• Archives of Reconstructive Microsurgery
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• v.9 no.2
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• pp.147-153
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• 2000

Soft tissue defects of the dorsum of foot and ankle can be covered from skin graft to free tissue transfer. The extent of injury which may be complex including the exposure of paratenons or bones requires free flap reconstruction. Some of the precautions for reconstruction are providing minimal bulkiness and well conforming to irregular contour thus making normal footwear possible. Though the muscle flap having its advantages and versatility, the fascial flap such as temporoparietal fascial flap has been considered the choice for reconstruction of the dorsum of foot and ankle. The purpose of our study is to utilize the advantages and versatility of the muscle flap as a first choice for reconstruction for the defects involving the dorsum of foot and ankle. The gracilis muscle with its anatomic and donor characteristics, it can be utilized to maximal effect by expanding its slim muscle width removing the epimysium and reducing its bulk by muscle atrophy through denervation. We present our experience with ten cases of reconstruction for the dorsum of foot and ankle using the gracilis muscle free flap. Results were satisfactory without flap loss, skin loss and infection. The contour and aesthetic aspect of the foot was satisfactory. Gait analysis showed near normal gait without limitations from everyday activities. Normal footwear was tolerable in all the cases. The keys to consider in the reconstruction of the dorsum of foot and ankle are appropriate bulkiness, conforming to its contour and able to apply normal footwear. With minimal donor morbidity and satisfying results, the extended gracilis muscle should be considered as the first line for reconstruction of the ankle and dorsum of foot.

• Archives of Reconstructive Microsurgery
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• v.21 no.1
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• pp.56-60
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• 2012

Purpose: Thumb reconstruction plays most important role in hand injuries because total loss of a thumb constitutes about 40% disability in the hand. The reconstruction can be accomplished by pollicization, free toe-to-thumb transfer, wrap around procedure and lengthening extraction. However, we sometimes need consecutive or double free flaps in the reconstruction of mutilating hand injuries. Methods: We reconstructed a mutilating hand injury in a 54-years old man. Because of severe crushing injury of right thumb and index fingers, we reconstructed a thumb with pollicization using nearly amputated middle finger. Although it survived completely, the adjacent soft tissues which had been covered by fillet flap from the space past was necrosed on 1 month. We debrided the necrotic tissues and covered it with anteromedial thigh perforator free flap consecutively because he had an anatomical variation in branches of lateral femoral circumflex artery. Results: He had an uneventful postoperative course without any complication such as infection, dehiscence and flap necrosis. Three months later, he had undergone tenolysis and defatting procedure of flap site. He recovered the some amount of grip function and was happy with the result. Conclusion: In severe hand trauma including thumb amputation, thumb reconstruction using pollicization and perforator free flap could be an alternative option. It provides minimal donor site morbidity and an acceptable functional result.

• Archives of Reconstructive Microsurgery
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• v.21 no.1
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• pp.21-26
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• 2012

The radial artery superficial palmar branch free flap is based on the perforators of the superficial palmar branch of the radial artery and its venae comitantes. This flap can be used as a sensible flap including palmar cutaneous branch of the median nerve. Forty radial artery superficial palmar branch free flaps were performed at Centum Institute during October 2010 to December 2011. There were 32 males and 8 females and their mean age were 48 years (range 30 to 66 years). The thumb injured in 13 patients, the index finger in 16 patients, the middle finger in 4 patients, the ring finger in 2 patients, and the little finger in 5 patients. The mean size of the flap was $2.5{\times}3.5$ cm(range $2{\times}2.5$ to $3{\times}7$ cm). The donor site was always closed primarily. The overall survival rate was 90.2 percent. The flaps showed well-padded tissue with glabrous skin. All patients have touch sensation and showed 12 mm two point discrimination in an average(range 8 to 15 mm). Donor site morbidity was conspicuous. One patient showed unsightly scar. Early postoperative range of motion of the affected thumb showed slightly limited radial and palmar abduction. But it improved after postoperative 2 months, and patients did not complaint limitation of motion. In conclusion, the radial artery superficial palmar branch free flap can be used as an option for soft tissue reconstruction of finger defects where local or island flaps are unsuitable.

