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A Salvage Strategy for the Fibula Osteocutaneous Flap Without Traditional Perforator: A Case Report of Peroneal Artery Tibialis Anterior Cutaneous Perforator Skin Paddle. J Craniofac Surg 2023; 34:e111-e113. [PMID: 35905499 DOI: 10.1097/scs.0000000000008804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 04/25/2022] [Indexed: 11/25/2022] Open
Abstract
The fibula osteocutaneous flap is the most commonly used flap to repair jaw defects, which can be used for composite soft and hard tissue reconstruction. Traditionally, the skin paddle of the fibula osteocutaneous flap is based on perforators from the peroneal artery, which is affifixed to the posterior crural septum between the peroneus and the soleus. The anatomy is relatively constant, and the perforators of skin paddle variation encounter in clinical occasionally. The authors report a case of reconstruction of mandible and soft tissue with fibula osteocutaneous flap after extensive radical resection of squamous cell carcinoma of the mouth floor. In this case, the authors raised a skin paddle based on the anterior tibial perforator of peroneal artery from the anterolateral intermuscular septum between the peroneus and the anterior calf muscles, which successfully rescued the traditional perforator absence and avoided exploration for a second donor site.
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Wiesmueller M, Meixner CR, Weber M, Kesting M, Nagel AM, Wuest W, May MS, Roemer FW, Uder M, Heiss R. Time-of-Flight Angiography in Ultra-High-Field 7 T MRI for the Evaluation of Peroneal Perforator Arteries Before Osseomyocutaneous Flap Surgery. Invest Radiol 2023; 58:216-222. [PMID: 36165876 PMCID: PMC9914154 DOI: 10.1097/rli.0000000000000926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 08/11/2022] [Indexed: 10/14/2022]
Abstract
OBJECTIVES Presurgical identification and morphologic characterization of the peroneal perforator arteries (PPAs) are essential for osseomyocutaneous flap surgery. The aim of this study was to evaluate PPAs using time-of-flight (TOF) angiography in 7 T magnetic resonance imaging in comparison with dual-energy computed tomographic angiography (CTA). MATERIALS AND METHODS In this prospective study, TOF angiography and CTA of both lower legs were acquired before flap surgery from 07/2019 to 02/2020. Magnetic resonance imaging was performed using a dedicated 28-channel knee coil with an acquisition time of 9:55 minutes (voxel size: 0.4 × 0.4 × 0.8 mm). Computed tomographic angiography was acquired with a third-generation dual-source computed tomography on the same day. Virtual monoenergetic reconstructions at 40 keV photon energy served as the standard of reference for PPA identification and subtyping. Two independent readers assessed the image quality, quantity, length assessment, and classification according to surgical considerations of PPAs for TOF angiography and CTA. Both TOF angiography and CTA were used for presurgical flap design and were evaluated by an orofacial surgeon. RESULTS Ten patients (mean age, 59.9 ± 14.9 years; 7 men) were included. Time-of-flight angiography and CTA identified 53 and 51 PPAs in total, respectively. Time-of-flight angiography showed superior image quality (both readers, P < 0.05). Time-of-flight angiography enabled specific classification of PPA subtypes more often (53 vs 39; P < 0.05), and both readers reported higher diagnostic confidence for TOF angiography than CTA in all patients (interrater agreement κ = 0.8; P < 0.05). Regarding length assessment, PPAs were significantly more conspicuous with TOF angiography (TOF mean , 50 ± 11 mm; CTA mean , 40 ± 9 mm; P = 0.001). In comparison with CTA, TOF angiography prospectively changed the orofacial surgeon's final decision on the presurgical selected PPAs in 60% of cases. CONCLUSIONS Presurgical assessment of PPAs is feasible using TOF in 7 T magnetic resonance imaging. Moreover, TOF angiography was superior to CTA for classifying and identifying PPAs, which may facilitate the planning of reconstructive surgery.
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Affiliation(s)
| | | | - Manuel Weber
- Department of Oral and Maxillofacial Surgery, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Marco Kesting
- Department of Oral and Maxillofacial Surgery, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Armin M. Nagel
- From the Institute of Radiology, University Hospital Erlangen
- Division of Medical Physics in Radiology, German Cancer Research Centre (DKFZ), Heidelberg, Germany
| | - Wolfgang Wuest
- From the Institute of Radiology, University Hospital Erlangen
| | - Matthias S. May
- From the Institute of Radiology, University Hospital Erlangen
| | - Frank W. Roemer
- From the Institute of Radiology, University Hospital Erlangen
- Quantitative Imaging Center (QIC), Department of Radiology, Boston University School of Medicine, Massachusetts
| | - Michael Uder
- From the Institute of Radiology, University Hospital Erlangen
| | - Rafael Heiss
- From the Institute of Radiology, University Hospital Erlangen
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Duc NQ, Lam VN, Tien NP. An anatomic study of the perforators from the peroneal artery. A new method to locate the cutaneous perforator. Ann Med Surg (Lond) 2022; 78:103735. [PMID: 35600195 PMCID: PMC9118520 DOI: 10.1016/j.amsu.2022.103735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 04/28/2022] [Accepted: 05/03/2022] [Indexed: 10/26/2022] Open
Abstract
Background The goal of this study was to investigate the anatomy of the perforators from the peroneal artery in Vietnamese patients. Methods 30 cadaver's legs were dissected and investigated for the distribution, course, origin, number and types of perforators of the peroneal artery. The locations of the exit points on the skin of perforators were marked in relation to reference points and segments. Results The total number of cutaneous perforating branches of the peroneal artery from 30 specimens was 149, which included 63 (42.2%) musculocutaneous perforators and 86 (57.8%) septocutaneous perforators. In most cases, the perforator branches were located in the range from 4 to 7 of the total fibula length (69.8%). The average number of perforating vessels in a leg was 4.9, ranging from 1 to 8 vessels. All the perforators were positioned behind the posterior border of the peroneal bone. In all the dissected samples presented, there was always one cutaneous perforator within a distance of 18 mm from the F point, which is the junction between the 6/10 and 7/10 segments at the posterior border of the fibular bone. Conclusion The abundance of cutaneous perforators in Vietnamese patients can be used to plan various combined skin and bone flaps. A cutaneous perforator was consistently found near the F point, and this factor can be used in the planning of a bone flap with accompanying skin for monitoring survival of the underlying fibular bone flap.
