• Archives of Plastic Surgery
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• v.46 no.4
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• pp.324-329
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• 2019

Background Multiple approaches for nipple reconstruction exist, and none is considered superior to all others. The star flap is one of the most popular methods for nipple reconstruction, but gradual height loss is a major concern. We present a new modification of the star flap that incorporates a de-epithelialized dermal flap, along with the associated surgical results. Methods We reviewed the medical records of patients who underwent nipple reconstruction using the modified star flap method. The design was different from the conventional star flap in that the lateral wings were changed into a trapezoidal shape and de-epithelialized dermal flaps were added. The patients were followed up at 2, 4, 6, and 12 months postoperatively, and nipple height was measured. The postoperative nipple height achieved using the modified method was compared with that obtained using the traditional method. Results From February 2013 to June 2017, 32 patients received surgery using the modified star flap, and 18 patients who underwent nipple reconstruction before 2013 comprised the conventional method group. All patients had undergone breast reconstruction with an abdominal tissue-based flap. The mean follow-up period was 14.4 months in the modified method group and 17.3 months in the conventional method group. The mean maintenance of projection at 12 months postoperatively was $56.28%{\pm}18.58%$ in the modified method group, and $44.23%{\pm}14.15%$ in the conventional method group. This difference was statistically significant (P<0.05). Conclusions The modified method using a de-epithelialized dermal flap provides reliable maintenance of projection in patients who have undergone abdominal tissue-based breast reconstruction.

• Archives of Craniofacial Surgery
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• v.19 no.4
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• pp.254-259
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• 2018

Background: The esthetic and functional outcomes of periorbital defect reconstruction are very important because of the complex anatomy and specialized functions of this region. The orbicularis oculi myocutaneous (OOMC) flap is useful for the reconstruction of periorbital defects. But, according to the location and depth of the defects, the reconstruction using OMC flaps with various techniques is rare. The authors have used various kinds of OOMC flaps in various situations and we present an analysis of our experiences. Methods: From November 2001 to July 2017, we used 36 OOMC flaps to reconstruct 30 periorbital defects in 25 patients. We analyzed the cause of the defect, its location, the type of concomitant surgery, the method of flap movement, and complications. Results: Of the 30 defects, basal cell carcinoma was the most common cause, accounting for 20 cases. When the used OOMC flap was classified according to the location of the defects, the switch flap was used in nine cases among 15 defects of lower eyelid, and the V-Y advancement flap was mainly used for other parts. As surgical methods according to the depth of defect were classified, all cases involving the tarsal plate were reconstructed with a composite graft. In case of skin and muscles, they were reconstructed only with OOMC flap or with full-thickness skin graft. Conclusion: The OOMC flap provides good skin quality that is very similar to that of the defect tissue. Depending on the location and depth of the defect, the OOMC flap may be used properly in a variety of ways to achieve good results.

• 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.48 no.1
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• pp.15-25
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• 2021

Thoracodorsal artery (TDA) flaps, ranging from the vascular-pedicled thoracodorsal artery perforator (TDAP) flap, the propeller TDAP flap, and the muscle-sparing latissimus dorsi (MSLD) flap to the conventional latissimus dorsi (LD) flap and the extended LD flap, can all be used for breast reconstruction. The aim of this paper and review is to share our experiences and recommendations for procedure selection when applying TDA-based flaps for breast reconstruction. We describe the different surgical techniques and our thoughts and experience regarding indications and selection between these procedures for individual patients who opt for breast reconstruction. We have performed 574 TDA flaps in 491 patients: 60 extended LD flaps, 122 conventional LD flaps, two MSLD flaps, 233 propeller TDAP flaps, 122 TDAP flaps, and 35 free contralateral TDAP flaps for stacked TDAP breast reconstruction. All the TDA flaps are important flaps for reconstruction of the breast. The LD flap is still an option, although we prefer flaps without muscle when possible. The vascular-pedicled TDAP flap is an option for experienced surgeons, and the propeller TDAP flap can be used in most reconstructive cases of the breast, although a secondary procedure is often necessary for correction of the pedicle bulk. The extended LD flap is an option for women with a substantial body mass index, although it is associated with the highest morbidity of all the TDA flaps. The MSLD flap can be used if the perforators are small or if dissection of the perforators is assessed to be hazardous.

