• Archives of Plastic Surgery
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• v.37 no.6
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• pp.769-774
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• 2010

Purpose: As the soft tissue defect around the knee is difficult to reconstruct, local flap or free flap is used. Distally based anterolateral thigh pedicled flap introduced by Zhang uses sufficient reverse flow supplied from the vascular network around the knee. We report successful reconstruction of defect around knee by this method. Methods: Four patients with skin & soft tissue defect around knee have been treated for reconstruction using the distally based anterolateral thigh pedicled flap. First, the doppler was used to check the perforator flap of the descending branch of the lateral circumflex femoral artery and to draw and dissect the perforator flap as much as needed. After the dissection, the proximal of the descending branch was clamped and checked for sufficient supply of blood flow from the reverse flow and then ligated. It was dissected along the descending branch and in order to prevent damage to the joined parts of the descending branch and the lateral superior geniculate artery, a more careful ligation was done starting from 10 cm superior to the knee. The defect was reconstructed after securing enough vascular pedicle to cover all the damaged parts. Results: Not all patients suffered from flap necrosis. In case of the patient with chronic osteomyelitis, slight venous congestion was observed right after the surgery but it disappeared the following day. All three patients had no occurences of additional complications. Conclusion: Distally based anterolateral thigh pedicled flap was enough to provide large flap for knee reconstruction. It had sufficient blood flow and vascular pedicle. It also had taken short operation time compared to the free flap operation. The distally based anterolateral thigh pedicled flap used by the authors is a very useful way of reconstructing the area around knee.

• Archives of Reconstructive Microsurgery
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• v.14 no.2
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• pp.105-111
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• 2005

Perforator flaps have become increasingly popular in microsurgery nowadays and are being used widely for many cases of reconstruction after trauma and cancer ablation. And thoracodorsal perforator based free flap is one of them having the merits of carrying a large skin paddle with leaving intact innervation and function of the remaining latissimus dorsi muscle. We made a homogeneous thin flap excluding the main muscle with a long vascular pedicle and tried to decrease the donor site morbidity. But, it needs a long learning-curve and we have met marginal flap necrosis frequently. Besides, prolonged operation time for complete perforator dissection may be a tedious job to the microsurgeon. To overcome these disadvantages, we usually included very small portion of the latissimus dorsi muscle during this flap elevation around the pedicled 2-3 thoracodorsal perforators during this flap elevation. We performed 3 cases of thoracodorsal perforator based free flap at Hallym university sacred heart hospital between May and August 2005 for the soft tissue defect of the scalp and feet. The average flap size was $8{\times}14\;cm$. Although it is not a true perforator flap, we can get the reliability for the flap survival with much better blood circulation and save the time of one or two hours to dissect the perforators completely. All cutaneous flaps survived completely without any complication except one fatty female who had the very small superficial fat necrosis due to flap bulkiness. We believe the thoracodorsal perforator based free flap can be extended its versatility and reliability by including the very small portion of the muscle around the perforators.

• Archives of Plastic Surgery
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• v.46 no.5
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• pp.455-461
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• 2019

Background Various surgical management methods have been proposed for ischial sore reconstruction, yet it has the highest recurrence rate of all pressure ulcer types. A novel approach combining the advantages of a perforator-based fasciocutaneous flap and a muscle flap is expected to resolve the disadvantages of previously introduced surgical methods. Methods Fifteen patients with ischial pressure ulcers with chronic osteomyelitis or bursitis, who underwent reconstructive procedures with an inferior gluteal artery perforator (IGAP) fasciocutaneous flap and a split inferior gluteus maximus muscle flap from January 2011 to June 2016, were analyzed retrospectively. The split muscle flap was rotated to obliterate the deep ischial defect, managing the osteomyelitis or bursitis, and the IGAP fasciocutaneous flap was rotated or advanced to cover the superficial layer. The patients' age, sex, presence of bursitis or osteomyelitis, surgical details, complications, follow-up period, and ischial sore recurrence were reviewed. Results All ischial pressure ulcers were successfully reconstructed without any flap loss. The mean duration of follow-up was 12.9 months (range, 3-35 months). Of 15 patients, one had a recurrent ulcer 10 months postoperatively, which was repaired by re-advancing the previously elevated fasciocutaneous flap. Conclusions The dual-flap procedure with an IGAP fasciocutaneous flap and split inferior gluteus maximus muscle flap for ischial pressure ulcer reconstruction is a useful method that combines the useful characteristics of perforator and muscle flaps, providing thick dual padding with sufficient vascularization while minimizing donor morbidity and vascular pedicle injury.