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Affiliation(s)
- Nguyen Quang Duc
- 108 Military Central Hospital, 1 Tran Hung Dao Street, Hanoi, Viet Nam
| | - Vu Ngoc Lam
- 108 Military Central Hospital, 1 Tran Hung Dao Street, Hanoi, Viet Nam
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Liu K, Zhang W, Wang Y, Xiang DW, Shi HB, Liu QL. Fibula osteal flap with proximal peroneal perforator skin paddle for composite oromandibular reconstruction: A case report. Medicine (Baltimore) 2020; 99:e23590. [PMID: 33327322 PMCID: PMC7738134 DOI: 10.1097/md.0000000000023590] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Cutaneous perforators of peroneal vessels are divided into proximal and distal perforators on the basis of perforator distributions and musculocutaneous or septocutaneous properties. The traditional fibular osteocutaneous free flap is raised over the distal two-thirds of the fibula with a skin paddle based on distal perforators, which is affixed to the posterior crural septum. However, the skin pedicle may not be available due to anatomic variations or intraoperative injuries. Herein, because of the absence of distal perforators, we reserved and expropriated proximal perforators originating from the musculocutaneous branch of the superior part of the peroneal artery before it divided into nutrient and arcuate arteries and successfully harvested a separate osteal fibula and proximal perforator skin paddle with a single vascular pedicle-peroneal vessel. PATIENT CONCERNS A 62-year-old man with a 6-month history of mandibular swelling and soft tissue invasion was referred to us. DIAGNOSIS Panoramic radiography and computed tomography showed an irregular radiolucent lesion of the mandibular body, and histopathological analysis confirmed a follicular-pattern ameloblastoma. INTERVENTIONS The diseased mandible and soft tissue were resected and reconstructed with a vascularized fibular osteal flap with the proximal perforator skin paddle. OUTCOMES The mandibular contour was successfully restored; the skin paddle in the mouth was in good condition after 8 months of follow-up. LESSONS The proximal perforator is reliable and practical for supplying a skin paddle and has significant potential for future applications. We recommend reserving the proximal perforator skin paddle as a backup flap when planning to raise a fibula flap, since unavailability or injury of the traditional fibular skin island based on distal perforators occurs frequently. This approach can avoid the exploration for a second donor site, save surgical time, and reduce surgical complexity. Moreover, we anticipate more frequent use of the proximal perforator flap in the future because of its flexibility and large volume, and since it can be combined with the osteal fibula or fibular osteocutaneous flap. However, an understanding of the traits of the proximal perforator and determination of its peroneal origin by computed tomography angiography is crucial for predesigning fibular osteal flaps with a proximal perforator skin paddle.
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Affiliation(s)
- Kang Liu
- Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, Jilin University, Changchun
| | - Wei Zhang
- Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, Jilin University, Changchun
| | - Yue Wang
- Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, Jilin University, Changchun
- Department of Oral and Maxillofacial Surgery, Yantai Affiliated Hospital of Binzhou Medical University, Yantai, PR China
| | - Dan-Wei Xiang
- Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, Jilin University, Changchun
| | - Hai-Bo Shi
- Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, Jilin University, Changchun
| | - Qi-Lin Liu
- Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, Jilin University, Changchun
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Attia S, Diefenbach J, Schmermund D, Böttger S, Pons-Kühnemann J, Scheibelhut C, Heiss C, Howaldt HP. Donor-Site Morbidity after Fibula Transplantation in Head and Neck Tumor Patients: A Split-Leg Retrospective Study with Focus on Leg Stability and Quality of Life. Cancers (Basel) 2020; 12:cancers12082217. [PMID: 32784461 PMCID: PMC7465780 DOI: 10.3390/cancers12082217] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/06/2020] [Accepted: 08/07/2020] [Indexed: 12/21/2022] Open
Abstract
The free fibula flap has been one of the most important microvascular grafts for orofacial reconstruction for more than 30 years. The complication rates at the donor-site reported in literature are considered to be low, but the published data vary greatly in some cases. In particular, restrictions in the stability and balance of the involved leg and their effects on the quality of life have been described very inconsistently to date. Therefore, this study mainly focuses on the stability and balance of the affected leg in a split-leg design. Between December 2014 and January 2018, out of 119 subjects who underwent mainly jaw ablative tumor surgery and reconstruction using a fibula flap, 68 subjects were examined for donor site morbidity. Besides reporting general types of complications, two specific test procedures were used. The Star Excursion Balance Test (SEBT) as a practical test for ankle function and the Foot and Ankle Disability Index (FADI) as a questionnaire in order to assess quality of life, depending on the lower leg function. SEBT revealed an average of 55.3 cm with the operated leg as the supporting leg, which corresponds to 95.5% of 57.9 cm achieved with the healthy leg as the supporting leg. An average FADI score of 89.4% was recorded. SEBT and FADI seem to be suitable methods of examination for subjects post fibular transplantation and pointed out minimal limitations of the involved legs in comparison to the unaffected legs. These limitations were clinically not relevant and they had minor influence on the subjects’ quality of life and their daily activities.
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Affiliation(s)
- Sameh Attia
- Department of Cranio Maxillofacial Surgery, Justus-Liebig University Giessen, Klinik Str. 33, 35392 Giessen, Germany; (J.D.); (D.S.); (S.B.); (H.-P.H.)
- Correspondence: ; Tel.: +49-641-994-6110; Fax: +49-641-994-6109
| | - Jonas Diefenbach
- Department of Cranio Maxillofacial Surgery, Justus-Liebig University Giessen, Klinik Str. 33, 35392 Giessen, Germany; (J.D.); (D.S.); (S.B.); (H.-P.H.)
| | - Daniel Schmermund
- Department of Cranio Maxillofacial Surgery, Justus-Liebig University Giessen, Klinik Str. 33, 35392 Giessen, Germany; (J.D.); (D.S.); (S.B.); (H.-P.H.)
| | - Sebastian Böttger
- Department of Cranio Maxillofacial Surgery, Justus-Liebig University Giessen, Klinik Str. 33, 35392 Giessen, Germany; (J.D.); (D.S.); (S.B.); (H.-P.H.)
| | - Jörn Pons-Kühnemann
- Institute for Medical Informatics, Medical Statistics, Faculty of Medicine, Justus-Liebig University Giessen, Rudolf-Buchheim Str. 6, 35392 Giessen, Germany; (J.P.-K.); (C.S.)
| | - Christine Scheibelhut
- Institute for Medical Informatics, Medical Statistics, Faculty of Medicine, Justus-Liebig University Giessen, Rudolf-Buchheim Str. 6, 35392 Giessen, Germany; (J.P.-K.); (C.S.)
| | - Christian Heiss
- Department of Trauma, Hand and Reconstructive Surgery, Justus-Liebig University Giessen, Rudolf-Buchheim- Str. 7, 35392 Giessen, Germany;
| | - Hans-Peter Howaldt
- Department of Cranio Maxillofacial Surgery, Justus-Liebig University Giessen, Klinik Str. 33, 35392 Giessen, Germany; (J.D.); (D.S.); (S.B.); (H.-P.H.)
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Schuderer JG, Meier JK, Klingelhöffer C, Gottsauner M, Reichert TE, Wendl CM, Ettl T. Magnetic resonance angiography for free fibula harvest: anatomy and perforator mapping. Int J Oral Maxillofac Surg 2019; 49:176-182. [PMID: 31564478 DOI: 10.1016/j.ijom.2019.09.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 07/17/2019] [Accepted: 09/10/2019] [Indexed: 01/21/2023]
Abstract
The purpose of this study was to outline lower leg vessel anatomy and to investigate reliability and limitations of magnetic resonance angiography (MRA) in patients proposed for microvascular fibula transplantation (free fibula flap (FFF)). We retrospectively investigated MRAs of 99 patients considered for FFF. Frontal MRA planes and maximal intensity projections (MIPs) were evaluated for fibula lengths, anatomical branching pattern, arterial stenoses and fibular perforator positions in both legs (n=198). Normal branching patterns were observed in 168 (85.3%) legs. Twenty-nine (14.7%) legs presented abnormal branching patterns. Once (0.5%) the anterior, 19 times (9.6%) the posterior tibial artery were absent or hypoplastic. Nine (4.6%) lower legs presented an arteria peronea magna. Average length of the tibiofibular trunk (TFT) was 3.3±0.15cm. A total of 492 perforators were found with an average of 2.5 (±0.82±0.99) perforators per leg. A mapping of perforator run-offs was illustrated true to scale. Lower limb stenoses were distributed in the anterior tibial artery (14.1%), in the posterior tibial artery (11.1%) and in the fibular artery (8.1%). Smoking (P=0.828), diabetes (P=0.727) and peripheral arterial occlusive disease (P=0.172) did not correlate with presence of stenoses. Preoperative lower limb angiography avoids postoperative complications. MRA reliably and non-invasively identifies anatomical variants and arterial stenoses without radiation. Illustration of perforator run-offs enhances incision planning for fibula harvest.
