transfer of similar local tissue as a cutaneous flap with preservation of sensory potential would best serve the functional needs of the weight-bearing and non-weight-bearing surfaces of this region. Therefore it is recommended to use the limited skin of medial surface of foot that is similar to plantar region and non-weight-bearing area. In this paper we performed the medial plantar flap transfered as a fasciocutaneous island as one alterative for moderate-sized defects of the plantar forefoot, plantar heel, and area around the ankle in 25 cases and report the result, availability and problem of medial plantar flap. Materials and methods : We performed proximally based medial plantar flap in 22 cases and reverse flow island flap in 3 cases. Average age was $36.5(4{\sim}70)$ years and female was 3 cases. The causes of soft tissue defect were crushing injury on foot 4 cases, small bony exposure at lower leg 1 case, posterior heel defect with exposure of calcaneus 8 cases, severe sore at heel 2 cases, skin necrosis after trauma on posterior foot 4 cases, and defect on insertion area of Achilles tendon 6cases. Average follow up duration was 1.8(7 months-9.5 years) years. Results: Medial plantar flaps was successful in 22 patients. 18 patients preserved cutaneous branches of medial plantar nerve had sensation on transfered flap but diminished sensation or dysesthesia. At the follow up, we found there were no skin ulceration, recurrence of defect or skin breakdown in all 18 patients. But there was one case which occurred skin ulceration postoperatively among another 4 cases not contained medial plantar nerve. At the last follow up, all patients complained diminished sensation and paresthesia at medial plantar area distally to donor site, expecially with 4 patients having severe pain and discomfort during long-time walking. Conclusion : Medial plantar island flap based on medial plantar neurovascualr pedicle have low failure rate with strong fibrous skin and preserve sensibility of flap, so that it is useful method to reconstruct the skin and soft tissue defect of foot. But it should be emphasized that there are some complications such like pain and paresthesia by neuropraxia or injury of medial plantar nerve at more distal area than donor site. We may consider that medial plantar flap have limited flap size and small arc of rotation, and require skin graft closure of the donor defect and must chose this flap deliberately.

• Archives of Plastic Surgery
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• v.35 no.4
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• pp.379-384
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• 2008

Purpose: Currently, using perforator artery flaps especially anterolateral thigh flaps are widely used for reconstruction of extremities, head and neck. Obtaining a precise anatomical picture prior to operation will translate to a more accurate, efficient and safe procedure. Authors used 3D-image work up via 64-slice MDCT to make a more precise preoperative plan. Methods: A total of 10 patients underwent soft tissue reconstruction with anterolateral thigh flap from December 2006 to December 2007. The 64-Channel MDCT (LightSpeed VCT, GE, USA) was used and 3D images were reconstructed. Findings from MDCT were applied to the preoperative planning and confirmed with intraoperative findings. Results: The average number of perforator arteries from lateral circumflex femoral artery was 2. The average lengths of vascular pedicle from the origin of lateral circumflex femoral artery to the first and second perforator artery were 11.0 cm and 20.0 cm, respectively. The average diameter of the pedicle artery was 2.2 mm. The locations of the perforator arteries were mapped and localized on the body surface based on the MDCT result. These were confirmed through direct visualization intraoperatively. Conclusion: MDCT has an advantage of obtaining accurate images of the general anatomy and even fine structures like perforator arteries. By using this state-of-the-art diagnostic imaging technique, it is now possible to make an operative plan safely and easily.

• Archives of Plastic Surgery
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• v.37 no.5
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• pp.712-716
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• 2010

Purpose: Extensive lumbosacral defects after removal of spinal tumors have a high risk of wound healing problems. Therefore it is an effective reconstructive strategy to provide preemptive soft tissue coverage at the time of initial spinal surgery, especially when there is an instrument exposure. For soft tissue reconstruction of a lumbosacral defect, a variation of the gluteal flap is the first-line choice. However, the musculocutaneous flap or muscle flap that is conventionally used, has many disadvantages. It damages gluteus muscle and causes functional disturbance in ambulation, has a short pedicle which limits areas of coverage, and can damage perforators, limiting further surgery that is usually necessary in spinal tumor patients. In this article, we present the superior gluteal artery perforator turn-over flap that reconstructs complex lumbosacral defects successfully, especially one that has instrument exposure, without damaging the ambulatory function of the patient. Methods: A 67 year old man presented with sacral sarcoma. Sacralectomy with L5 corpectomy was performed and resulted in a $15{\times}8\;cm$ sized complex soft tissue defect in the lumbosacral area. There was no defect in the skin. Sacral stabilization with alloplastic fibular bone graft and reconstruction plate was done and the instruments were exposed through the wound. A $18{\times}8\;cm$ sized superior gluteal artery perforator flap was designed based on the superior gluteal artery perforator and deepithelized. It was turned over 180 degrees into the lumbosacral dead space. Soft tissue from both sides of the wound was approximated over the flap and this provided in double padding over the instrument. Results: No complications such as hematoma, flap necrosis, or infection occurred. Until three months after the resection, functional disturbances in walking were not observed. The postoperative magnetic resonance imaging scan shows the flap volume was well maintained over the instrument. Conclusion: This superior gluteal artery perforator turn-over flap, a modification of the conventional superior gluteal artery perforator flap, is a simple method that enabled the successful reconstruction of a lumbosacral defect with instrument exposure without affecting ambulatory function.