• Archives of Plastic Surgery
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• v.49 no.1
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• pp.108-114
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• 2022

Reconstruction of defects around the knee region requires thin and pliable skin. The superior lateral genicular artery (SLGA) flap provides an excellent alternative to muscle-based flaps. The anatomy and the surgical techniques of the SLGA flap were reviewed and the results of cases using the SLGA flap for coverage of knee and proximal leg defects were analyzed. SLGA flaps were performed in two cases and followed up for at least 6 months. Twelve articles on the use of the SLGA flap were also identified. A review of 39 cases showed that the mean diameter of the perforator supplying the skin of the flap was 1.04 mm, while the mean diameter of the SLGA at its origin was 1.78 mm. The mean length of the pedicle measured from the origin of the popliteal artery was 7.44 cm. The average dimensions of the flap were 14.8×6.6 cm with primary closure of the donor site in 61.5% of cases. Of these cases, 38.5% were due to trauma, 23.1% were post-burn complications, 12.8% were defects after resection of tumors, and 10.3% were for ulcers post-bursectomy. The most common complication was flap tip necrosis. All studies reported favorable outcomes with complete wound healing.

• Journal of Trauma and Injury
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• v.36 no.4
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• pp.369-375
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• 2023

Purpose: The reconstruction of defects around the knee and the proximal third of the leg necessitates thin, pliable skin with a stable and sensate soft tissue cover. This study analyzed the use of a proximally based sural artery flap for the coverage of such defects. Methods: This prospective clinical interventional study involved 10 patients who had soft tissue defects over the knee and the proximal third of the leg. These patients underwent reconstruction with a proximally based sural artery flap. The study analyzed various factors including age, sex, etiology, location and presentation of the defect, defect dimensions, flap particulars, postoperative complications, and follow-up. Results: There were 10 cases, all of which involved men aged 20 to 65 years. The most common cause of injury was trauma resulting from road traffic accidents. The majority of defects were found in the proximal third of the leg, particularly on the anterolateral aspect. Defect dimensions varied from 6×3 to 15×13 cm², and extensive defects as large as 16 cm×14 cm could be covered using this flap. The size of the flaps ranged from 7×4 to 16×14 cm², and the pedicle length was 10 to 15 cm. In all cases, donor site closure was achieved with split skin grafting. This flap consistently provided a thin, pliable, stable, and durable soft tissue cover over the defect with no functional deficit and minimal donor site morbidity. Complications, including distal flap necrosis and donor site graft loss, were observed in two cases. Conclusions: The proximally based sural fasciocutaneous flap serves as the primary method for reconstructing medium to large soft tissue defects around the knee and the proximal third of the leg. This technique offers thin, reliable, sensate, and stable soft tissue coverage, and can cover larger defects with minimal complications.

• Korean Journal of Head & Neck Oncology
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• v.6 no.2
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• pp.79-84
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• 1990