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Affiliation(s)
- J G Schuderer
- Department of Oral and Maxillofacial Surgery, University Hospital Regensburg, Regensburg, Germany.
| | - J K Meier
- Department of Oral and Maxillofacial Surgery, University Hospital Regensburg, Regensburg, Germany
| | - C Klingelhöffer
- Department of Oral and Maxillofacial Surgery, University Hospital Regensburg, Regensburg, Germany
| | - M Gottsauner
- Department of Oral and Maxillofacial Surgery, University Hospital Regensburg, Regensburg, Germany
| | - T E Reichert
- Department of Oral and Maxillofacial Surgery, University Hospital Regensburg, Regensburg, Germany
| | - C M Wendl
- Department of Radiology, University Hospital Regensburg, Regensburg, Germany
| | - T Ettl
- Department of Oral and Maxillofacial Surgery, University Hospital Regensburg, Regensburg, Germany
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Gaillard J, Bourcheix LM, Masquelet AC. Perforators of the fibular artery and suprafascial network. Surg Radiol Anat 2017; 40:927-933. [PMID: 28936687 DOI: 10.1007/s00276-017-1927-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 09/15/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Soft tissue defect on lower limb can result in an intractable wound. Surgeons resort in flaps to cover these injuries. Including fascia as in the case of a fasciocutaneous flap increases survey of the flap. Rising a perforator flap avoids to sacrifice a major vessel whence the nourishing perforator artery is born. We wanted to explore suprafascial distribution of the fibular skin perforator arteries supposing possible to find out a vascular axis composed of anastomoses of the fibular perforator vessels. MATERIALS AND METHODS Systematic observation was carried out on ten injected legs about the fibular perforator distribution, and especially their suprafascial course. RESULTS Dissection allowed us to raise in all specimens a large fasciocutaneous paddle including a fine arteriolar vessel connecting fibular perforators. Perforators were isolated along from the leg and we found suprafascial arteriole connecting all perforators from the fibular head to the lateral malleolus. There were a total number of 126 perforators for 10 legs. The mean length of the fibula was 32.9 cm. No perforator was located at more than 2 cm from fibular posterior border. Proximal perforators were closer to posterior fibular side than distal perforators. We found that fibular perforators clustered in the middle and upper third of the leg. CONCLUSION This study proves the real existence of a microvascular suprafascial axis formed by fibular perforator anastomoses and stretching over the entire length of the fibula, from the fibular head to the distal tip of the lateral malleolus. This suprafascial vascular axis could be an anatomical basis for a fasciocutaneous fibular flap.
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Affiliation(s)
- Julien Gaillard
- Laboratory of Anatomy, School of Surgery, Assistance Publique des Hôpitaux de Paris, 7 rue du Fer à Moulin, 75221, Paris cedex 05, France. .,Department of orthopaedic, traumatology and reconstructive surgery, Hôpital Saint-Antoine, 184, rue du Fg Saint Antoine, 75571, Paris, France. .,Groupe Hospitalier Paris Est, Assistance Publique des Hôpitaux de Paris, Paris, France.
| | - Laurent-Marie Bourcheix
- Laboratory of Anatomy, School of Surgery, Assistance Publique des Hôpitaux de Paris, 7 rue du Fer à Moulin, 75221, Paris cedex 05, France.,IFCM-Institut Français de Chirurgie de la Main, 5 Rue du Dôme, 75116, Paris, France
| | - Alain-Charles Masquelet
- Laboratory of Anatomy, School of Surgery, Assistance Publique des Hôpitaux de Paris, 7 rue du Fer à Moulin, 75221, Paris cedex 05, France.,Department of orthopaedic, traumatology and reconstructive surgery, Hôpital Saint-Antoine, 184, rue du Fg Saint Antoine, 75571, Paris, France.,Groupe Hospitalier Paris Est, Assistance Publique des Hôpitaux de Paris, Paris, France
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Photo Epilation with Intense Pulsed Light for Thinning of Anterior Hairline after Hairline Correction Surgery in East Asians. Arch Plast Surg 2017; 44:157-161. [PMID: 28352605 PMCID: PMC5366523 DOI: 10.5999/aps.2017.44.2.157] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 11/22/2016] [Accepted: 12/02/2016] [Indexed: 12/01/2022] Open
Abstract
Background Thin hairs are critical to achieve natural result in female hairline correction surgery. However, there are few studies on the usefulness of hair thinning by intense pulsed light (IPL) after hairline correction surgery in East Asian females. Methods Hair thinning using IPL was performed in 54 women who had complained about thick hairs along the frontal hairline after hairline correction surgery. Patient mean age was 31.2 years old and patients were an average of 2.1 years post-hairline correction surgery. Initial treatment used 10 J, while second and third sessions were conducted with 10 to 15 J according to responsiveness to treatment. Results Mean thickness of individual hairs assessed before the procedure was 78.86 µm. The mean number of procedures was 1.6 per patient. Forty of 54 subjects (74%) achieved satisfactory hair thinning with only one procedure from 78.01 to 66.14 µm after treatment. The measured thickness was 66.43 µm at the end of the first year in patients who were satisfied after one procedure. Thirteen cases achieved satisfactory hair thinning after two sessions. Mean thickness was 74.44 µm and 67.51 µm, before and after the second session. One case required a third session with 15J, thinning from 89.00 to 66.50 µm. Conclusions Hair thinning by IPL is a very useful method to provide a natural look after hairline correction surgery in East Asians, who have naturally thick hair.
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Peroneal Flap: Clinical Application and Cadaveric Study. Arch Plast Surg 2017; 44:136-143. [PMID: 28352602 PMCID: PMC5366520 DOI: 10.5999/aps.2017.44.2.136] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Revised: 12/27/2016] [Accepted: 01/04/2017] [Indexed: 11/08/2022] Open
Abstract
Background The goal of this study was to investigate the anatomy of the peroneal artery and its perforators, and to report the clinical results of reconstruction with peroneal artery perforator flaps. Methods The authors dissected 4 cadaver legs and investigated the distribution, course, origin, number, type, and length of the perforators. Peroneal artery perforator flap surgery was performed on 29 patients. Results We identified 19 perforators in 4 legs. The mean number of perforators was 4.8 per leg, and the mean length was 4.8 cm. Five perforators were found proximally, 9 medially, and 5 distally. We found 12 true septocutaneous perforators and 7 musculocutaneous perforators. Four emerged from the posterior tibia artery, and 15 were from the peroneal artery. The peroneal artery perforator flap was used in 29 patients. Retrograde island peroneal flaps were used in 8 cases, anterograde island peroneal flaps in 5 cases, and free peroneal flaps in 16 cases. The mean age was 59.9 years, and the defect size ranged from 2.0 cm×4.5 cm to 8.0 cm×8.0 cm. All the flaps survived. Five flaps developed partial skin necrosis. In 2 cases, a split-thickness skin graft was performed, and the other 3 cases were treated without any additional procedures. Conclusions The peroneal artery perforator flap is a good alternative for the reconstruction of soft tissue defects, with a constant and reliable vascular pedicle, thin and pliable skin, and the possibility of creating a composite tissue flap.
