• Archives of Plastic Surgery
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• v.36 no.1
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• pp.75-79
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• 2009

Purpose: The transverse rectus abdominis musculocutaneous(TRAM) flap is the most commonly used autogenous tissue flap for breast reconstruction. Postoperatively, partial flap loss or fat necrosis are relatively common and it may result in a smaller breast volume with marked contour irregularities. These defects are not easy to reconstruct with local tissue rearrangement or with breast implants. The current authors present the results of 2 patients who underwent Latissimus dorsi(LD) flap reconstruction to correct partial flap or fat necrosis that developed after TRAM flap breast reconstruction. Method: Case1: A 50 - year - old woman with left breast cancer visited for breast reconstruction after radical mastectomy. Initially, breast reconstruction with pedicled TRAM was performed. Postoperatively partial flap necrosis was developed. Secondary breast reconstruction using LD flap was done. Case2: A 51 - year - old woman with left breast cancer visited for breast reconstruction after radical mastectomy. Initially, breast reconstruction with pedicled TRAM was performed. Postoperatively fat necrosis was developed. Secondary breast reconstruction using LD flap was done. Results: Secondary breast reconstruction using LD flap survived completely and produce successful reconstruction. There was no significant complication in both patients. Conclusion: LD flap provides sufficient, vascularized skin and soft tissue. The flap can be molded easily to replace deficient tissue in all areas of the breast. These attributes make it an ideal candidate for salvage of the partially failed TRAM flap breast reconstructio.

• Archives of Plastic Surgery
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• v.35 no.2
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• pp.174-180
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• 2008

Purpose: While radiotherapy remains an essential part of the multidisciplinary treatment of cancers, it may cause unwanted consequences such as tissue break down and chronic non-healing wounds as a result of hypoxia, hypovascularity, and hypocellularity. The conservative treatment of osteoradionecrosis was effective only in the early stages or has a limited result. The surgical treatment of osteoradionecrosis includes various local fasciocutaneous flaps, local myocutaneous flaps and different kinds of free flaps with cancellous bone graft or alloplastic material after removal of all devitalized tissue. This study reviews recent cases of osteoradionecrosis in Severance hospital and investigates the use of various flaps for reconstruction of osteoradionecrosis. Methods: From 2000 to 2006, a total of 29 patients, nine men and twenty women with a mean age of 60.4 years were identified and included in the study. Fasciocutaneous flaps were used on 7 patients and myocutaneous flaps were used on the remaining patients. Mean follow-up period was 10.4 months. Results: In the fasciocutaneous flap group, we noted two complications including total flap failure and a partial flap necrosis. In the myocutaneous flap group, four complications were noted including a partial flap necrosis and 3 cases of wound dehiscence. Considering the complications noted in this study, the natural history of progression to flap necrosis appeared to follow the following sequence of events: marginal flap necrosis, infection, wound dehiscence, flap floating and partial flap necrosis, serially. Conclusion: Successful surgical treatment of osteoradionecrosis includes wide radical debridement and reconstruction with a well vascularized flap like myocutaneous flap or fasciocutaneous flap.

• Journal of Korean Foot and Ankle Society
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• v.11 no.2
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• pp.232-237
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• 2007

Introduction: To report the result of the thigh perforator free flap for the reconstruction of the soft tissue defect of the lower extremities and usefulness of this flap. Materials and Methods: We have performed 23 cases of thigh perforator free flap to reconstruct the soft tissue defect of the lower extremities between February 2004 and July 2005. The anterior aspect of the legs were 9 cases, the ankle joints were 4 cases, the dorsal aspect of the feet were 6 cases, the sole of the feet were 4 cases as recipient sites. The anterolateral thighs were 13 cases, the anteromedial thighs were 10 cases as donor sites. The size of the flap ranged from $4{\times}5\;cm$ to $12{\times}18\;cm$. The mean flap area was $73.2\;cm^2$. The length of the pedicle ranged from 5 cm to 15 cm. Every patient except children was operated under the spinal anesthesia. Results: 21 flaps (91.3%) survived, 2 flaps (8.7%) failed. In the 21 flaps that had survived, there were partial necrosis in 4 cases, which healed without any additional operation. In the 13 anterolateral thigh perforator flaps, 9 cases survived totally, 3 cases had the partial necrosis, 1 case failed. In the 10 anteromedial thigh perforator flaps, 8 cases survived totally, 1 case had the partial necrosis, 1 case failed. Conclusion: The authors had a good result with the thigh perforator free flap and believe that this flap is a good option for the reconstruction of the soft tissue defect of the lower extremities, because this flap has a thin thickness and it is easy to dissect the vessels. Moreover the patients can be operated with supine position.