• Journal of Trauma and Injury
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• v.36 no.3
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• pp.217-223
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• 2023

Purpose: Defects involving the ankle and foot are often the result of road traffic accidents. Many such defects are composite and require a flap for coverage, which is a significant challenge for reconstructive surgeons. Various locoregional options, such as reverse sural artery, reverse peroneal artery, peroneus brevis muscle, perforator-based, and fasciocutaneous flaps, have been used, but each flap type has limitations. In this study, we used the distally based lateral supramalleolar flap to reconstruct distal dorsal defects of the foot. The aim of this study was to analyze the efficacy of the flap in reconstructing distal dorsal defects of the foot. The specific objectives were to study the adequacy, reach, and utility of the lateral supramalleolar flap for distal defects of the dorsum of the foot; to observe various complications encountered with the flap; and to study the functional outcomes of reconstruction. Methods: The distal dorsal foot defects of 10 patients were reconstructed with distal lateral supramalleolar flaps over a period of 6 months at a tertiary care center, and the results were analyzed. Results: We were able to effectively cover distal foot defects in all 10 cases. Flap congestion was observed in two cases, and minor graft loss was seen in two cases. Conclusions: The distally based lateral supramalleolar flap is a good pedicled locoregional flap for the coverage of distal dorsal foot and ankle defects of moderate size, with relatively few complications and little morbidity. It can be used as a lifeboat or even substitute for a free flap.

• Archives of Plastic Surgery
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• v.36 no.3
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• pp.348-350
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• 2009

Purpose: The objective of this study is to present a reliable method of scrotal reconstruction. Methods: 75 year - old - man visited the out patient department of urology for chronic itching sensation in his scrotal area, diagnosed as Bowen's disease. After the wide resection of scrotal lesion, reconstruction was carried with pedicled anterolateral thigh perforator flap. All operation procedure was done with an usual manner, previously reported. Donor site was closed primarily. Results: In 6th month follow - up period, there was no event, such as flap necrosis, wound dehiscence, tumor recurrence. And tactile sensation was recovered. Conclusion: In the Korean literature, there have not been the report that describes the reconstruction of scrotal defect using pedicled anterolateral thigh perforator flap. Pedicled anterolateral thigh perforator flap is reliable and robust flap for scrotal reconstruction.

• Korean Journal of Bronchoesophagology
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• v.3 no.2
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• pp.307-312
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• 1997

Reconstruction of the pharyngoesophagus is one of the most difficult challenges in head and neck surgery. The goals of pharyngoesophageal reconstruction include restoration of a person's ability to swallow and to speak with minimal morbidity, but no current reconstruction modality is clearly best. Following its first introduction as fasciocutaneous flap by Yang in 1981, the forearm flap based on radial artery has become recognized as a very reliable and relatively easy one to use. The forearm flap has thin, pliable and predominantly hairless skin and scant subcutaneous layer In addition, its vascular pedicle is long and of large caliber, which greatly increases the chance of successful revascularization. The forearm flap shows the potentiality for better functional rehabilitation in swallowing and speech as well as the possibility of three dimensional reconstruction. We experienced a case of radial forearm free flap for the reconstruction in a patient with the hypopharyngeal stricture. The early return of oral feeding was possible and successfully enough to return to the normal daily activity.

• Archives of Plastic Surgery
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• v.45 no.3
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• pp.246-252
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• 2018

Background Slim patients or those with large breasts may be ineligible for breast reconstruction with an abdominal flap, as the volume of the flap may be insufficient. This study aimed to establish that abdominal tissue-based breast reconstruction can be well suited for Korean patients, despite their thin body habitus. Methods A total of 252 patients who underwent postmastectomy breast reconstruction with an abdominal flap from October 2006 to May 2013 were retrospectively reviewed. The patients' age and body mass index were analyzed, and a correlation analysis was performed between the weight of the mastectomy specimen and that of the initial abdominal flap. Results The average weights of the mastectomy specimen and initial abdominal flap were 451.03 g and 644.95 g, respectively. The ratio of the weight of the mastectomy specimen to that of the initial flap was $0.71{\pm}0.23$. There was a strong positive linear relationship between the weight of the mastectomy specimen and that of the initial flap (Pearson correlation coefficient, 0.728). Thirty nulliparous patients had a final-to-initial flap weight ratio of $0.66{\pm}0.11$. The 25 patients who underwent a contralateral procedure had a ratio of $0.96{\pm}0.30$. The adjusted ratio of the final flap weight to the initial flap weight was $0.66{\pm}0.12$. Conclusions Breast weight had a strong positive relationship with abdominal flap weight in Koreans. Abdominal flaps provided sufficient soft tissue for breast reconstruction in most Korean patients, including nulliparous patients. However, when the mastectomy weight is estimated to be >700 g, a contralateral reduction procedure may be considered.