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Free Hand Perforator Concept in Osteocutaneous Free Fibula Flap Through Posterior Approach. J Craniofac Surg 2017; 28:559-563. [DOI: 10.1097/scs.0000000000003342] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Peroneal artery-vein index as a potential factor of thrombosis occurrence in free osteocutaneous fibula flap. J Craniomaxillofac Surg 2016; 44:1314-9. [PMID: 27499515 DOI: 10.1016/j.jcms.2016.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Revised: 06/02/2016] [Accepted: 07/06/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Despite high popularity and great success rates of free osteocutaneous fibula flaps, the flap failure caused by vascular thrombosis is still a challenging problem. The authors present their evaluation of a potential thrombosis risk factor - a peroneal artery-vein index. METHODS The authors evaluated the diameters of peroneal vessels and peroneal artery-vein indexes based on the computed tomography angiographies in 10 patients who underwent a mandible reconstruction with a free fibula flap and compared the results with clinical outcome. RESULTS In one case the flap was lost, because of thrombosis in the donor vein. This patient presented superficial varicose veins of both lower extremities. Peroneal vein diameters in this patient ranged from 5,05 mm to 6,68 mm and were higher than in patients without complications. The peroneal artery-vein index in the patient with thrombosis ranged from 0,37 to 0,50 with median 0,40 and was lower than in patients without complications. CONCLUSIONS High disproportion between peroneal artery and concomitant veins might be a potential risk factor of the occurrence of venal thrombosis. Detailed perioperative examination of peroneal veins in patients with varicosities should be considered.
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One-Stage Reconstruction of Composite Extremity Defects with a Sural Neurocutaneous Flap and a Vascularized Fibular Graft. Plast Reconstr Surg 2013; 132:428e-437e. [DOI: 10.1097/prs.0b013e31829ad16c] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Nelson JA, Fischer JP, Brazio PS, Kovach SJ, Rosson GD, Rad AN. A review of propeller flaps for distal lower extremity soft tissue reconstruction: Is flap loss too high? Microsurgery 2013; 33:578-86. [DOI: 10.1002/micr.22134] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Revised: 04/04/2013] [Accepted: 04/17/2013] [Indexed: 11/11/2022]
Affiliation(s)
- Jonas A. Nelson
- Division of Plastic Surgery; Perelman School of Medicine at the University of Pennsylvania; Philadelphia PA
| | - John P. Fischer
- Division of Plastic Surgery; Perelman School of Medicine at the University of Pennsylvania; Philadelphia PA
| | - Philip S. Brazio
- Department of Surgery; University of Maryland School of Medicine; Baltimore MD
| | - Stephen J. Kovach
- Division of Plastic Surgery; Perelman School of Medicine at the University of Pennsylvania; Philadelphia PA
| | - Gedge D. Rosson
- Department of Plastic Surgery; Johns Hopkins Hospital; Baltimore MD
| | - Ariel N. Rad
- Department of Plastic Surgery; Johns Hopkins Hospital; Baltimore MD
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Propeller perforator flaps in distal lower leg: evolution and clinical applications. Arch Plast Surg 2012; 39:94-105. [PMID: 22783507 PMCID: PMC3385316 DOI: 10.5999/aps.2012.39.2.94] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Revised: 01/31/2012] [Accepted: 02/01/2012] [Indexed: 12/22/2022] Open
Abstract
Simple or complex defects in the lower leg, and especially in its distal third, continue to be a challenging task for reconstructive surgeons. A variety of flaps were used in the attempt to achieve excellence in form and function. After a long evolution of the reconstructive methods, including random pattern flaps, axial pattern flaps, musculocutaneous flaps and fasciocutaneous flaps, the reappraisal of the works of Manchot and Salmon by Taylor and Palmer opened the era of perforator flaps. This era began in 1989, when Koshima and Soeda, and separately Kroll and Rosenfield described the first applications of such flaps. Perforator flaps, whether free or pedicled, gained a high popularity due to their main advantages: decreasing donor-site morbidity and improving aesthetic outcome. The use as local perforator flaps in lower leg was possible due to a better understanding of the cutaneous circulation, leg vascular anatomy, angiosome and perforasome concepts, as well as innovations in flaps design. This review will describe the evolution, anatomy, flap design, and technique of the main distally pedicled propeller perforator flaps used in the reconstruction of defects in the distal third of the lower leg and foot.
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Lubek J, Coletti D. Guarded retractor for use in fibula-free flap harvest/reconstruction. J Oral Maxillofac Surg 2011; 70:2218-20. [PMID: 22177815 DOI: 10.1016/j.joms.2011.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2011] [Revised: 09/16/2011] [Accepted: 09/16/2011] [Indexed: 11/18/2022]
Affiliation(s)
- Joshua Lubek
- University of Maryland, Department of Oral and Maxillofacial Surgery, Baltimore, MD, USA
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Vascular anatomy of the integument of the lateral lower leg: an anatomical study focused on cutaneous perforators and their clinical importance. Plast Reconstr Surg 2011; 128:188-198. [PMID: 21701335 DOI: 10.1097/prs.0b013e3182174303] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Certain studies have attempted to investigate the vascular anatomy of the integument of the lateral aspect of the lower leg. However, many issues remain controversial. The aim of this study was to investigate in detail the distribution and characteristics of cutaneous perforators of the lateral aspect of the lower leg. METHODS Fifty-two fresh cadaver legs were dissected. The lateral lower leg was divided into five zones, and all cutaneous perforators were identified. Only perforators with a diameter greater than 0.5 mm were dissected further, and the type, location, course, length, and origin of those perforators were recorded. RESULTS Three hundred two perforators were dissected. Two hundred twelve were septocutaneous (70.2 percent), 43 were septomusculocutaneous (14.2 percent), and 47 were musculocutaneous (15.6 percent). The majority of perforators (78.1 percent) originated from the peroneal artery. The peroneal artery was the dominant source vessel in all except for the proximal zone. The tibial-peroneal trunk predominated in the proximal zone. High contribution of the posterior tibial artery was noticed in the distal zone. Higher percentages of perforators were recorded in the middle and midproximal zones (26.8 percent and 25.2 percent, respectively). Septocutaneous perforators were present in all five zones, with higher percentages in the middle and middistal zones. Septomusculocutaneous and musculocutaneous perforators were identified in all except for the distal zone. CONCLUSION The authors' findings provide information about the cutaneous perforators/perforasomes of the lateral aspect of the lower leg, useful for reliable planning and harvesting of perforator-based flaps in this area.
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Bognár G, Lóderer Z, Kovács I, Tamás R, Csáki G, Kardos I, Suri C. [Combined transplantation of a free skin island flap supplied by a septo-cutaneous perforator of the posterior tibial artery and the underlying fibula for the full reconstruction of the mandible and the mouth floor]. Magy Seb 2011; 64:125-8. [PMID: 21672684 DOI: 10.1556/maseb.64.2011.3.5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Microsurgical transplantation of the osteo-cutaneous fibula as a free flap to reconstruct the defect following radical resection of a mouth floor's tumor is a well-known and often applied procedure. Anatomy of the vessels supplying this flap is recognized but it may have some rare and unexpected variations. In this case report we discuss the reconstruction of the middle and lateral parts of the mandible which was resected due to a T4 gingival tumor. Interestingly, the aforementioned segment of the fibula and the overlying skin island were supplied by different pedicles, both emerging from the posterior tibial vessels. Both flaps were transplanted using autologous arterial and venous grafts of the peroneal artery and vein in case of the fibula. We believe this case is worth publishing due to its relative rarity in the literature and the applied surgical method.
