• Archives of Reconstructive Microsurgery
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• v.13 no.1
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• pp.1-6
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• 2004

Advances in microvascular techniques and refinements in microsurgical tissue transfers have enabled surgeons to combine different tissue components and reconstruction into a single-stage operation in extensive or composite defect following injury. Some problems and consideration for extensive or composite defects are form, shape, function, and dimension of the defect sites. Therefore combination of two or more flaps is required to reconstruct extensive or composite defect. This paper presents our clinical experience of four cases of combined free flaps with or without sequential microanastomosis in reconstruction of upper extremity based on peroneal flowthrough, thoracodorsal, and dorsalis pedis vascular system. Satisfactory results were obtained without flap loss and complications. The free flaps were combined in th following fashion; two cases by bridge fashion, one by chimeric microanastomosis and one by simple chimeric fashion. The median follow-up time on all patients was 21.7 months. Donor site morbidity was minimal. Extensive soft tissue or composite defects can be effectively covered by various combined flaps. Even though the risk for complication exists, the options of combination with or without sequential microanastomosis can add a functional or sensory dimension to reconstruction of complex wounds.

• Archives of Reconstructive Microsurgery
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• v.17 no.2
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• pp.115-119
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• 2008

Purpose: We reconstructed the skin defect of hands exposing tendons and/or bone with distally based ulnar artery flap and report our cases. Materials and Methods: Between March 2005 and September 2007, 6 cases of skin defect were reconstructed with distally based ulnar artery flap. Defect site were 5 cases of hand dorsal side and 1 case of hand volar side. The average defect size was $3{\times}3\;cm^2$. There were 4 men and 2 women and mean age was 55.5 years. We evaluated the viability of flap, postoperaive complication, healing time, patient's satisfaction. Results: There was no flap failure in 6 cases. But 1 case with recurrent discharge was healed with several times adequate debridement and delayed suture. 1 case with flap edema which might be due to venous congestion was healed with hand elevation and use of low molecular weight heparin. Mean time to heal the skin defect was 4 weeks. No infection and recurrence was found in follow up period. Cosmetic results as judged by patients were that 3 cases are good and 3 cases are fair. Conclusion: Distally based ulnar artery flap is good treatment method among the numerous methods in the cases of skin defect, with soft tissue exposed, which is not covered with debridment and skin graft. Distally based ulnar artery flap is useful method for the skin defect of hands because it is simple procedure, has constant blood supply and relatively good cosmetic effect.

• Archives of Reconstructive Microsurgery
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• v.17 no.2
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• pp.101-107
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• 2008

Purpose: Free flaps from the great toe are an established method for reconstruction of absent or partially amputated thumbs. However, options differ as to which technique represents the ideal solution for each level of amputation. Various methods of distal thumb reconstruction have been proposed. We prefer to transplant the entire great toe nail complex with the almost all of the pulp rather than a portion of the nail. This paper reflects our experience in using the great toe mini wrap-around flap for distal thumb reconstruction. Materials and Methods: In the period from October of 2005 to July of 2007, 9 patients were treated for traumatic thumb defects localized at the distal phalanx of the thumb. The patients included seven men and two women. The mean age was 44 years (range, 21~60) and the dominant right hand was involved in seven of nine patients. Results: The transferred flaps have survived completely in all cases. The mean range of motion in the interphalangeal joints was 51o, with 73% of the normal uninjured opposite hands. The two-point discrimination was 10.5 mm (range, 5~13 mm). In Semmes-Weinstein monofilament test, the sensibility was 4.31 in 4 cases, 3.61 in 3 cases and 2.83 in 2 cases. The pinch power was 64% (range, 55~95%) of the opposite hand. All patients were satisfied with the appearance of the reconstructed thumb and felt comfortable at final follow-up. Conclusion: We have successfully reconstructed 9 cases of traumatic distal thumb defects using the mini wrap-around free flap. The mini wrap-around free flap in great toe is an excellent alternative method for distal thumb reconstruction in selected patients.

• Archives of Reconstructive Microsurgery
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• v.17 no.2
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• pp.68-74
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• 2008

Segmental defects of the tibia after open fractures, sepsis and a tumor surgery are among the most difficult and challenging clinical problems. Tibia defects in these situations are complicated with infection and are resistant to conventional bone grafting techniques. The aim of this study is to report the results and discuss the role of free flap followed by ipsilateral vascularized fibular transposition (IVFT) for reconstruction of tibia defects. Ten patients had free flap followed by IVFT in the period 1989~2007. Mean age was 25.3 years. The patients were followed for an average of 3.4 years. All flaps were survived including 1 case with venous thrombosis requiring additional surgery. The average time to union of proximal and distal end was 5.2 months, 8.2 months, each other. All transposed fibula were viable at last follow-up. IVFT offers the advantages of a vascularized graft. In patients with large bone and soft tissue defects combined with infection, free flap followed by IVFT is an useful and reliable method without microvascular anastomosis.