• Archives of Reconstructive Microsurgery
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• v.21 no.1
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• pp.14-20
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• 2012

Purpose: Defect after ablation of hypopharyngeal cancer often requires reconstruction by free tissue transfer. Since neo-hypopharynx is totally buried, various methods have been suggested for monitoring. We propose a modified design of anterolateral thigh (ALT) free flap for reconstruction of pharyngolaryngectomy defect, which has an exteriorized part for clinical monitoring and allows for primary closure. Materials and Methods: Three consecutive patients with hypopharyngeal cancer were reconstructed with ALT flap with modified design: 1) distal part of flap was elongated into fusiform shape and used as exteriorized monitoring segment with a deepithelized bridge and 2) proximal part was designed as curve so the maximum width of the flap was reduced to less than 10 cm. Results: Patient 1, 2 had uneventful postoperative course with healthy skin color and fresh pin prick bleeding. In patient 3, defect after cancer ablation was shorter than usual and deepithelized bridge was longer. When the general hemodynamic status of the patient was aggravated in postoperative course, the color of monitoring skin was changed. Viability of the whole flap was confirmed by endoscopy. However, leakage developed after 3 weeks and repair was necessary. In all patients the donor sites were closed primarily. Conclusion: By the modified design of ALT flap, clinical monitoring can be possible by examining exteriorized monitoring flap and also donor site can be closed primarily. However possibility of false positive exists and technical caution and patient selection is needed because of danger of leakage.

• Archives of Reconstructive Microsurgery
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• v.21 no.1
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• pp.1-7
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• 2012

Purpose: This retrospective study was to determine the functional results of patients who were amputated of their fingertip between patients who were treated with replantation and patients who were treated with thenar flap. Materials and Methods: From 2004 to 2007, we identified and operated 159 patients who were diagnosed with fingertip amputations. Of 159 patients, Eighty-two patients were treated by replantation (67 in men and 14 in women) and the mean age at the operation was 41 years (range, 15-68 years). Seventy-nine patients was treated with thenar flap(54 in men and 25 in women) and the mean age at the operation was 43 years(range, 21-70 years). We compared variables between two groups including, age, gender, diagnosis, duration of hospital admission, grip strength, two-point discrimination, Semmes Weinstein monofilament test, active range of motion (ROM) of the proximal and distal interphalangeal (PIP and DIP) joint, pain (or tenderness), paresthesia, cold intolerance, the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, and finger for activities of daily living (ADLs). Results: The duration of admission was longer in Replantation group than in Thenar flap group(p=0.001). However, the grip strength (p=0.003) and Semmes Weinstein monofilament test (p=0.029) in the Replanation group were statistically superior to the Thenar flap group. The average DASH disability (p=0.003)/symptom score (p=0.007) and ADLs (p<0.001) in the Replantation group was statistically better. In addition, cold intoleranace test of Thenar flap group is worse than the Replantation group. Conclusion: This study demonstrate that fingertip replantation have demonstrated not only to obtain the best appearance but also to gain better functional outcome. However, it is impossible to perform replatation, the thenar flap can be limited alternative method for fingertip amputation in aspect of preservation of range of motion and hospitalization time.

• Archives of Plastic Surgery
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• v.34 no.6
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• pp.753-758
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• 2007

Purpose: Penoscrotal extramammary Paget's disease is a rare cutaneous malignancy that primarily affects the elderly. To prevent local recurrence, adequate surgical excision with its intraoperative frozen section, proper reconstruction, and careful follow-ups are required. The present study describes the treatment of patients with penoscrotal extramammary Paget's disease, focusing on the reconstruction after the ablation of lesion. Methods: Nine patients were selected who had undergone a local pedicle flap procedure due to the large defects after ablation of extramammary Paget's disease of the penoscrotal area, during the period of 1999 to 2005. Wide excision combined with intraoperative frozen sectioning was performed, and the penoscrotal wound was reconstructed with a local skin flap. Three flaps were chosen depending on the size of the defect. If the defect size was small and the scrotal tissue was adequate, scrotal flap(n=5) was enough for its reconstruction. However, as there were large defects with insufficient remnant scrotal tissue, a groin flap(n=2) or an anterolateral thigh flap(n=2) were performed. Results: There were no complications with the postoperative wound. Furthermore, no local recurrence was noted during two to six years of follow-up period (mean average 3.7 years). Conclusion: For the resurfacing the penoscrotum at large defects after ablation of extramammary Paget's disease, we performed reconstruction with a local flap. In the aspect of both function and cosmetic concerns, the results were satisfactory.　

• Archives of Plastic Surgery
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• v.37 no.5
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• pp.607-612
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• 2010