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Affiliation(s)
- Gábor Bognár
- Semmelweis Egyetem II. sz. Sebészeti Klinika 1125 Budapest Kútvölgyi út 4.
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Schmulder A, Gur E, Zaretski A. Eight-year experience of the Cook-Swartz Doppler in free-flap operations: microsurgical and reexploration results with regard to a wide spectrum of surgeries. Microsurgery 2011; 31:1-6. [PMID: 20683856 DOI: 10.1002/micr.20816] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Microvascular free flap has become an increasingly popular useful method of reconstruction over the past few decades. Minimizing failure rates in these operations is a primary goal in every microsurgical unit that can be accomplished by early recognition. METHODS In this retrospective study, we tracked the admission of the implantable Doppler in the microsurgical unit (2000-2007) and evaluated parameters measured from 473 consecutive patients who underwent a total of 548 microsurgical procedures (489 primary surgeries and 59 reexplorations). The effectiveness of the Cook-Swartz Doppler (Cook Medical®) was examined in juxtapose general and subspecialty's aspects: in each microsurgical subspecialty, we compared the overall success and failure rates of the group with the implantable Doppler (n = 259) with the control group monitored by clinical means (n = 289). We also examined the duration, outcomes, and the effectiveness of this device in reexploration operations. RESULTS Overall, success rates were improved by using the implantable Doppler contrary to clinical assessment (96.14% vs. 89.27%) with a statistical significant (P < 0.005). The device was most effective in ENT (94.6% vs. 84%), breast reconstructive surgeries (97.3% vs. 82.36%), and orthopedic oncology (97.37% vs. 83.72%), whereas with reanimation operations and trauma/orthopedics subspecialties, it showed no necessity. In neurosurgery and in other/esthetic surgeries, the study was too small to draw definite deductions. CONCLUSIONS We recommend the usage of the implantable Doppler probe as an effective monitoring system for free-flap surgeries, with emphasis on subspecialties where the device demonstrated better results than traditional monitoring methods.
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Affiliation(s)
- Ariel Schmulder
- Plastic Surgery, Hand Surgery-Burn Center, RWTH University Hospital, Aachen, Germany.
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Lu TC, Lin CH, Lin CH, Lin YT, Chen RF, Wei FC. Versatility of the pedicled peroneal artery perforator flaps for soft-tissue coverage of the lower leg and foot defects. J Plast Reconstr Aesthet Surg 2011; 64:386-93. [PMID: 20538534 DOI: 10.1016/j.bjps.2010.05.004] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2010] [Revised: 05/05/2010] [Accepted: 05/07/2010] [Indexed: 11/28/2022]
Affiliation(s)
- Ting-Chen Lu
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, 5, Fu-Hsing St. Kuei-Shan, Taoyuan, Taiwan
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Time-resolved and bolus-chase MR angiography of the leg: branching pattern analysis and identification of septocutaneous perforators. AJR Am J Roentgenol 2010; 195:858-64. [PMID: 20858810 DOI: 10.2214/ajr.09.3766] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The goal of this study was to compare time-resolved MR angiography (MRA) and bolus-chase MRA in the identification of peroneal artery septocutaneous perforators and for classification of the branching pattern of the arterial tree in the leg in a cohort of candidates for fibular free flap transfer operations. MATERIALS AND METHODS Retrospective analysis was performed on imaging data from 53 legs of 27 patients (age range, 27-88 years) who underwent time-resolved MRA (FLASH; TR/TE, 2.5/1.0; flip angle, 22°; voxel dimensions, 1.54 × 1.25 × 1.5 mm; acquisition time, 2.27 s/frame) and bolus-chase MRA (FLASH; 3.2/1.2; flip angle, 25°; voxel dimensions, 0.94 × 0.89 × 1 mm) at 3 T with gadobenate dimeglumine administered at 0.05 and 0.10 mmol/kg, respectively. The branching pattern was analyzed; the total number of septocutaneous perforators for each leg was calculated from the time-resolved and bolus-chase MRA data; and the results were combined. The total and average number of septocutaneous perforators per leg and the frequency of various branching patterns were calculated. The techniques were compared in terms of branching pattern and number of visible septocutaneous perforators. RESULTS A total of 84 septocutaneous perforators (1.58 ± 1.05 [SD] per leg) were identified. Pattern 1A was found in 42 legs; 1B, two legs; 2A, one leg; 2B, one; 3A, four; 3B, one; and 3D, two legs. Classification with time-resolved MRA was successful for 53 legs and with boluschase MRA for 51 legs (Z = 0.713, p = 0.24, one-tailed, not significant). Twenty-two septocutaneous perforators were identified with time-resolved MRA and 82 with bolus-chase MRA. CONCLUSION MRA of the leg can be used to investigate the branching pattern and identify septocutaneous perforators in a single step. With the imaging parameters and contrast dose used in this study, septocutaneous perforators can be better identified with boluschase MRA, although this result may be partially related to the higher gadolinium dose used in this technique.
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López-Arcas JM, Arias J, Del Castillo JL, Burgueño M, Navarro I, Morán MJ, Chamorro M, Martorell V. The Fibula Osteomyocutaneous Flap for Mandible Reconstruction: A 15-Year Experience. J Oral Maxillofac Surg 2010; 68:2377-84. [DOI: 10.1016/j.joms.2009.09.027] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2008] [Revised: 07/08/2009] [Accepted: 09/16/2009] [Indexed: 10/19/2022]
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Boriani F, Bruschi S, Fraccalvieri M, Cipriani R. Leg perforators and leg length: An anatomic study focusing on topography and angiogenesis. Clin Anat 2010; 23:593-605. [PMID: 20544953 DOI: 10.1002/ca.20981] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Filippo Boriani
- Department of Plastic Reconstructive and Aesthetic Surgery, University of Turin, Italy.
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Jupiter JB, Fernandez DL, Levin LS, Wysocki RW. Reconstruction of posttraumatic disorders of the forearm. J Bone Joint Surg Am 2009; 91:2730-9. [PMID: 19884450 DOI: 10.2106/00004623-200911000-00027] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Jesse B Jupiter
- Hand and Upper Limb Service, Massachusetts General Hospital, Yawkey Building, Suite 2100, 55 Parkman Street, Boston, MA 02114, USA.
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25
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Ribuffo D, Atzeni M, Saba L, Guerra M, Mallarini G, Proto EB, Grinsell D, Ashton MW, Rozen WM. Clinical study of peroneal artery perforators with computed tomographic angiography: implications for fibular flap harvest. Surg Radiol Anat 2009; 32:329-34. [PMID: 19756349 DOI: 10.1007/s00276-009-0559-y] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2009] [Accepted: 09/02/2009] [Indexed: 10/20/2022]
Abstract
PURPOSE Previous studies of cutaneous perforators of the peroneal artery have shown great variability, and attest to the significant anatomical variability in this region. Furthermore, the vascular anatomy of the region has been considered unreliable in the prediction of ideal perforator topography. Preoperative imaging has been suggested as a means for improving preoperative awareness, with Doppler ultrasound and eco-colour (duplex) ultrasound as useful tools. Multi-detector row computed tomographic angiography (CTA or angio CT), has emerged as a significant improvement, providing non-invasive operator-independent details of the vascular anatomy. We utilised this tool to perform an in vivo, anatomical study of the peroneal artery perforators, and demonstrating the usefulness of CTA in planning the osteocutaneous free fibula flap. METHODS Forty-one consecutive patients (82 limbs) underwent CTA of the lower limb vasculature, with the anatomical details of the peroneal artery cutaneous perforators assessed. RESULTS CTA was able to demonstrate the size, course and penetration pattern of all perforators over 0.3 mm in diameter, with measurements for perforators over 0.8 mm diameter recorded for analysis. Of 171 such perforators, accurate identification of the size (mean diameter 1.91 mm), course (59.6% septocutaneous, 29.2% musculocutaneous and 11.1% septomusculocutaneous) and location was achieved. CONCLUSION The vascular anatomy of peroneal artery perforators is highly variable, and thus there is a role for preoperative imaging. CTA can demonstrate cases where there is aberrant or non-preferred anatomy, or select the limb of choice for harvest.