• Archives of Reconstructive Microsurgery
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• v.7 no.2
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• pp.146-156
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• 1998

Microvascular surgery has been widely used clinically for over 30 years. Although many types of free skin and myocutaneous flap are being used at present, surgeons are still looking for new flaps to suit the specific requirements of different recipient sites, to reduce the deformity at the donor site, to ease the management of the flap and to increase the success rate of those operations. The lateral thigh free flap was designed and reported simultaneously with the medial thigh free flap by Baek in 1983. The flap, based on the third perforator of the profunda femoris artery. is designed on the posterolateral aspect of the distal thigh. Clinically, the vascular variations and the locations of perforators of this system can be determined preoperatively with simple angiograms and Dopper audiometry. The lateral thigh free flap is suitable for reconstruction of defects in an oral floor with tongue and esophageal deficits, scalp defects with dural defects, and large full thickness defects of the lip. The advantages of this flap are safe elevation, a long vascular pedicles with a large lumen, skin that is generally thin, and good pliability. Furthermore, the skin territory is very wide and long. The donor site is hidden and therefore more acceptable to the patient. The disadvantage of this flap is that the anatomy of the pedicle vessels has irregular derivation from the main vessel. We had reconstructed lateral thigh free flap to the nine patients from January, 1997 to July, 1998 and got satisfactory results. In this paper we illustrate the arterial anatomy of the thigh and usefulness of this flap for the reconstruction of the head and neck.

• Archives of Reconstructive Microsurgery
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• v.13 no.1
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• pp.43-50
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• 2004

One of the major advantages of microsurgical reconstruction for defects of the hand is that these techniques allow for selection of the most ideal tissue to reconstruct a particular defect, thus optimizing the functional and aesthetic outcome. The dorsalis pedis free flap is an excellent reconstructive tool for various hand reconstructions. It has a reliable vasculature with vessels that are relative large on a long pedicle. It provides thin pliable tissue and be innervated by deep peroneal nerve. Coupled with its thinness and pliability, it is ideal for innervated cover of critically sensitive area, especially such as the hand. Thus it can be used as a cutaneotendinous flap, or an osteocutaneous flap. Otherwise, the major criticism with this flap is related to its uncertain vascularity and the donor defect. It is the purpose of this paper to outline our technique of flap elevation and donor site closure and to indicate our current use of this flap in hand reconstruction. We have treated 10 cases (6 burn scar contracture cases, 4 acute hand trauma cases) of hand reconstruction from Dec. 3, 1997 to Mar. 4, 2004 using dorsalis pedis free flap. The key points for sucess in terms of a viable flap and acceptable donor site are the preservation of the critical dorsalis pedis-first dorsal metatarsal vascular axis and the creation of a viable bed for grafting. In addition, we substituted preserved superficial fat skin graft for split thickness skin graft and wet environment was offered for good graft take. Preserved superficial fat skin is defined as composite graft containing epidermis, dermis and superficial fat layer. With sufficient care in flap elevation and donor site closure, a good graft take of preserved superficial fat skin under wet environment can be achieved with no functional disability and minimal cosmetic deformity in donor site. This flap has proved itself to be a best choice for hand reconstruction.

• Maxillofacial Plastic and Reconstructive Surgery
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• v.35 no.6
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• pp.437-447
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• 2013

The fibula is one of the most useful sources for harvest of a vascularized bone graft. The fibula is a straight, long, tubed bone, much stronger than any other available bone that can currently be used for a vascularized graft. It has a reliable peroneal vascular pedicle with a large diameter and moderate length. There is a definite nutrient artery that enters the medullary cavity, as well as multiple arcade vessels, which add to the supply of the bone through periosteal circulation. The vascularized fibula graft is used mainly for long segment defects of the long tubed bone of the upper and lower extremities. It can provide a long, straight length up to 25 cm in an adult. The fibula can be easily osteotomized and can be used in reconstruction of the curved mandible. Since the first description as a vascularized free fibula bone graft by Taylor in 1975 and as a mandibular reconstruction by Hidalgo in 1989, the fibula has continued to replace the bone and soft tissue reconstruction options in the field of maxillofacial reconstruction. For the better understanding of a fibular free flap, the constant anatomical findings must be learned and memorized by young doctors during the specialized training course for the Korean National Board of Oral and Maxillofacial Surgery. This article reviews the anatomical basis of a fibular free flap with Korean language.

