• Archives of Plastic Surgery
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• 제48권6호
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• pp.646-650
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• 2021

Head and neck reconstruction poses unique challenges in rehabilitating surgical defects in terms of integrity, function, and form. The radial forearm free flap (RFFF) has been widely used for defect coverage, especially in the head and neck area, but its versatility allows it to be used for soft-tissue reconstruction in various parts of the body. The vascular features of the flap are quite constant and reliable. Nevertheless, abnormalities of the forearm vascular tree have been described over the decades. We report a case of intraoral reconstruction after verrucous carcinoma recurrence in a 74-year-old woman with an unusual forearm flap, which we called the median forearm free flap, based on a median branch of the radial artery that was preoperatively detected using handheld Doppler ultrasonography. The distally located skin paddle was predominantly supplied by the aberrant median vessel with its perforators. The flap was thus safely harvested with this atypical pedicle. Successful reconstruction of the intraoral defect was achieved, with an uneventful postoperative course.

• Archives of Plastic Surgery
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• 제42권4호
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• pp.446-452
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• 2015

Background Various techniques are used for performing breast reduction. Wise-pattern and vertical scar techniques are the most commonly employed approaches. However, a vertical scar in the mid-lower breast is prominent and aesthetically less pleasant. In contrast, a semicircular horizontal approach does not leave a vertical scar in the mid breast and transverse scars can be hidden in the inframammary fold. In this paper, we describe the experiences and results of semicircular horizontal breast reductions performed by a single surgeon. Methods Between September 1996 and October 2013, our senior author used this technique in 38 cases in the US and at our institution. We used a superiorly based semicircular incision, where the upper skin paddle was pulled down to the inframammary fold with the nipple-areola complex pulled through the keyhole. Results The average total reduction per breast was 584 g, ranging from 286 to 794 g. The inferior longitudinal pedicle was used in all the cases. The average reduction of the distance from the sternal notch to the nipple was 13 cm (range, 11-15 cm). The mean decrease in the bra cup size was 1.7 cup sizes (range, a decrease of 1 to 3). We obtained very satisfactory results with a less noticeable scar, no complication such as necrosis of the nipple or the skin flap, wound infection, aseptic necrosis of the breast tissue, or wound dehiscence. One patient had a small hematoma that resolved spontaneously. Conclusions This technique is straightforward and easy to learn, and offers a safe, effective, and predictable way for treating mammary hypertrophy.

• Archives of Plastic Surgery
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• 제47권5호
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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.

• Maxillofacial Plastic and Reconstructive Surgery
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• 제33권6호
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• pp.549-558
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• 2011

The latissimus dorsi myocutaneous flap (LDMF) was initially described at the turn of the century by Tansini et al, and latissimus dorsi myocutaneous free flap (LDMFF) was also first described for the coverage of a chronically infected scalp by Maxwell et al. As a pedicled flap, LDMF has been often used for breast reconstruction and for soft tissue replacement near the shoulder and the lower reaches of the head and neck. LDMFF is a flat and broad soft tissue flap with large-caliber thoracodorsal vessels for microvascular anastomosis. A skin paddle of the LDMFF can be more than $20{\times}40$ cm, so very large defects in the oral cavity and outer facial region can be covered by this LDMFF. Other advantages include consistent vascular anatomy, acceptable donor site morbidity and the ability to perform simultaneous flap harvest with tumor resection. For a better understanding of LDMFF as a routine reconstructive procedure in large defects of the oral cavity and facial legion, anatomical findings must be learned and memorized by young doctors during the special curriculum periods for the Korean national board of oral and maxillofacial surgery. This review article discusses the anatomical basis of LDMFF with Korean language.

• Asian Pacific Journal of Cancer Prevention
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• 제13권8호
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• pp.4137-4140
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• 2012

The authors present five cases of combined oral mucosa-mandible defects reconstructed with the vascularized internal oblique-iliac crest myoosseous free flap. This technique has many advantages compared to other conventional methods such as the radial flap, scapula flap, and fibula flap. Vascularized iliac crest flaps provide sufficient high-quality bone suitable for reconstructing segmental madibular defects. Although fibular flaps allow longer donor bone tissue to be harvested, the iliac crest can provide an esthetic shape for mandibular body reconstruction and also provides sufficient bone height for dental implants. Conventional vascularized iliac crest myoosseous flaps have excessive soft tissue bulk for reconstruction of intraoral soft tissue defects. The modification discussed in the present article can reduce soft tissue volume, resulting in better functional reconstruction of the oral mucosa. Another advantage is that complete replacement of the oral mucosa is observed in as early as one month post-operation. The final mucosal texture is much better than that obtained with other skin paddle flaps, which is especially beneficial for the placement of dental implant prostheses. Donor site morbidity looks to be similar to, if not less than that observed for other modalities in terms of function and esthetics. For combined oral mucosa-mandible defects, the vascularized internal oblique-iliac crest myoosseous free flap shows good results with respect to hard and soft tissue reconstruction.

