Closure of upper extremity soft-tissue defects using the new "supra-crest" fasciocutaneous free flap

Lumbar Artery Perforator Flaps: A Systematic Review of Free Tissue Transfers and Anatomical Characteristics

BACKGROUND

The lumbar artery perforator (LAP) flap has gained popularity as a versatile flap in reconstructive surgery; however, few studies have analyzed salient characteristics of this flap. We set out to provide a comprehensive appraisal of free tissue transfers of LAP flaps with specific attention to anatomic features and clinical outcomes.

METHODS

Using preferred reporting items for systematic reviews and meta-analyses guidelines, we identified clinical, radiographic, and cadaveric studies of LAP flaps and assessed outcomes, complications, and anatomic parameters, such as pedicle length, diameter, location, and course.

RESULTS

A total of 254 articles were initially reviewed, of which 18 met the final inclusion criteria. Ten studies were primarily concerned with anatomic characteristics, and most clinical studies related to breast reconstruction. The operative durations varied between 4.8 and 9.2 hours. Partial and total flap losses were estimated at 2.6% and 7.6%, respectively. Acute revision rates ranged from 16% to 24% related to hematoma, arterial thrombus, and venous thrombus. Donor-site seromas were frequently encountered in breast reconstruction with an incidence of 17% to 78%.

CONCLUSIONS

The LAP flap has demonstrated favorable outcomes in various reconstructive scenarios. The caudal perforators generally offer more pedicle length, greater pedicle diameter, and septocutaneous course and may be better suited for flap design. For breast reconstruction, the LAP flap is a useful alternative to abdominal-based flaps, and special attention should be given to optimizing pedicle length using interposition grafts and methods that minimize seroma formation at the donor site.

Microvascular myocutaneous flaps in the lumbosacral area using the iliac artery and vein as recipient vessels

Lumbosacral tissue defects are usually closed with local flaps. Sometimes in large high-situated defects free microvascular flaps are used. However, finding a suitable recipient vessel for microvascular anastomosis in this region is difficult. In large soft-tissue defects high in the lumbar area, closure with a free flap using the iliac artery and vein as recipient vessels channelled from the pelvic cavity to the back through a drill canal in a bone presents an alternative option where other vessels are damaged by radiotherapy or infection. This has been used successfully in two cases.

Upper limb free flap reconstruction after tumor resection

Free tissue transfer is the autologous transplantation of composite tissue and its arterial and venous blood supply to a distant site. Free tissue transfers, also called free flaps, may include skin, fascia, muscle, or bone. Free flaps were once considered highly complex procedures; now they are frequently used as the reconstructive option of choice. While several variables must be considered when one plans a free tissue transfer, the most important consideration is the size and location of the defect created by the tumor resection. Free tissue transfer is a multistep procedure, including preparation of the recipient site, harvesting of the flap, and transfer and revascularization of the flap. For upper extremity reconstruction, the gracilis muscle flap has been particularly useful, as has the lateral arm fasciocutaneous flap. Semin. Surg. Oncol. 19:246-254, 2000.

A new design of the iliac crest microsurgical free flap without including the "obligatory" muscle cuff

The iliac crest free flap has undergone a gradual evolution to provide more functional and cosmetic oromandibular reconstructions. The soft-tissue cutaneous component has largely resisted refinement and currently constitutes the flap's principal drawback. Conventionally, the cutaneous vessel's soft-tissue encasement and a protective cuff of abdominal muscle are harvested to ensure skin perfusion. These protective measures, however, produce a bulky flap that is tethered to the bone and difficult to inset into complex three-dimensional defects. A series of anatomic and clinical investigations has confirmed that in 30 percent of individuals, the skin island can be elevated on a dominant cutaneous branch from the deep circumflex iliac artery. Harvesting the skin as an axial pattern flap greatly increases its independence from the bone, improving maneuverability. A small collar of abdominal muscle is incised around the pedicle, obviating the need for the customary 2.5-cm protective muscle cuff. Exclusion of the abdominal muscular component reduces the flap's volume, decreases the need for secondary debulking, and reduces the donor site morbidity.