• Archives of Plastic Surgery
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• v.48 no.1
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• pp.121-126
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• 2021

Background Despite the wide demand for thin flaps for various types of extremity reconstruction, the thin elevation technique for anterolateral thigh (ALT) flaps is not very popular because of its technical difficulty and safety concerns. This study proposes a novel perforator-centralizing technique for super-thin ALT flaps and analyzes its effects in comparison with a skewed-perforator group. Methods From June 2018 to January 2020, 41 patients who required coverage of various types of defects with a single perforator-based super-thin ALT free flap were enrolled. The incidence of partial necrosis and proportion of the necrotic area were analyzed on postoperative day 20 according to the location of superficial penetrating perforators along the flap. The centralized-perforator group was defined as having a perforator anchored to the middle third of the x- and y-axes of the flap, while the skewed-perforator group was defined as having a perforator anchored outside of the middle third of the x- and y-axes of the flap. Results No statistically significant difference in flap thickness and dimension was found between the two groups. The arterial and venous anastomosis patterns of patients in both groups were not significantly different. Only the mean partial necrotic area showed a statistically significant difference between the two groups (centralized-perforator group, 3.4%±2.2%; skewed-perforator group, 15.8%±8.6%; P=0.022). Conclusions The present study demonstrated that super-thin ALT perforator flaps can be elevated safely, with minimal partial necrosis, using the perforator-centralizing technique.

• Journal of Korean Foot and Ankle Society
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• v.24 no.4
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• pp.148-155
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• 2020

Purpose: Minor foot amputations are performed for recurrent or infected ulcers or osteomyelitis of the diabetic feet. Patients may require a large amount of bone resection for wound closure. On the other hand, this results in more foot dysfunction and a longer time to heal. The authors describe fillet flap coverage to avoid more massive resection in selected cases. This study shows the results of fillet flap coverage for the closure of diabetic foot minor amputation. Materials and Methods: This was a retrospective case series of patients who underwent forefoot and midfoot amputation and fillet flap for osteomyelitis or nonhealing ulcers between March 2013 to November 2017. In addition, the patient comorbidities, hospital days, complications, and duration to complete healing were evaluated. Results: Fourteen fillet flap procedures were performed on 12 patients. Of those, two had toe necrosis, nine had forefoot necrosis, and three had midfoot necrosis. Eleven forefoot amputations and three midfoot amputations were performed. Among forefoot necrosis after a fillet flap, three patients had revision surgery for partial necrosis of the flap, and two patients had an additional amputation. Two patients had additional amputations among those with midfoot necrosis. By the fillet flap, the amputation size was reduced as much as possible. The mean initial healing days, complete healing days, and hospital stay was 70.6 days, 129.0 days, and 60.0 days, respectively. Conclusion: The fillet flap facilitates restoration of the normal foot contour and allows salvage of the metatarsal or toe.

• Archives of Plastic Surgery
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• v.49 no.3
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• pp.324-331
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• 2022

Prior abdominal liposuction can be viewed as a relative or absolute contraindication to abdominally based autologous breast reconstruction given concerns for damaged perforators and scarring complicating intraoperative dissection. This systematic review aims to explore the outcomes of abdominally based breast reconstruction in patients with a history of abdominal liposuction. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-guided literature search was conducted using PubMed, Scopus, and Web of Science from the earliest available date through June 2020. Deep inferior epigastric perforator, muscle-sparing transverse rectus abdominis musculocutaneous (TRAM), superficial inferior epigastric artery, and pedicled TRAM flaps were included for evaluation. Complications included total or partial flap loss, fat necrosis, seroma, delayed wound healing, and donor site complications. After inclusion criteria were applied, 336 non-duplicate articles were screened, yielding 11 for final review, representing 55 flaps in 43 patients. There was no instance of total flap loss, eight (14.5%) flaps developed partial loss or fat necrosis, three (5.4%) flaps had delayed wound healing, and two (4.6%) patients had donor site complications. Most authors (8/11) utilized some type of preoperative imaging. Doppler ultrasonography was the most used modality, and these patients had the lowest rate of partial flap loss or flap fat necrosis (8%), followed by those without any preoperative imaging (10%). In conclusion, this review supports that patients undergoing abdominally based autologous breast reconstruction with a history of abdominal liposuction are not at an increased risk of flap or donor site complications. Although preoperative imaging was common, it did not reliably decrease complications. Further prospective studies are needed to address the role of imaging in improving outcomes.

• Archives of Plastic Surgery
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• v.34 no.2
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• pp.229-236
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• 2007

Purpose: Breast reconstruction with deep inferior epigastric perforator(DIEP) free flap is known to be the most advanced method of utilizing autologous tissue. The DIEP free flap method saves most of the rectus abdominis muscle as well as anterior rectus sheath. Therefore, the morbidity of the donor site is minimized and the risk of hernia is markedly decreased. Methods: We chose the internal mammary artery and its venae comitantes as recipient vessels, and deep inferior epigastric vessels as donor vessels. The number and location of the perforators derived from medial or lateral branch of deep inferior epigastric artery(DIEA) in 23 DIEP flaps were identified. Ten patients underwent evaluation of their abdominal wall function preoperatively and 6 months postoperatively by using Lacote's muscle grading system. Results: Of the 23 patients, a patient with one perforator from lateral branch of DIEA experienced partial necrosis of flap. Total flap loss occurred in one patient. Mild abdominal bulging was reported in one patient 4 months postoperatively probably because of early vigorous rehabilitational therapy for her frozen shoulder. Postoperative abdominal wall function tests in 10 patients showed almost complete recovery of muscle function upto their preoperative level of upper and lower rectus abdominis and external oblique muscle function at 6 months postoperatively. All patients have been able to resume their daily activities. Conclusion: The breast reconstruction with DIEP free flap is reliable and valuable method which provide ample soft tissue from abdomen without compromising the integrity of abdominal wall. Selection of reliable perforators is important and including more than two perforators may decrease fat necrosis and partial necrosis of flap.

