The Propeller Concept Applied to Free Flaps and the Proposal of a “Clock Flap” Nomenclature

2017 ◽  
Vol 33 (S 01) ◽  
pp. S48-S52
Author(s):  
Carlo Rossello ◽  
Carlo Salomone ◽  
Giuliana Carrega ◽  
Lamberto Felli ◽  
Giorgio Burastero ◽  
...  
Keyword(s):  
Donor Site ◽  
Free Flaps ◽  
Donor Site Morbidity ◽  
Safe Procedure ◽  
Perforator Flaps ◽  
Recipient Site ◽  
Reconstructive Procedures ◽  
Nomenclature System ◽  
Aesthetic Results ◽  
Vessel Axis

Background It is a common experience for reconstructive surgeons to feel the necessity for large flaps and minimal donor-site morbidity at the same time. In the reported cases where we felt this call intraoperatively, we have met our need by applying the “propeller concept” to fasciocutaneous or composite flaps, separating and rotating its different tissue components. Methods We present a series of five cases in which we separated and rotated diversely fascial and cutaneous components of free perforator flaps to enhance the extension of the flap or to tailor it better on the tissue gap for optimal functional and aesthetic results. We also propose a simple nomenclature system for rotation angles' definition, summarized as the “clock flap” classification, where the different components of the flap represent the arms of a clock which has the main vessel axis on the 12–6 line. Results All reconstructive procedures succeeded with only minor complications. No partial failure due to vessel rotations was noticed. Conclusion Applying “propeller style” rotations to different components of free flaps seems to be a safe procedure which may help maximize flap performance in terms of coverage of the recipient site, while minimizing scars and impairment of the donor site. Also, the proposed nomenclature gives the opportunity to record and compare surgical procedures for statistical analysis.

Microsurgical Scalp Reconstruction: An Overview of the Contemporary Approach

2021 ◽  
Author(s):  
Ping Song ◽  
Lee L. Q. Pu
Keyword(s):  
Preoperative Evaluation ◽  
Donor Site ◽  
Free Flaps ◽  
Donor Site Morbidity ◽  
Primary Role ◽  
Recipient Site ◽  
Recipient Vessel ◽  
Scalp Reconstruction ◽  
Core Concepts ◽  
Contemporary Approach

Abstract Background Microsurgical scalp reconstruction has evolved immensely in the last half-century. The core concepts of microsurgical scalp reconstruction have always been to transfer soft tissue of a sufficient quality to within the defect while minimizing donor site morbidity. Refinements in scalp reconstruction consist of both improvement in reducing donor site morbidity and enhancing recipient site contour and balance. Furthermore, technical advancements and the vast experience within our field have allowed for preoperative evaluation of recipient vessels that are more favorable in proximity to the scalp. Methods In this review, we aim to describe the contemporary approach to microsurgical scalp reconstruction. This is to include the indications of choosing free flaps as well as how to select the ideal flap based on patient-oriented factors. The need for cranioplasty, recipient vessel selection, operative technique, and reoperations is also reviewed. In addition, our considerations and the nuances within each category are also described. Summary Scalp reconstructions involve the fundamental tenants of plastic surgery and demand application of these principles to each case on an individual basis and a successful reconstruction must consider all aspects, with backup options at the ready. Two workhorse free flaps, the anterolateral thigh perforator and latissimus dorsi muscles flaps, serve a primary role in the contemporary approach to microsurgical scalp reconstruction. Conclusion We hope this review can lay the foundation for which future plastic surgeons may continue to build and advance the approach to complex microsurgical scalp reconstruction.

scholarly journals Perforator-Pedicled Propeller Flaps for Lower Extremity Reconstruction

2020 ◽  
Vol 34 (03) ◽  
pp. 200-206
Author(s):  
Mohamed A. Ellabban ◽  
Ahmed I. Awad ◽  
Geoffrey G. Hallock
Keyword(s):  
Lower Extremity ◽  
Donor Site ◽  
Free Flaps ◽  
Donor Site Morbidity ◽  
Peripheral Vascular ◽  
Perforator Flaps ◽  
Vascular Insufficiency ◽  
Lower Extremity Reconstruction ◽  
Extremity Reconstruction ◽  
Bone Exposure