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Affiliation(s)
- Diego Ribuffo
- Section of Plastic Surgery, Department of Surgery, Cagliari University Hospital, S.S. 554, Monserrato (CA), Italy
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Fukaya E, Saloner D, Leon P, Wintermark M, Grossman RF, Nozaki M. Magnetic resonance angiography to evaluate septocutaneous perforators in free fibula flap transfer. J Plast Reconstr Aesthet Surg 2009; 63:1099-104. [PMID: 19577973 DOI: 10.1016/j.bjps.2009.06.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2008] [Revised: 03/24/2009] [Accepted: 06/02/2009] [Indexed: 11/25/2022]
Abstract
BACKGROUND In harvesting free fibula composite flaps, preoperative knowledge of the lower limb vascular anatomy is essential to prevent ischaemic complications or flap failure. Magnetic resonance angiography (MRA) allows imaging of the septocutaneous perforators (< or = 1-2mm diameter) of the peroneal artery used in the free fibula flap. METHODS We investigated seven patients undergoing the free fibula flap preoperatively with high-resolution MRA images to study the following: 1) tibio-peroneal anatomy, 2) peripheral artery disease, 3) the positions of the perforator vessels on the peroneal artery and their course in the posterolateral intermuscular septum and 4) the cutaneous distribution of the perforators, and to compare them to surgical findings. RESULTS MRA demonstrated tibio-peroneal anatomy in sufficient detail to exclude anatomic variants and significant peripheral vascular disease, detected septocutaneous perforators arising from the peroneal artery coursing in the posterolateral intermuscular septum and determined the skin terminus of the septocutaneous perforators. All septocutaneous perforators found during surgery were detected prospectively on high-resolution MRA. CONCLUSION Lower leg vascular anatomy assessment with high-resolution MRA determined the location of the septocutaneous perforators of the peroneal artery preoperatively with accuracy and precision. This anatomical knowledge provides for a safer procedure and the opportunity to plan surgical details preoperatively.
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Affiliation(s)
- Eri Fukaya
- Department of Plastic and Reconstructive Surgery, Tokyo Women's Medical University, 8-1 Kawada-cho Shinjuku-ku, Tokyo 162 8666, Japan.
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Perforators of the Lower Leg: Analysis of Perforator Locations and Clinical Application for Pedicled Perforator Flaps. Plast Reconstr Surg 2008; 122:161-170. [PMID: 18594401 DOI: 10.1097/prs.0b013e3181774386] [Citation(s) in RCA: 147] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gait analysis of donor leg after free fibular flap transfer. Int J Oral Maxillofac Surg 2008; 37:625-9. [DOI: 10.1016/j.ijom.2008.04.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2007] [Accepted: 04/11/2008] [Indexed: 11/23/2022]
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Plastisch-rekonstruktive Verfahren in der interdisziplinären Therapie chronischer Wunden. Chirurg 2008; 79:546-54. [DOI: 10.1007/s00104-008-1503-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Kremer T, Bickert B, Germann G, Heitmann C, Sauerbier M. Outcome Assessment after Reconstruction of Complex Defects of the Forearm and Hand with Osteocutaneous Free Flaps. Plast Reconstr Surg 2006; 118:443-54; discussion 455-6. [PMID: 16874216 DOI: 10.1097/01.prs.0000227742.66799.74] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Complex defects of the forearm and hand often require microvascular reconstruction with osteocutaneous free flaps for limb salvage. METHODS Fifteen patients with osseous and soft-tissue defects of the forearm and hand were treated with osteocutaneous flaps (1992 to 2004) and evaluated for postoperative results. Assessment focused on range of motion, pain, grip strength, and Disabilities of Arm, Shoulder, and Hand questionnaire score. Donor- and recipient-site morbidity was documented. RESULTS The defects resulted from trauma, infection, or malignancy. Reconstruction was possible by microvascular osteoseptocutaneous fibula transplantation (n = 8), osteocutaneous scapular or parascapular flaps(n = 6), and osteocutaneous lateral arm flap (n = 1). The average patient age was 38 years. The median osseous defect was 11.7 cm, and all patients needed additional soft-tissue reconstruction. All defects could be reconstructed in a one-step procedure after serial débridement or oncologic resection. Patients' hand function was markedly reduced compared with the unaffected extremity, but functional results were still satisfactory, with a mean Disabilities of Arm, Shoulder, and Hand score of 25.3 reflecting a moderate disability in activities of daily living. Two patients developed pseudarthrosis, and one had to undergo an ablation procedure because of persistent infection. Two patients developed wound dehiscence at the donor site, and one patient required a fasciotomy due to an imminent compartment syndrome after fibula harvest. For all patients, the functional results were acceptable when the potential alternatives were taken into consideration. This was also reflected by a high individual satisfaction rate. CONCLUSION This analysis demonstrates that limb salvage with osteocutaneous free flaps is the treatment of choice for three-dimensional defects of the forearm and hand.
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Affiliation(s)
- Thomas Kremer
- Department of Hand, Plastic, and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic and Hand Surgery, The University of Heidelberg, Ludwigshafen, Germany
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Clinical Applications of Free Soleus and Peroneal Perforator Flaps. Plast Reconstr Surg 2005. [DOI: 10.1097/01.prs.0000138810.14520.2b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Heitmann C, Levin LS. Applications of the vascularized fibula for upper extremity reconstruction. Tech Hand Up Extrem Surg 2003; 7:12-7. [PMID: 16518250 DOI: 10.1097/00130911-200303000-00004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
There are limited reconstructive options for segmental bone defects of the upper extremity larger than 6 cm in length, especially when associated with soft-tissue loss. Among the limited treatment options the osteoseptocutaneous fibular transplant is well established. The anatomy is reliable, the blood supply is constant, and the operative technique can be standardized. The advantage of including skin with the vascularized fibular transplant is twofold. First, the skin paddle can be used to augment the soft-tissue envelope. Second, the skin paddle serves as a monitor, providing an immediate, ongoing, and reliable method to monitor the blood flow to the graft. The osteoseptocutaneous fibular transplant proved to be an effective treatment of combined segmental bony and soft-tissue defects of the forearm and humerus.