• Archives of Reconstructive Microsurgery
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• v.20 no.2
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• pp.89-95
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• 2011

Purpose: The purpose of this study was to evaluate the clinical results of anterolateral thigh free flap on soft tissue defect following wide excision in malignant soft tissue tumor of lower extremities. Methods: Between February 2005 to April 2010, we followed up 19 cases who were undergoing anterolateral thigh free flap because of soft tissue defect following wide excision of malignant soft tissue tumor in lower extremity, including 9 cases were heel, 5 cases in foot, 3 cases in ankle, 2 cases in knee and leg. We observed that of implanted area's color, peripheral circulation at 3, 5, 7 days after operation and evaluated operating time, amount of hemorrhage, implanted skin necrosis, additional operations, complications. And we also evaluated the oncologic results, including local recurrence, metastasis, and morbidity. Results: Average operation time of wide excision and anterolateral thigh free flap was 7 hour 28 minutes. 18(94.7%) of total 19 cases showed successful engraftment, on the other hand, failure of engraftment due to complete necrosis of flap in 1 case. In 18 cases with successful engraftment, reoperation was performed in 4 cases. Among them, removal of hematoma and engraftment of flap after bleeding control was performed in 3 cases, because of insufficient circulation due to the hematoma. In the remaining 1 case, graft necrosis due to flap infection was checked, and grafted after combination of wound debridement and conservative treatment such as antibiotics therapy, also skin graft was performed at debrided skin defect area. Skin color change was mainly due to congestion with hematoma, flap was not observed global congestion or necrosis except 4 cases which shows partial necrosis on margin that treated with conservative therapy. Conclusions: Anterolateral thigh free flap could be recommended for reconstruction of soft tissue defect following wide excision of malignant soft tissue tumor in lower extremity.

• Archives of Plastic Surgery
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• v.51 no.1
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• pp.87-93
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• 2024

This study aimed to analyze cases of anterolateral thigh (ALT) free flap used for hand reconstruction with terminal perforator-to-digital artery anastomosis. Patients who underwent ALT free flap placement with terminal perforator-to-digital artery anastomosis for hand reconstruction between January 2011 and August 2021 were included. The number, length, and diameter of the perforators and veins, flap size, and operative time were investigated through a retrospective review of charts and photographs. The occurrences of arterial thrombosis, venous thrombosis, arterial spasm, and flap necrosis were analyzed. In total, 50 patients were included in this study. The mean diameter and length of the perforators were 0.68 mm and 3.25 cm, respectively, and the mean number of veins anastomosed was 1.88, with a mean diameter of 0.54 mm. Complications included four cases of arterial thrombosis, one case of venous thrombosis, seven cases of partial necrosis, and one case of total flap failure. Regression analysis showed that a longer perforator was associated with arterial thrombosis whereas larger flap size and number of anastomosed veins were associated with partial necrosis (p < 0.05). The terminal perforator-to-digital artery anastomosis offers advantages in using compact free flaps with short pedicle lengths to cover small hand defects.

• Archives of Reconstructive Microsurgery
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• v.13 no.2
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• pp.107-116
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• 2004

Flaps are necessary, when important structures such as bone, tendon, nerve and vessel are exposed. Arterialized venous free flap is suited to the coverage of finger and hand because the thickness of venous flap is thin. Authors performed 65 cases arterialized venous free flap for the soft tissue reconstruction of the hand and finger. The size of donor defect were from $1{\times}1cm\;to\;7{\times}12cm$. The mean flap area was $9.1cm^2$. The recipient sites were finger tip in 34 cases, finger shaft in 29 cases and hand in 2 cases. The donor sites were volar aspect of distal forearm in 40 cases, thenar area in 17 cases and foot dorsum in 6 cases. The types of arterialized venous free flap were A-A type in 4 cases and A-V type in 61 cases. The length of afferent vein was from 0.5 cm to 3 cm (mean 1.7 cm) and efferent vein was from 1 cm to 10 cm (mean 2.2 cm). 58 flaps(89.2%) survived eventually. 42 flaps(64.6%) survived totally without any complication. 8 flaps(12.3%) showed the partial necrosis but they were healed without any additional operations. 8 flaps (12.3%) showed the partial necrosis requiring the additional skin graft. We had a satisfactory result by using arterialized venous free flap for the soft tissue reconstruction of finger and hand. We believe that volar aspect of distal forearm, thenar area, foot dorsum are suited as a donor site and the short length of the flap pedicle, the strong arterail inflow affect the survival rate of arterialized venous free flaps.