• Archives of Plastic Surgery
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• 제45권4호
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• pp.340-344
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• 2018

Background In performing extended latissimus dorsi (ELD) flap procedures, a skin paddle design on the bra line helps reduce visible scarring. This improves the patient's satisfaction with the outcome. However, such a design leads to a longer operation time and increased fatigue of the surgeon due to the narrow operative field. In this study, the authors propose a method that elongates the axillary incision line posteriorly by 1.5 cm from the lateral border of the latissimus dorsi muscle. We examined whether this method could shorten the operation time and compared the incidence of complications between patients who underwent this novel procedure and patients who underwent the traditional procedure. Methods In this study of patients who underwent ELD flap procedures for immediate breast reconstruction, 89 underwent surgery with the elongated axillary incision and 45 underwent surgery without the elongated incision. The total operation time and complications were retrospectively examined based on the patients' medical records, and we examined whether there was any statistically significant difference in the total operation time. Results In the experimental group with the elongated axillary incision, the operation time ranged from 125 to 255 minutes (median, 175 minutes). In contrast, in the control group without the elongated axillary incision, the operation time ranged from 142 and 340 minutes (median, 205 minutes). The operation time was statistically significantly different between the two groups, and no significant complications were observed in the experimental group. Conclusions Elongation of the axillary incision alone may shorten the operation time of the ELD flap procedure without causing additional complications.

• 대한두개안면성형외과학회지
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• 제13권1호
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• pp.41-45
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• 2012

Purpose: Fibular osteocutaneous free flap is the procedure of choice for mandibular reconstruction. However, the anatomic consistency and the reliability of the skin paddle have been considered to be questionable and the utilization of the fibular osteocutaneous free flap can be challenging for the inexperienced surgeon. Preoperative computed tomography (CT) angiography can support revolutionary help with the operator design of the fibular osteocutaneous flap. The purpose of this article is to share the valuable experience of support with preoperative CT angiography. Methods: Three consecutive patients, who needed mandibular reconstruction, were treated with fibular osteocutaneous free flap. Each of the patients had undergone lower extremity CT angiography before the surgery. The CT angiographies were scrupulously investigated to calculate the locations and the tracts of the peroneal artery perforators. We compared the findings of the CT angiography with those of the real operation. Results: The information about the perforators was sufficiently matched with the findings of the operation. With the use of preoperative CT angiography, we were able to achieve confident performance during operation, shortening of operation time, and fine outcomes with a no flap failure. Conclusion: The CT angiography of lower extremity can provide reliable information of the perforators of the fibular osteocutaneous free flap.

• Archives of Reconstructive Microsurgery
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• 제14권2호
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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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• 제50권6호
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• pp.586-592
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• 2023

Background One-stage reconstruction with "thin perforator flaps" has been attempted to salvage limbs and restore function. The deep inferior epigastric perforator (DIEP) flap is a commonly utilized flap in breast reconstruction (BR). The purpose of this study is to present the versatility of DIEP flaps for the reconstruction of large defects of the extremities. Methods Patients with large tissue defects on extremities who were treated with thin DIEP flaps from January 2016 to January 2018 were included. They were minimally followed up for 36 months. We analyzed the etiology and location of the soft tissue defect, flap design, anastomosis type, outcome, and complications. We also considered the technical differences in the DIEP flap between breast and extremity reconstruction. Results Overall, six free DIEP flaps were included in the study. The flap size ranged from 15 × 12 to 30 × 16 cm². All flaps were transversely designed similar to a traditional BR design. Three flaps were elevated with two perforators. Primary closure of the donor site was possible in all cases. Five flaps survived with no complications. However, partial necrosis occurred in one flap. Conclusion A DIEP flap is not the first choice for soft tissue defects, but it should be considered for one-stage reconstruction of large defects when the circulation zone of the DIEP flap is considered. In addition, this flap has many advantages over other flaps such as provision of the largest skin paddle, low donor site morbidity with a concealed scar, versatile supercharging technique, and a long pedicle.

• Maxillofacial Plastic and Reconstructive Surgery
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• 제27권3호
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• pp.226-237
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• 2005

Purpose : Extensive defect of oral and maxillofacial area is usually reconstructed with composite flap including skin paddle. However, if the defects are lined with only skin components, the mucosa's role in mastication and texture are not restored. Furthermore, stiffness and hair-growing prevent denture rehabilitation and good oral hygiene. This study was performed to overcome the disadvantages of composite soft tissue flaps including the skin and to make a model for myo-mucosal flaps. Materials and methods : Buccal mucosa sized $0.5\times1.0\;cm^2$ from New Zealand rabbit (around 1.5kg) was harvested and cultivated by the modification of Rheinwald and Green's keratinocyte culture method. Cultured mucosa was grafted on the fascia of latismus dorsi as form of mucosal sheet. After 7, 10, 14 days, the myomucosal flap was excised and evaluated under light microscope with H & E and immunohistochemical staining. As control group, harvested buccal mucosa from rabbit was transplanted to gracilis muscle(n=6). Results : From 7 days after prelamination, the basal layer of the grafted mucosa resembled that of normal mucosa. As control group, transplanted mucosa had original shape but there's slight inflammatory reaction. Prelaminated mucosa has 19.8$\pm$4.59 cell layers and some samples have more than 20 layers. The expression rate of PCNA was relatively strong (42.9%$\pm$14.1) at the basal layer of grafted mucosa and the laminin was found at the basal layer. On the contrary, prelaminated mucosa at 10 days showed moderate expression rate of PCNA(32.4%$\pm$4.62). We found the mucosal layer was somehow disappeared and there is strong inflammatory reaction. After 14 days prelamination, the grafted oral keratinocytes were almost disappeared and expression of PCNA was not observed. Conclusion : We can make 75 fold large mucosal($3850mm^2$) sheet from small samples of mucosa $(50mm^2)$. Epithelial sheet that grafted on the fascia of muscle underwent differentiation and proliferation. But after 10, 14 days, there was strong inflammatory reaction and the grafted mucosa was destroyed from surface layer. In rabbit model, transfer of fascio-mucosal flap should be done from 7 to 10 days after prelamination.