AbstractReconstruction of the lower extremity is considered a major challenge due to frequent bone exposure and the absence of local tissue redundancy, as well as often due to the presence of vascular insufficiency. Many surgeons have preferred free flaps especially for reconstructing the more distal lower limb defects until the evolution of pedicled perforator flaps and propeller flaps in particular provided a like-with-like reconstruction of the lower extremity without affecting the main vessels of the limb or the underlying muscles, and without the risk of any microanastomosis especially in patients with multiple comorbidities. Perforator-pedicled propeller flaps as local flaps in the lower extremity are best suited for small- and medium-sized defects with minimal donor-site morbidity, regardless of the cause of the defect. Any of the three source vessels of the leg can provide reliable perforators for propeller flap coverage of the distal leg and foot. The three main risk factors that are relative contraindications may be advanced age, diabetes mellitus, and atherosclerotic peripheral vascular disease.

scholarly journals Reconstruction of Distal Phalangeal Injuries with Homodigital Island Flap: a Case Report

1970 ◽  
Vol 1 (4) ◽  
Author(s):  
Parintosa Atmodiwirjo ◽  
Sachraswaty Laidding
Keyword(s):  
Skin Graft ◽  
Donor Site ◽  
Free Flaps ◽  
Donor Site Morbidity ◽  
Island Flap ◽  
Palmar Arch ◽  
Cold Intolerance ◽  
Recipient Site ◽  
Fingertip Reconstruction

Background: Reconstruction of distal phalangeal defects with exposure of bone, tendon, or joint can be a difficult reconstructive problem, particularly since immediate coverage is of paramount importance for preserving function. The objectives of distal phalangeal defect or fingertip reconstruction included preservation of functional length and sensibility, prevention of symptomatic neuromas, acceptable donor site morbidity, the absence of cold intolerance, mineralization of aesthetic deformity, and quick return to occupational activities.Patients and Method: A review of one case, 26 years old male with phalangeal defect at tip to radial site of 3th finger of right hand, with tendon and bone exposed. After adequate debridement, shape and size of the defect are measured, the flap designed at the ulnar site of the same finger and the vascular of the flap is marked to palmar arch. Lazy “S” incision performed, donor flap is elevated with pedicle and transferred to the recipient site. Donor site was covered up with skin graft. Result: After follow up the homo digital island flap was healed nicely and the skin graft take was 100%, length is less diminish, sensibility conformed with two-point description, joint flexibility is good.Summary: Homodigital island flap is a useful safe option for fingertip or distal phalangeal reconstruction because it offers multiple advantages in comparison with advancement, regional, and free flaps, with an almost negligible donor site defect and can be done in a 1-stage procedure.

scholarly journals Suprafascial Free Flaps: Classification and Comprehensive Review of the Literature

2021 ◽  
Vol 6 ◽  
pp. 247275122110205
Author(s):  
Sebastian Rios ◽  
María Isabel Falguera-Uceda ◽  
Alicia Dean ◽  
Susana Heredero
Keyword(s):  
Survival Rate ◽  
Preoperative Planning ◽  
Donor Site ◽  
Free Flaps ◽  
Donor Site Morbidity ◽  
Anterolateral Thigh Flap ◽  
Cochrane Library ◽  
Review Of The Literature ◽  
Comprehensive Review ◽  
Search Terms