Purpose: Maxillectomy for malignant tumor resection often leads to functional and aesthetic sequalae. Reconstruction following maxillectomy has been a challenging problem in the field of head and neck cancer surgery. In this article, we described three dimensional midface reconstructions using free flaps and their functional and aesthetic outcomes. Methods: We reconstructed 35 cases of maxillectomy defects using 9 radial forearm free flaps, 7 lattisimus dorsi musculocutaneous free flaps, 6 rectus abdominis musculocutaneous free flaps, 4 fibular osteocutaneous free flaps, and 9 anterolateral thigh free flaps, respectively. We classified post-maxillectomy defects by Brown's classification. 1 Articulation clarity was measured with picture consonant articulation test. Swallowing function was evaluated with the University of Washington quality-of-life Head and Neck questionnaire by 4 steps.2 Aesthetic outcomes were checked to compare preoperative with postoperative full face photographs by 5 medical doctors who did not involve in our operation. Results: The average articulation clarity was 92.4% (100-41.9%). 27 (81.9%) patients were able to eat an unrestricted diet. Aesthetic results were considered excellent in 18 patients (51.4%). Functional results were best in the group reconstructed with fibular osteocutaneous free flap. Considering the range of wide excision, aesthetic results is best in the group reconstructed with anterolateral thigh free flap. Conclusion: The free flap is a useful technique for the reconstruction of the midface leading to good results, both functionally and aesthetically. Especially, because osteocutaneous flap such as fibular osteocutaneous free flap offered bone source for osteointegrated implant, It produces the best functional results. And perforator flap like as anterolateral thigh free flap reliably provides the best aesthetic results, because it provides sufficient volume and has no postoperative volume diminution.

• Archives of Plastic Surgery
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• v.37 no.5
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• pp.571-576
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• 2010

Purpose: Reconstruction of soft tissue defects of the foot often requires free-flap transfer. Free muscle flap transfer and skin grafts on the muscle has been an option for these defects. Here we present our experiences of foot reconstruction using an endoscopy-assisted free muscle flap harvest. Methods: Using endoscopy-assisted free muscle flap harvests, four patients with soft tissue defects of the foot were treated with a free muscle flap and skin graft. The gracilis muscle was used for two patients and the rectus abdominis muscle for two. A single small transverse skin incision was placed on the lower abdomen for the rectus abdominis muscle. A small transverse skin incision on the proximal thigh was the only incision for harvesting the gracilis muscle flap. The small incisions were enough for the muscle flap to be pulled through. Results: The flaps survived successfully in all cases. Contours were good from both functional and aesthetic aspects. No breakdowns or ulcerations of the flap developed during long-term follow-up. Resultant scars were short and relatively hidden. Functional morbidities such as abdominal bulging were not noted. Conclusion: Endoscopy-assisted harvest of muscle flap and transfer with skin graft is a good option for soft tissue defects of the foot. Morbidities of the donor site can be minimized with endoscopic flap harvest. This method is preferable for young patients who want a small donor site scar.

• Archives of Plastic Surgery
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• v.37 no.5
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• pp.565-570
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• 2010

Purpose: Due to the closed and humid condition of the perineal area, wound problems occurring at this site are sometimes complicated, especially following postoperative radiation therapy. Moreover, the anal sphincter is a very important functional structure but reconstruction of the anal sphincter after severe trauma poses a challenging problem to plastic surgeons. In this article, we demonstrate the usefulness of the pedicled gracilis flap in the reconstruction of the perineal area. Methods: From September 2008 to November 2009, 6 patients, 4 males and 2 females, underwent surgery of the perineal area. The age of the patients ranged from 21 to 62 years (mean age was 48). The mean follow up period was 14 months. In 4 cases, the patient presented with wound problems after postoperative radiation therapy for anal cancer. In 2 cases, the patient presented with traumatic sphincter damage. Only the gracilis muscle was used in the 4 cases and a musculocutaneous flap was used in the 2 cases involving skin defects, respectively. Results: Among the 6 patients, 1 patient underwent hematoma evacuation of the donor site, and 1 patient presented with prolapse of the vaginal mucosa which recovered spontaneously. There were no report of other complications and there were no wound recurrences. Minimal incontinence was observed in all patients who underwent sphincter reconstruction, but all were satisfied with the overall results. Conclusion: The gracilis flap is useful in the reconstruction of the perineal area, such as in cases of radiotherapy induced wound problems and sphincter damage following severe trauma, due to its easy accessibility, rich vascularity, and minimal donor site morbidity.

• Journal of Veterinary Clinics
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• v.32 no.5
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• pp.449-453
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• 2015

A 7-year-old spayed female Somali-cross cat was admitted with a 4-week history of anorexia, vomiting, weight loss, and lethargy. The cat was diagnosed with hepatic lipidosis. With intensive care and nutritional support via a nasogastric feeding tube for 3 weeks, the clinical signs of hepatic lipidosis were improved. However, skin lesions were found in the left and right scapular regions during the treatment that were suspected to be due to feline skin fragility syndrome (FSFS). Intensive wound healing therapy with granulated sugar, laser therapy, and a surgical flap was conducted. Skin lesions improved uneventfully without other clinical signs or recurrence of any skin lesion for a year. To our knowledge, this is the first report of a good prognosis in a hepatic disorder and concurrent FSFS.