• Archives of Reconstructive Microsurgery
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• v.11 no.1
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• pp.11-18
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• 2002

Large soft tissue defects around the knee joint are known to significantly diminish joint function. Severe soft tissue defects on the anterior aspect of the knee joint especially bring on significant joint motion limitation. Although simple split skin grafts can cover the skin defect, the progressing scar contracture of the grafted skin causes joint stiffness. One of the best solutions of large soft tissue defects around the knee joint is covering the defect with a good quality skin flap. Separated flaps with one vascular pedicle are good candidates for covering anterior and posterior aspects of the joint for example. Authors performed 12 cases of combined scapular and latissimus dorsi free flaps from 1984 to 2000. Among them, we experienced 5 cases of knee joint defect covering using the double free flap for coverage of the soft tissue defect with preservation of the knee joint function and satisfactory results. The system of flaps based on the subscapular artery and vein provides a variety of composite free flaps. The possible flaps that can be harvested based on this single vascular pedicle include the scapular and parascapular skin flap, the serratus anterior and latissimus dorsi muscular flap, the lateral scapular bone flap, the latissimus dorsi-rib flap, and the serratus anterior-rib flap. This combined flap is available for multiple tissue defects or complex defects because it can be incorporated with skin, muscle and bone flaps. A main advantage is the independent vascular pedicles of each component, which allow freedom in orientation of each components. Consequently it can be freely applied to any form of three dimensional defects on the upper and lower extremities. The combination of scapular cutaneous flap and latissimus dorsi musculocutaneous flap can be resurfaced for massive cutaneous defects on the extremities. We report the use of the combined scapular and latissimus dorsi free flap in five patients to reconstruct massive defects on the extremities with resultant improved joint function. There was no flap failure and minimal complications and disadvantages. The anatomy of this flap is reviewed and the indication and advantages are discussed. All of the five flaps survived and there was no scar contracture affecting the joint motion.

• Archives of Reconstructive Microsurgery
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• v.8 no.1
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• pp.35-43
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• 1999

There are lots of reconstructive ways like direct closure, skin graft, local flap, regional flap, distant flap, free flap and so on. Microsurgical reconstruction is regarded as the last step in various reconstructive methods. So the failure of this last step causes the troublesome situation for both of patients and surgeon. The purpose of this paper is to investigate the problems in failed free flap surgery and to introduce the strategy of appropriate management in wound of free flap failure. We performed 252 cases of free flap surgeries from May, 1988 to June, 1998. Among these cases, we failed 9 cases of free flaps. Patients' age ranged from 19 to 63. There were 7 males and 2 females. Site of failure were 3 head and neck areas, 2 hands, and 4 lower extremities. However there was no failure in breast, trunk, buttock, and genitalia. 7 patients who had region of head and neck, and lower extremity underwent the second free flap surgery successfully in postoperative 4 to 16 days following debridement of necrotic tissue. However 2 patients who had region in hand were managed with conventional treatment like skin graft and distant flap. Vein grafts were needed in 3 cases of 7 second free flaps, and 1 patients needed sequentially-linked free flaps with two flaps. The second free flaps were inevitable for head and neck area because the large complex wound may cause the lifethreatening condition without immediate coverage with well vascularized flap. Lower extremity also needed second free flap for limb salvage. Hand could be managed with conventional method, even though healing time was quite delayed. We thought second free flap surgery in free flap failure cases should be performed with more careful preoperative evaluation and refined surgery. Success of second free flap surgery could recover the very difficult situation due to previously failed operation.

• Archives of Plastic Surgery
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• v.32 no.1
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• pp.12-18
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• 2005

The Transverse rectus abdominis musculocutaneous (TRAM) flap has been commonly used for autologous breast reconstruction. Despite these clinical usefulness, the TRAM flap is prone to partial flap or fat necrosis in especially pedicled flap. To improve flap survival, the surgical delay procedures and pharmacological treatments have been developed. In many studies for the pharmacological treatment, Lipo-$PGE_1$ has demonstrated a marked ability to improve flap survival and it's effect has been proved similar to surgical delay procedure. The purpose of this study is to determine the most effective route of Lipo-$PGE_1$ administration as a pharmacological treatment in TRAM flap of the rat. Fifty male Sprague-Dawley rats weighing 300-350 gm were divided into five groups, One week before flap elevation, Lipo-$PGE_1$($2{\mu}g/kg$) was injected three times in a week and than the left inferior epigastric vessel based TRAM flap ($5.0{\times}3.0cm$) elevated; group I: no procedure before flap elevation; group II: intraperitoneal injection; group III: intravenous injection; group IV: subcutaneous injection; group V: topical application. A flap was assessed at postoperative 7 days by comparison of flap survival rate, vessel counts(H-E stain), and vascular endothelial growth factor(VEGF) protein expressed by Western blot. The results demonstrated that the mean percentages of the flap survival area in group III were significantly higher than that of any other group(p<0.05). The vessel counts of all experimental groups were statistically higher than that of control group(p<0.05). Only in group III, the VEGF protein expression was increased significantly than control group and there are no difference in other experimental groups. In conclusion, the intravenous administration of the Lipo-$PGE_1$ is the most effective on flap survival, and the VEGF induced by Lipo-$PGE_1$ has some positive effects on new vessel formation and flap survival.