Study Design: Suprafascial free flaps have become common place in reconstructive surgery units. Nomenclature related to these flaps has not been uniform throughout the scientific literature, especially in regard to planes of dissection. This study is designed as a comprehensive review of the literature. Objectives: Our study highlights which flaps are used most frequently, their main indications, their survival rate, and how they have evolved in the last few decades as innovations have been introduced. Methods: A review of the literature was performed using keywords and Medical Subject Headings search terms. PubMed, Embase, and Cochrane Library were searched using the appropriate search terms. Data collected from each study included flap type, dissection plane, preoperative planning, area of reconstruction, as well as complications, donor-site morbidity and survival rate. Results: Seven hundred and fifty-five studies were found based on the search criteria. After full-text screening for inclusion and exclusion criteria 34 studies were included. A total of 1332 patients were comprised in these studies. The most common types of flaps used were superficial circumflex iliac perforator flap (SCIP), anterolateral thigh flap (ALT), and radial forearm flap. The most common areas of reconstruction were head & neck and limbs. There was no significant difference in survival rates between flaps that were raised in different planes of dissection. Conclusions: Based on the author’s review of the literature, suprafascial flaps are reliable, they have low donor site morbidity, and there is a wide selection available for harvest. The use of new technologies for preoperative planning, such as CT-Angiography and UHF ultrasound, have contributed to have more predictable results. We propose a standardized classification for these flaps, in order to create a uniform nomenclature for future reference.

scholarly journals Free flaps in Surgical Dermatology: comparison between fasciocutaneous and myocutaneous free flaps in facial reconstructions

2011 ◽  
Vol 86 (6) ◽  
pp. 1145-1150
Author(s):  
Francisco Miguel Camacho-Martínez ◽  
Angel Rollón ◽  
Clara Salazar ◽  
Elena M Rodríguez-Rey ◽  
David Moreno
Keyword(s):  
Free Flap ◽  
Malignant Tumors ◽  
Donor Site ◽  
Free Flaps ◽  
Single Step ◽  
Rectus Abdominis ◽  
Original Position ◽  
Random Pattern ◽  
Recipient Site ◽  
Palmar Surface

BACKGROUND: Dermatologic surgeons routinely harvest pedicled flaps at distance with an axial or random pattern to repair facial defects. These types of skin flaps are time-consuming and have high economic, social and personal costs. These drawbacks could be avoided with the introduction of a single-step transfer of free flaps to the recipient site, with microvascular anastomosis. OBJECTIVE: To demonstrate that better results are obtained with myocutaneous or fasciocutaneous free flaps and which one is more suitable in surgical dermatology. MATERIAL AND METHODS: We selected two patients of opposite sexes and similar ages who had undergone Mohs surgery to remove recurrent malignant tumors that were located in the upper cheek bordering the zygomatic zone. The woman was treated with a fasciocutaneous radial free flap and the man with a rectus abdominis free flap. RESULTS: Both patients had excellent immediate postoperative outcomes. Complications observed in the male patient were related to a previous pulmonary alteration. The fasciocutaneous radial free flap reconstruction was easier to perform than the rectus abdominis free flap; nevertheless, the radial free flap is very thin and, although the palmaris longus tendon is used, it does not yield enough volume, requiring later use of implants. In contrast, the rectus abdominis free flap transfers a wide flap with enough fat tissue to expand in the future. As for the cosmetic results regarding the donor site, the rectus abdominis free flap produces better-looking scars, since secondary defects of the palmar surface cannot be directly closed and usually require grafting - a situation that some patients do not accept. CONCLUSIONS: In surgical dermatology, each case, once the tumor has been extirpated, requires its own reconstructive technique. The radial free flap is suitable for thin patients who are willing to cover their arm with a shirt. The rectus abdominis free flap is best suited for obese patients with deep and voluminous defects, although it is necessary to dislocate the navel from its original position

Free Flaps in the Reconstruction of Hand and Distal Forearm Injuries

1992 ◽  
Vol 17 (2) ◽  
pp. 185-188 ◽  
Author(s):  
A. REIGSTAD ◽  
K. R. HETLAND ◽  
K. BYE ◽  
M. RØKKUM
Keyword(s):  
Donor Site ◽  
Hand Surgery ◽  
Free Flaps ◽  
Donor Site Morbidity ◽  
Medium Size ◽  
Nerve Grafts ◽  
Partial Necrosis ◽  
Tendon Grafts ◽  
Large Skin ◽  
Forearm Injuries