This paper is a review of our experience with radical resection for cancer of the oral cavity with particular emphasis upon the value of myocutaneous(i.e., musculocutanous) flaps employed in the surgical reconstruction in patient survival. During the past 15 years, 98 patients underwent resection of cancer arising in the oral cavity and oropharynx. Of these, 14 had composite resections in which the mandible was not sectioned, and 4 underwent en bloc resections without neck dissections in the face of post-radiation recurrence. When these excluded, 84 patients who underwent COMMANDO procedures with or without myocutaneous flaps were suitable for analysis of recurrence and survival according to the various surgical technics employed. 1) According to the surgical technic, there were 24 standard COMMANDO procedures in whom no regional or myocutanous flap was used; 12 patients who underwent reconstruction employing a forehead flap; 19 patients in whom a posterior cervical 'nape' flap was employed; 27 patients who underwent myocutaneous or osteo-myocutaneous flap repair; and two patients who had double flap repair. 2) The uncorrected two-year disease free survival was 41% for standard COMMANDOs, 17% for forehead flap COMMANDOs; 35% for nape flap COMMANDOs; and 35% for myocutaneous flap COMMANDO procedures. 3) The two-year disease-free survival by Stage was 100% in Stage I, 45% in Stage II, 41% in Stage III, and 18% in Stage IV. 4) When myocutanous flaps cases were compared with Group I, comprised of matched historical controls including both Standard COMMANDOs and those who had undergone regional flap repairs(that is, forehead and nape flap COMMANDOs)there was no difference, both groups showing a 40% 2-year disease-free survival. 5) When musculocutanous flap cases were compared with Goup II, which was composed of matched historical controis limited to patients who had undergone regional flap repairs(that is, forehead and nape flap cases only)there was no difference, both groups showing a 27% 2-year desease-free survival. 6) When musculocutanous flap cases were compared with Group III, composed of patients who had undergone classic COMMANDO procedures without any sort of flap repair, there was a striking difference; the patients undergoing MC flap repair showed 50% 2-year disease-free survival, whereas the classic COMMANDO cases showed a 25% survival free of disease. 7) Locoregional recurrence was also evaluated in the four categories; for standard COMMANDO cases it was 25%, for nape flap cases 26% ; for forehead flap cases, 33%, and for the musculocutaneous flap cases, the lowest recurrence rate, 22%. These results are of particular significance in view of the fact that the proportion of advanced cases(Stage III and IV)in each category was 67% of standard cases, 79% of nape flap patients, 100% of forehead flap cases, and 96% of musculocutaneous flap cases.

• Archives of Plastic Surgery
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• v.37 no.5
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• pp.547-554
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• 2010

Purpose: The purpose of this study is to delineate the optimal time of venous revascularization for preventing the flap necrosis due to venous occlusion, and to clarify the usefulness of tissue oxygen pressure ($TcpO_2$) in the determination of the point of time for venous revascularization. Methods: Thirty-six, $3{\times}3\;cm$ sized epigastric island flap was elevated in left abdomen of male Sprague-Dawley rat weighing 250 gram. Flaps were randomly assigned to six groups of six flaps according to the duration of venous occlusion with microvascular clamp; 10 minutes in the group I as the control, 60 minutes in the group II, 2 hours in the group III, 3 hours in the group IV, 4 hours in the group V, and 6 hours in the group VI, respectively. Just before removal of clamp after flap was reposed in situ, the ratio of $TcpO_2$ (tissue oxygen pressure) of the island flap to that of right abdomen was calculated in each group, and tissue specimen was harvested from the distal area of the flap for histological evaluation of vascular change. Five days later, survival area of the flap was estimated, and evaluated the correlation between the tissue oxygen pressure and the rate of flap survival. Results: The $TcpO_2$ and the survival rate of flap were decreased proportionally with the duration of venous occlusion. The ratio of the $TcpO_2$ of the flap is decreased abruptly to below sixty percentile compared to the $TcpO_2$ of normal tissue, and the survived area of the flap is decreased to nine-tenth of the designed size after three hours of total venous occlusion. Histologically, the number of congested vessels was increased according to venous occluded time, and proportionally increased after 3-hours of occlusion significantly. Conclusion: There is a close correlation between the $TcpO_2$ and the survival rate of flaps according to the duration of venous occlusion. Therefore, the $TcpO_2$ represents the hemodynamic changes within the flap, and thought to be an alternative effective tool in the flap monitoring for venous revascularization.