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Affiliation(s)
- Christoph Heitmann
- Division of Plastic, Reconstructive, Maxillofacial and Oral Surgery Duke University Medical Center Durham, North Carolina, U.S.A
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Cho BC, Kim SY, Park JW, Baik BS. Blood supply to osteocutaneous free fibula flap and peroneus longus muscle: prospective anatomic study and clinical applications. Plast Reconstr Surg 2001; 108:1963-71. [PMID: 11743385 DOI: 10.1097/00006534-200112000-00019] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
From January of 1998 to December of 1999, a total of 24 fibula free flaps in 24 patients were evaluated in a prospective clinical study. Once the perforators were identified, they were dissected toward the parent vessel and labeled according to type. The soleus and flexor hallucis longus muscles of the fibula were dissected, and the proximal part of the pedicle was reached. Subsequently, the configuration of all muscular branches to the peroneus muscle was studied. The types of skin perforators of the peroneal artery were noted as septocutaneous, musculocutaneous, or septomusculocutaneous. A total of 86 perforators were identified in 24 legs. The average number of perforators per leg was 3.58 +/- 0.71. Among them, 22 were musculocutaneous, 31 were septomusculocutaneous, and were 33 septocutaneous. The septocutaneous branches were significantly more distal than the musculocutaneous and septomusculocutaneous perforators. Eight perforators were identified 25 cm distal from the fibular head and six were identified at 15 cm. Five perforators were then identified at each distance of 8, 12, 19, and 22 cm distal from the fibular head. The total number of muscular branches to the peroneus longus was 62, with an average of 2.58 +/- 0.45. Most muscular branches were found between 8 and 16 cm distal to the fibular head. Nine branches were identified at 13 cm distal to the fibular head, eight at 9 cm, and seven at 12 cm. The number of dominant branches with the largest diameter was seven at 13 cm distal from the fibular head, five at 12 cm, five at 16 cm, and two at 11 cm. In summary, when designing an osteocutaneous free fibula flap 10 to 20 cm from the fibular head, it is recommended that a soleus and flexor hallucis longus muscle cuff be included to incorporate these perforators. In contrast, when designing a flap 20 to 30 cm from the fibular head, it is possible to elevate the flap without incorporating the soleus or flexor hallucis muscles.
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Affiliation(s)
- B C Cho
- Department of Plastic and Reconstructive Surgery, Kyungpook National University Hospital, Taegu, Korea.
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Choi SW, Kim HJ, Koh KS, Chung IH, Cha IH. Topographical anatomy of the fibula and peroneal artery in Koreans. Int J Oral Maxillofac Surg 2001; 30:329-32. [PMID: 11518357 DOI: 10.1054/ijom.2001.0055] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Vascularized fibula flaps have many advantages in the restoration of the contour and function of the mandible. Potential disadvantages include, unreliable skin paddle and the limited volume of the fibula. This study was designed, to clarify the anatomy of the peroneal artery to the fibula and lateral leg skin, and to measure the dimensions of the fibula available for dental implant placement in Korean. Through the dissection of 63 legs of Korean cadavers, we demonstrated that in most cases the musculoperiosteal (mp) and septocutaneous (sc) branches of the peroneal artery were distributed at the middle and lower thirds of the fibula. There were double the number of mp perforators to the skin compared to sc branches. This indicates the inclusion of a generous > 1 cm cuff of Peroneous longus and flexor hallucis longus (FHL) in the distal and middle third of the fibula. The location of the nutrient foramen was just proximal to the midpoint. Thus, a 15-20 cm length of the fibula is available in Koreans and an 8 12 mm length of implant can be placed to the fibula, which provides sufficient bone to reconstruct a large mandibular defect.
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Affiliation(s)
- S W Choi
- Department of Oral and Maxillofacial Surgery, College of Dentistry, Yonsei University, Seoul, Korea
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Saitoh S, Hata Y, Murakami N, Seki H, Kobayashi H, Shimizu T, Takaoka K. The 'superficial' peroneal artery: a variation in cutaneous branching from the peroneal artery, nourishing the distal third of the leg. BRITISH JOURNAL OF PLASTIC SURGERY 2001; 54:428-33. [PMID: 11428776 DOI: 10.1054/bjps.2001.3598] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Two different vascular patterns were encountered in cutaneous branches from the peroneal artery to the posterolateral aspect of the distal third of the leg in 22 flaps from 22 patients who underwent cutaneous or osteocutaneous peroneal flap surgery. In the type 1 vascular pattern, a branch from the peroneal artery, named the 'superficial peroneal artery', nourished the posterolateral aspect of the leg by splitting into several septocutaneous branches. In the type 2 pattern a few septocutaneous branches originated directly from the main peroneal artery and nourished the same area as that fed by the type 1 branch. The type 1 vascular pattern has not been reported to date but was seen in nine out of the 22 consecutive peroneal flaps. The superficial peroneal artery, with its considerable vascular diameter, may serve as a recipient vessel for free flaps or may serve as a donor nutrient vessel for a cutaneous flap, which can be transferred without sacrificing the main peroneal artery. Awareness of these two vascular patterns in the distal third of the leg should also help to reduce the small percentage of skin-flap failures that occur when the cutaneous or osteocutaneous peroneal flap is used.
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Affiliation(s)
- S Saitoh
- Department of Orthopaedics, Shinshu University School of Medicine, Matsumoto City, Japan
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Pelissier P, Casoli V, Demiri E, Martin D, Baudet J. Soleus-fibula free transfer in lower limb reconstruction. Plast Reconstr Surg 2000; 105:567-73. [PMID: 10697162 DOI: 10.1097/00006534-200002000-00014] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Free-fibula transfer has been widely used since 1975. Many modifications have been described; one of them, association of the lateral part of the soleus muscle to the fibula, is reported here through a 14-case series. This composite flap is intended for extensive defects of the lower limbs involving bone and soft tissues. The flap is considered by the authors to be reliable, with a constant vascularization. A 20-cm length offibula may be harvested associated either with the lateral part of the soleus muscle or with the whole muscle. Moreover, the soleus muscle represents a vascular security inasmuch as it preserves both medullar and periosteal bone supply. Fourteen cases have been performed by the authors since 1978 and could be reviewed with a minimum 2-year follow-up. Average length of bone defect was 12 cm, and average length offibula harvested was 18.6 cm. Soft-tissue defect was always associated and ranged from 8 x 4 cm to 20 x 30 cm. The fibula was harvested with the lateral part of the soleus muscle in 10 cases and with the whole soleus muscle in 4 cases. One total treatment failure was reported and was related to intimal degenerative lesions on veins used for arteriovenous bypass. In other patients, mean time for bone healing was 11 months. Patients could walk again, on average, 17 months after reconstruction. Sequelae at the donor site were minimal.
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Affiliation(s)
- P Pelissier
- Service de Chirurgie Plastique, Hôpital Pellegrin, Bordeaux, France.
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Levin LS. The use of the vascularizedosteoseptocutaneous fibula transplant for extremity tumor reconstruction. ACTA ACUST UNITED AC 1999. [DOI: 10.1016/s1048-6666(99)80026-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Winters HA, de Jongh GJ. Reliability of the proximal skin paddle of the osteocutaneous free fibula flap: a prospective clinical study. Plast Reconstr Surg 1999; 103:846-9. [PMID: 10077073 DOI: 10.1097/00006534-199903000-00010] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The vascularization of the skin paddle of 20 osteocutaneous fibula free flaps in 20 patients was studied. All skin paddles were designed over the proximal and middle third of the fibula. A parallel vascularization of the skin was found in 10 cases. In these cases, an axial (septo)musculocutaneous perforator was found to originate high in the peroneal artery or even in the popliteal artery. This branch runs parallel to the peroneal artery without any further connections with it. In 5 of these 10 cases, no other skin perforators were located within the boundaries of the skin paddle. Harvesting such a flap in the traditional way by blind inclusion of a muscle cuff results in ligation of the supplying vessel of the skin paddle and subsequent loss of the skin. In this series, this would have been the case in 5 of the 20 patients (25 percent). This might explain the bad reputation of the skin paddle of this flap. The high prevalence of the described vascular configuration in a proximally designed skin paddle justifies à vue dissection of all musculocutaneous perforators up to their origin, unless one or more septocutaneous perforators are found within the boundaries of the flap.