• Maxillofacial Plastic and Reconstructive Surgery
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• v.20 no.3
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• pp.246-249
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• 1998

With the recent progress of microsurgical techniques, radial forearm free flap has an established place in oral reconstruction. Providing thin, soft and pliable skin with a large and constant vascular pedicle, this flap is optimal for intraoral reconstruction. One of the disadvantages of the flap is donor site morbidity, therefore various methods can be used to reduce it. A male complained of palatal and retromolar area mass with ulceration, which was diagnosed as squamous cell carcinoma. He also complained of discomfort and mouth opening limitation, attributed to the location and characteristics of the mass. Because of mouth opening limitation, mandibular swing approach was performed to allow for the surgical approach to the mass. After the surgical excison of the lesion, the intraoral defect was successfully reconstructed with radial forearm free flap.

• Archives of Reconstructive Microsurgery
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• v.10 no.2
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• pp.111-117
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• 2001

Introduction : The Functional muscle transfer is used to reconstruct the injuried muscle and paralysis of the shoulder. Especially transfer of the trapezius has been the treatment of choice but it has disadvantages of inadequate function and deformed contour, and instability of humeral head in case of acromion resection. We report an operation for shoulder reconstruction after wide resection of malignant fibrous histiocytoma, using rotational latissimus dorsi flap and review the operation method and clinical outcome. Materials and Methods : A patient, 53 year old, with malignant fibrous histiocytoma in the acromioclavicular joint area had been underwent wide excision, including the deltoid, clavicular head of pectoralis major, part of trapezius, lateral 1/3 of clavicle and acromion including scapular spine. The rotational latissimus dorsi flap with its neurovascular pedicle was dissected and then placed over the resected area and transfer of muscle attached at coracoid process was done to achieve stability of the humeral head. The range of motion of the shoulder and test of muscle power were evaluated for functional outcome. Total follow-up period is 2 years 11 months. Results : At last follow-up, the range of motion of the shoulder is abduction $90^{\circ}$, flexion $90^{\circ}$, internal rotation $40^{\circ}$, external rotation $50^{\circ}$ and the muscle power is 4 grade in all direction and then we obtained good functional results. There are no complications such as instability or subluxation of the humeral head and deformed contour and he is a disease-free survival state. Conclusions : The transfered latissimus dorsi flap provides adequate lever arm and stabilization and covering of the humeral head by sufficient muscle volume and width. This procedure can be useful not only for the paralysed deltoid reconstruction but also for use in reconstructive surgery after wide resection of the shoulder for malignant tumor.

• Archives of Reconstructive Microsurgery
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• v.1 no.1
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• pp.9-16
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• 1992

Volkmann's ischemic contracture is the end result of an untreated, delayed or Inadequately decompressed compartment syndrome in which muscle ischemia and necrosis have occurred. Once the muscle necrosis have happened, the involved muscle undergo permanent change into fibrous tissue. So secondary shortening and distal joint contracture will be a final outcome, which results in marked functional impairment of hand and forearm. Even though several procedures, such as muscle sliding operation has been attempted, overall results were far from satisfaction, compare to healthy opposite hand. The management of these unfavorable condition of the forearm and hand was regarded as one of challenging area in orthopedics. Recently new approach, using microsurgical technique which transfers functioning muscle unit, has been developed and its result was much better than any other methods in the aspect of an active motion. Among these musculocutaneous free flaps, gracilis has obtained special reputation due to its easiness to handle such as elevation of flap and reliable neurovascular pedicle. Other advantages are flexibility of flap size to adjust variable size of the defect in the forearm and minor morbidity of the donor site. Authors have performed 7 cases of functioning gracilis musulocutaneous free flap transplantation for the functional loss of forearm and hand due to Volkmann's ischemic contracture or muscle and skin defect due to severe trauma since November, 1981 till May, 1991. The results in most cases were satisfactory and acceptable.

• Archives of Reconstructive Microsurgery
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• v.23 no.2
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• pp.70-75
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• 2014

Purpose: Soft-tissue reconstruction in the knee area requires thin, pliable, and tough skin. The range of motion of the knee also acts as a limitation in using only local flaps for coverage. The author has successfully used various perforator flaps for soft tissue reconstruction around the knee while preserving its functional and cosmetic characteristics. Materials and Methods: Out of the twenty patients assessed from April 2009 to March 2011, seven received anterolateral thigh perforator flaps, four received medial sural perforator island flaps, four received lateral supragenicular perforaor perforator flaps, and five received medial genicular artery flaps. The age of the patients ranged from 44 to 79 and the size of the defects ranged from $4{\times}5cm$ to $17{\times}11cm$. Fifteen of the twenty patients had histories of total knee replacement (TKR) surgery. Results: There were no flap losses in any of the twenty patients assessed. Two patients showed partial losses in the distal area of the flap, but were treated through careful wound care. One patient presented with pedicle adhesion at the drainage site from a past TKR, but it did not hinder the flap survival. Primary closure at the donor site was possible in nine patients, while split skin graft was necessary for the other 13. Conclusion: In soft tissue reconstruction of the knee, various perforator flaps can be used depending on the condition of the preoperation scar, wound site, and size. It also proved to provide better functional and cosmetic results than in primary wound closure or skin grafts.