We report a series of 32 free flap reconstructions following acute hand and forearm trauma. The series consists of two dorsalis pedis flaps, four scapular flaps and 26 lateral arm flaps. One flap became infected and failed completely, and a partial necrosis occurred in another flap. The transfers covered large skin defects, exposed tendons, tendon grafts, bone, bone grafts, joints, nerves and nerve grafts. The donor site morbidity was negligible. Our study shows that free microvascular flaps are a safe and convenient alternative to conventional flaps in hand surgery. The lateral arm flap seems very suitable for small and medium size defects.

Article Commentary: Optimizing Aesthetic Results in Skin Grafting

2012 ◽  
Vol 78 (2) ◽  
pp. 151-154 ◽  
Author(s):  
Ron Hazani ◽  
Ryan Whitney ◽  
Bradon J. Wilhelmi
Keyword(s):  
Donor Site ◽  
Skin Grafting ◽  
Donor Site Morbidity ◽  
Secondary Intention ◽  
Donor Skin ◽  
Aesthetic Results ◽  
The Aesthetic ◽  
Sheet Graft ◽  
Surrounding Skin ◽  
Tissue Defects

The aesthetic goal in skin grafting is to provide a cosmetically pleasing coverage of soft tissue defects while minimizing donor site morbidity. A skin graft should blend well with the color and texture of the surrounding skin, reduce wound size, and not interfere with the function of the reconstructed part. This review examines the key components of choosing the appropriate donor skin for a variety of defects. The decision-making process is based on the anatomic location of the defect; donor site availability; and graft size, thickness, and pigmentation. The aesthetic implications of using a sheet graft versus a meshed graft versus an expanded graft are discussed. Aside from addressing the aesthetic needs of the defect, attention is paid to the functional goals of the reconstructed part and reduced donor site morbidity. Partial graft failure can have significant deleterious effects on the aesthetic outcome of skin grafts. The need for further grafting or healing by secondary intention may result in additional scarring and deformity. Recommendations for improvement in graft take and infection control are presented.

Preliminary Experience with Perforator Flaps in Reconstruction of Soft-Tissue Defects of the Foot and Ankle

2005 ◽  
Vol 26 (3) ◽  
pp. 191-197 ◽  
Author(s):  
Frederick J. Duffy ◽  
James W. Brodsky ◽  
Christian T. Royer
Keyword(s):  
Soft Tissue ◽  
Donor Site ◽  
Donor Site Morbidity ◽  
Tissue Loss ◽  
Soft Tissue Reconstruction ◽  
Foot And Ankle ◽  
Soft Tissue Defects ◽  
Perforator Flaps ◽  
Microsurgical Reconstruction ◽  
Tissue Defects

Background: Microsurgical reconstruction has improved limb salvage in patients who because of many etiologies have soft-tissue loss from the lower extremities. Free-tissue transfer to the foot and ankle often interferes with postoperative function and footwear because of the bulk of a muscle flap. The foot and ankle often are best treated using thin flaps that will not contract and fibrose, particularly if secondary procedures are required. We hypothesized that perforator flaps, which are thin free-tissue transfers consisting of skin and subcutaneous tissue, both diminish donor site morbidity and are ideally suited for soft-tissue reconstruction of the foot and ankle. Methods: Ten patients had free- tissue transfers to the foot and ankle using perforator flaps during a 2-year period. Four had acute posttraumatic wounds, three had soft tissue defects with exposed hardware or bone graft after reconstructive surgery, and three had large soft-tissue defects after foot infection secondary to diabetes. Nine had reconstruction with anterolateral thigh perforator flaps and one had reconstruction with a deep inferior epigastric artery (DIEP) perforator flap. Results: All flaps survived. There were no deep infections. Three flaps had minor tissue loss requiring subsequent small skin grafts, all of which healed. There were no donor site complications and no interference of muscle function at the donor sites. Custom shoewear was not required to accommodate the flaps. Conclusion: This series highlights the success and utility of perforator flaps in microsurgical reconstruction of the foot and ankle. The greatest advantage of perforator flaps is the diminished donor site morbidity, which was achieved while maintaining high microsurgical success rates. These skin and fat flaps remained pliable and contracted less than muscle flaps, allowing for smooth tendon gliding and easy flap elevation for secondary orthopaedic procedures.