• Archives of Plastic Surgery
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• v.33 no.6
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• pp.784-788
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• 2006

Purpose: For the reconstruction of the ankle joint as well as the soft tissue defect in the distal lower leg, a free flap or a local flap has been used, and because of the condition of patients, if a complex microvascular surgery under general anesthesia could not be performed, it could be reconstructed by using the distally based lateral supramalleolar fascio-cutaneous island flap using the perforating branch of the peroneal artery in the ankle area. Methods: The study subjects were 4 male patients between 53 years and 73 years of age. 2 cases were tissue defect in the medial malleolus area due to systemic diseases such as gouty arthritis accompanied traffic accident, diabetes mellitus foot, atherosclerotic obliterans, etc., 1 case was the defect in the pretibia area, and 1 case was the defect underneath the lateral malleolus, which was reconstructed by the distally based lateral supramalleolar fascio-cutaneous island flap. The donor area was the skin harvested from the groin, and the full thickness skin graft was performed. The size of the flap varied from $4{\times}3cm$ to $9{\times}6cm$. As the flap border, the medial side was to the tibialis anterior tendon, the lateral side was to the fibula crest, and the proximal area was less than the fibula size. Results: The consequence is that, in total 4 cases, the congestion in the flap began from 12 hours after the surgery, and the progression of congestion was ceased on the 5th day after the surgery, and finally epidermal bulla and sloughing, partial necrosis was developed. After the end of necrosis, the defect area was reconstructed successfully by the second full thickness skin graft. Conclusions: Although the distally based lateral supramalleolar fascio-cutaneous island flap has the shortcoming of requiring the second skin graft, it has the advantages that it does not require a long complex microsurgery, the flap itself is thin, it is similar to the color of the skin in the recipient area, and it does not leave a big scar in the donor area. Therefore, it is thought that for the cases who could not undergo a long complex surgery due to systemic diseases or the cases of patients whose condition of the recipient area is not suitable for microsurgery, the lateral supramalleolar fascio-cutaneous island flap is very useful for the reconstruction of the distal lower leg and the ankle joint area.

• Korean Journal of Head & Neck Oncology
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• v.17 no.2
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• pp.190-193
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• 2001

Background and Objectives: Reliable and versatile free flap has become a mainstay in reconstruction of the head and neck. But until now pectoralis major myocutaneous flap (PMMCF) as workhorse is useful and has some advantages such as good viability, one-stage reconstruction and carotid protection. The objective of this study was to review the role and indication of PMMCF in this era of potent free flaps for head and neck reconstruction. Patients and Methods: Sixty one PMMCF and one hundred forty six free flaps used for head and neck reconstruction between 1991 and 2001 were reviewed retrospectively. We compared the applied sites of flap, the flap failure rate and complications. Results: Contrary to the free flap, use of PMMCF has gradually decreased after the middle of 1990s. PMMCF were mainly used for mucosal defect(33cases, 54.1%) and cervical skin defect(22cases, 36.1%) and free flap were mainly used for mucosal defect(129cases, 88.4%). In point of use of PMMCF according to years, from 1991 to 1997, 30cases(70%) are used to reconstruct mucosal defect and 12cases(29%) are used to reconstruct skin defect. But from 1998 to 2001, only 2cases(10.5%) are used to reconstruct mucosal defect and 13cases(68.4%) are used to reconstruct neck skin defect. In case of free flap, from 1991 to 1997, 41cases (87%) are used to reconstruct mucosal defect and from 1998 to 2001 88cases(89%) are used as same purpose. Three major necrosis (more than 50%) deveolped in 61 PMMCF (4.9%) and three major necrosis developed in 146 free flaps(2.1%). Conclusion: PMMCF is no longer flap of choice for primary reconstruction but it is a still one of a good tool in some head and neck reconstruction such as covering single wide defect of face or neck skin, back-up procedure of free flap, postoperative status, treatment of pharyngocutaneous fistula and covering vital structure.