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Affiliation(s)
- H A Winters
- Department of Plastic and Reconstructive Surgery at the Academisch Ziekenhuis Vrije Universiteit, Amsterdam, The Netherlands
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Chung YK, Chung S. Ipsilateral island fibula transfer for segmental tibial defects: antegrade and retrograde fashion. Plast Reconstr Surg 1998; 101:375-82; discussion 383-4. [PMID: 9462770 DOI: 10.1097/00006534-199802000-00017] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Five patients with segmental tibial defects whose contralateral fibula could not be used as a donor were treated with ipsilateral island fibular transfer in an antegrade or retrograde fashion. Antegrade-flow pedicled flaps based on the peroneal vessel as in the conventional free flap were used for the proximal or middle one-third tibial defects, whereas retrograde-flow pedicled flaps based on the communicating branch between the peroneal and posterior tibial vessels were used for the middle or distal one-third of the tibia. All patients had one of the following problems: a previously failed free flap, below-knee amputation of the opposite leg because of open tibia fracture, refusal to use the contralateral sound leg, or poor general condition to endure a lengthy operation. Four of the patients also had an associated fibular fracture on the same leg, which was ultimately used as one of the osteotomy sites. The follow-up period was from 31 to 48 months. Time to bony union ranged from 4 to 7 months. Time to full weight bearing was from 5 to 9 months after operation. All of the transferred fibulas showed hypertrophy after weight bearing. Nonunion occurred in two cases, which were treated with a long leg cast and cancellous bone graft, respectively. The limb was shorter by an average of 0.5 cm in three cases, longer by 1.1 cm in one case, and in the last case, it was uncheckable because the opposite limb was previously amputated. Limited arc of rotation was not a problem. Other disabling complications were not seen. We believe that these methods can be a valuable alternative to the contralateral free fibula flap in certain cases.
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Affiliation(s)
- Y K Chung
- Department of Plastic and Reconstructive Surgery, Yonsei University Wonju College of Medicine, Wonju Christian Hospital, Korea
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Jupiter JB, Gerhard HJ, Guerrero J, Nunley JA, Levin LS. Treatment of segmental defects of the radius with use of the vascularized osteoseptocutaneous fibular autogenous graft. J Bone Joint Surg Am 1997; 79:542-50. [PMID: 9111398 DOI: 10.2106/00004623-199704000-00009] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Nine patients who had a complex, combined skeletal and soft-tissue defect involving the radius were managed with operative reconstruction with use of a vascularized osteoseptocutaneous fibular autogenous graft. All of the patients were male, and the average age was thirty-two years (range, twenty-one to forty-two years). Three patients sustained the injury as the result of a gunshot wound and two each, as the result of a motor-vehicle accident, a fall from a height, or a machinery-related accident. Five patients had a concomitant fracture of the ulna. The average length of the radial defect was seven centimeters. Six patients had a deep osseous infection. The average length of the fibular autogenous graft was 7.9 centimeters, and the average size of the associated fasciocutaneous component was 11.8 by 5.9 centimeters. Two patients had a concomitant arthrodesis of the wrist. A split-thickness skin graft was used to close the donor site in six patients. Two patients had postoperative vascular complications that necessitated revision with an autogenous vein graft. One patient had a second operation six months postoperatively to correct an angular deformity that had developed secondary to a non-union at the graft-host bone junction. After an average duration of follow-up of twenty-four months, all but one of the patients had radiographic evidence of osseous union at both the proximal and the distal graft-host bone junction. No patient had evidence of resorption of the graft or symptoms referable to the donor leg at the time of the most recent examination. Six patients had returned to their preinjury occupation.
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Affiliation(s)
- J B Jupiter
- Massachusetts General Hospital, Boston 02114, USA
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Jones NF, Monstrey S, Gambier BA. Reliability of the fibular osteocutaneous flap for mandibular reconstruction: anatomical and surgical confirmation. Plast Reconstr Surg 1996; 97:707-16; discussion 717-8. [PMID: 8628764 DOI: 10.1097/00006534-199604000-00003] [Citation(s) in RCA: 101] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
There is ongoing controversy regarding the reliability of the skin island associated with the fibular osteocutaneous flap for mandibular reconstruction. Anatomical dissections and a clinical series of mandibular reconstructions using the fibular osteocutaneous flap have demonstrated unequivocally that a skin flap can be reliably harvested with the fibula based purely on the septal perforators, without needing to incorporate portions of the soleus or flexor hallucis longus muscles or to perform any intramuscular dissection or anastomosis of the muscle perforators. However, the skin island should be designed more distally over the distal third of the lower leg at the junction of the middle and distal thirds of the fibula. A fibular osteocutaneous flap was designed over the distal third of the fibula in 60 fresh cadavers, and each flap was completely isolated on the septum and all muscle perforators were ligated before dye injection. A major perforator through the soleus muscle or flexor hallucis muscle was identified in 41 of 60 dissections (67 percent) and discrete septal perforators were identified under loupe magnification in 45 dissections (75 percent). All 60 flaps demonstrated 100 percent reliable perfusion of the skin island after injection of the proximal peroneal artery with methylene blue or red latex. This anatomical study was corroborated with 100 percent survival of 34 fibular osteocutaneous flaps for mandibular reconstruction with the skin island designed over the distal third of the lower leg and based only on septal perforators without incorporating the soleus or flexor hallucis muscles. Reliability of this fibular osteocutaneous flap for mandibular reconstruction is attributed to (1) design of the skin island more distally over the distal third of the lower leg, (2) preoperative precision Doppler mapping of the perforators, and (3) design of the closing wedge osteotomies of the fibula to protect the septocutaneous perforators transversing through the posterior periosteum of the fibula.
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Affiliation(s)
- N F Jones
- Division of Plastic and Reconstructive Surgery at the University of Pittsburgh, PA, USA
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Shestak KC, Myers EN, Ramasastry SS, Jones NF, Johnson JT. Vascularized free-tissue transfer in head and neck surgery. Am J Otolaryngol 1993; 14:148-54. [PMID: 8338198 DOI: 10.1016/0196-0709(93)90023-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Microsurgical vascularized free-tissue transfer has had a dramatic impact on the field of head and neck reconstruction. This technique has extended the extirpative limits of resection by facilitating complex reconstruction of head and neck defects in one stage with very high success and minimal patient morbidity. Although its impact on improving cure rates and survival statistics has yet to be determined, it has proven very valuable in the palliation of patients with advanced malignancies. The horizons for future applications are infinite. Neurotization of free-flap transfer may potentially improve the functional outcome for patients. In the future, free flaps may be prefabricated to allow for improved mandibular reconstruction or tracheal reconstruction. These tissue composites may potentially be a vehicle through which adjuvant therapy can be better delivered to the tumor bed. Microsurgical free-tissue transfer will have an expanding role in the treatment of patients with head and neck tumors, and continued refinements in these techniques will open new vistas for the reconstructive surgeons in the future.
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Affiliation(s)
- K C Shestak
- Division of Plastic Surgery, University of Pittsburgh School of Medicine, PA 15213
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Abstract
Microvascular surgery plays a vital role in head and neck reconstruction. This paper deals with the complications arising from this form of surgery. They can be classified as general complications, anastomotic problems, and specific problems related to particular donor and recipient sites.
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Affiliation(s)
- M M al Qattan
- Division of Plastic Surgery, Toronto Hospital, University of Toronto, Ontario, Canada
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