scholarly journals An assessment of the anatomical basis of the thoracoacromial artery perforator flap

2003 ◽  
Vol 11 (1) ◽  
pp. 23-27 ◽  
Author(s):  
Christopher Robert Geddes ◽  
Maolin Tang ◽  
Daping Yang ◽  
Steven F Morris
Keyword(s):  
Head And Neck ◽  
Donor Site ◽  
Perforator Flap ◽  
Neck Region ◽  
Donor Site Morbidity ◽  
Pedicled Flap ◽  
Perforator Flaps ◽  
Thoracoacromial Artery ◽  
Lateral Thoracic Artery ◽  
Anatomical Basis

Background Musculocutaneous perforator flaps offer advantages over musculocutaneous flaps, including reduced donor site morbidity, more predictable reconstruction of soft tissue deformities, and a wider variety of flap options. Perforator flaps are becoming increasingly popular for many applications. In the present study, we set out to examine the various perforators of the thoracoacromial axis through the pectoralis major (PM) muscle with respect to their suitability for transfer to the head and neck region as a pedicled flap. Methods A series of 10 fresh cadavers were injected with lead oxide, gelatin and water (250 mL/kg) through the femoral vessels. The cadavers were cooled and the integument was removed. Perforating vessels from the underlying muscles were marked and the resulting angiograms of the integument and deep tissues were compared with the dissection notes describing the course, size and distribution of the perforating vessels. Results The perforators through the PM muscle to the overlying skin included three regional groups: perforators of the thoracoacromial axis; perforators of the medial intercostal vessels; and perforators of the lateral thoracic artery. The major group of perforators supplying the overlying skin was from the intercostal vessels. However, the thoracoacromial axis did consistently give rise to perforators in the upper portion of the PM muscle. In particular, there were reliable perforators from the clavicular and deltoid branches of the thoracoacromial artery. Discussion The present study illustrates the potential clinical applications of a series of perforator flaps based on the thoracoacromial axis, which may be useful in head and neck reconstructive surgery.

Application of Proximal Lateral Leg Perforator Flaps for Head and Neck Reconstructions

2014 ◽  
Vol 151 (5) ◽  
pp. 791-796 ◽  
Author(s):  
Honda Hsu ◽  
Peir-Rong Chen ◽  
Sou-Hsin Chien ◽  
Jiunn-Tat Lee
Keyword(s):  
Head And Neck ◽  
Donor Site ◽  
Tertiary Care ◽  
Case Series ◽  
Functional Results ◽  
Donor Site Morbidity ◽  
Head And Neck Reconstruction ◽  
Complication Rates ◽  
Recipient Site ◽  
The Mean

Objective Analyze the reliability, complications, and donor site morbidity of the proximal lateral leg flap when applied to head and neck reconstruction. Study Design Case series and chart review. Setting Tertiary care teaching hospital. Subjects and Methods Nineteen patients who underwent reconstruction of various head and neck defects with this flap were analyzed. The patient demographics, flap characteristics, method of donor site closure, scars of the donor area, complication rates, as well as functional results at the recipient site were assessed. Results The flap size ranged from 4 × 4 cm to 11 × 8 cm. Vascular pedicle length ranged from 5 to 9 cm. The mean distance of the perforator from the fibula head was 9.2 cm. The mean thickness of this flap was 5.5 mm. All the donor wounds were closed primarily. The flap survival rate was 100%. Conclusion This flap has the advantages of thinness, short harvesting time, minimal donor site morbidity, and primary closure at the donor site when the flap width is less than 6 cm. This flap may be useful for reconstruction in selected patients with small and thin heads and neck defects.

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