• Archives of Reconstructive Microsurgery
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• v.17 no.2
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• pp.75-81
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• 2008

Purpose: The aim of this study was to evaluate the outcome and the effectiveness of local flaps in lower extremity reconstruction. Materials and Methods: We have performed lower extremity reconstruction with local flap in 14 cases (10 males and 4 females) from May 2006 to February 2008. The mean age was 40.1 years (range, 16~67). The defect site was the tibia in 5 cases, the ankle in 1 case and the foot in 8 cases. The local flaps were reverse flow sural artery flap in 7 cases, gastrocnemius flap in 3 cases, lateral supramalleolar flap in 2 cases, dorsalis pedis flap in 1 case and medial hemisoleus flap in 1 case. Results: All flaps were survived. Venous congestion was developed in 1 case of the rerverse flow sural artery flap but healed with secondary rotational flap. Other flaps were good without any complications. Conclusion: If we choose precisely indicated local flap in lower extremity reconstruction, the resultant coverage of defect would be excellent.

• Archives of Reconstructive Microsurgery
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• v.17 no.2
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• pp.94-100
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• 2008

In the past decade, there has been increasing breast reconstructions after mastectomy, and the abdomen has been the gold standard for donor site. TRAM (transverse rectus abdominis myocutaneous), MSTRAM (muscle sparing transverse rectus abdominis myocutaneous), DIEP (deep inferior epigastric artery perforator), SIEA (superficial inferior epigastric artery) flap has been widely used nowadays. Among them, DIEP free flap spares the whole rectus abdominis muscle and anterior rectus sheath resulting in decreased donor site morbidity. Between March of 2006 and February of 2008, six patients had undergone immediate breast reconstructions using DIEP free flap. The mean age of patients was 48.5 years. All patients had unilateral breast reconstructions. We dissected two perforators which were included in the unilateral pedicle. Thoracodorsal artery and its venae comitantes were chosen as recipient vessels. For venous anastomosis, we used the GEM Microvascular Anastomotic Coupler System (Synovis Micro Companies Alliance, Inc., Birmingham, Ala.) in four cases. All flaps were survived completely except one who showed fatty abdomen in old age. She showed repetitive vascular spasm intraoperatively. None of the patients had abdominal hernia, bulge or weakness. We believe that DIEP free flap provides a reliable method for autologous breast reconstruction if the patients are selected appropriately and performed by a skillful surgeon.

• Archives of Reconstructive Microsurgery
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• v.17 no.2
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• pp.82-86
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• 2008

Purpose: Soft tissue defect can occur on the posterior aspect of the elbow after trauma or fracture fixation. To cover the defect and maintain elbow functions, various flap surgeries including latissimus dorsi muscle flap, lateral arm flap and radial forearm flap can be performed. We present the clinical results of transposition lateral arm flap for coverage of the elbow defect and discuss the cause of posterior soft tissue necrosis after fracture fixation. Materials and Methods: Two patients who had posterior soft tissue defect of the elbow after open reduction of the fractures around the elbow were treated with transposition lateral arm flap. The mean size of skin defect was 20 $cm^2$. The flap was elevated with posterior radial collateral artery pedicle and transposed to the defect area. Donor defect was covered with split thickness skin graft. The elbow was immobilized for 1 week in extended position and active range of motion was permitted. Results: All two cases of transposition lateral arm flap survived without marginal necrosis. The average range of motion of the elbow was 10~115 degrees. Mayo elbow performance score was 72 and Korean DASH score was 23. Conclusion: When elbow fractures are fixed with three simultaneous plates and screws, skin necrosis can occur on the posterior aspect of the elbow around olecranon area. If the size of skin defect is relatively small, transposition lateral arm flap is very useful option for orthopaedic surgeons without microsurgical technique.

• Archives of Reconstructive Microsurgery
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• v.18 no.2
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• pp.41-48
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• 2009

There are several advantages for groin flap, but its small and unpredictable vessels of pedicle have made it to lose its initial popularity. Although it would be ideal flap when it is focused on its useful advantages such as relative larger size, low donor site morbidity and possible bone graft, there have been few studies for prognostic factors for successful groin flap. Authors intended to determine prognostic factors which are relative with success of free groin flap. From January 1985 to December 2007, 107 patients who underwent groin flap for reconstruction of extremities were selected consecutively. Univariate and multivariate analysis were performed to determine prognostic factors which were related with success of groin flap. Eighty of 107 (74.8%) flaps survived. There was significant difference in success rate according to the recipient site. Nineteen of 20 cases (95%) survived in upper extremities, but 61 of 87 cases (70.1%) survived in lower extremities, which was statistically significant (p=0.022). Univariate analysis showed that mean diameter of donor veins was significantly larger in success group (p=0.021). Groin flap is recommended for reconstruction of upper extremities than lower extremities. It is thought to be critical that surgeons try to match vessel diameters between donor and recipient site.

• Archives of Reconstructive Microsurgery
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• v.22 no.1
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• pp.13-17
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• 2013

Purpose: Although a fasciocutaneous perforator artery as a vascular pedicle has previously been shown to be predominant in the anterolateral thigh (ALT) flap, recent studies have shown that a myocutaneous perforator artery is predominant. We have attempted to attain a clinical understanding of the vascular variations in the ALT flap. Materials and Methods: We confirmed the origin of a perforator artery in 11 cases of ALT flap. We then reviewed the variations of the descending branch of the lateral femoral circumflex artery, known as the major origin of the flap, and the overall variations associated with an ALT flap. Results: In a total of 11 cases, there were 18 perforator arteries of the ALT flaps. In addition, there were 9 fasciocutaneous perforator arteries and another 9 myocutaneous ones. However, depending on the origin, there was great variability in the perforator artery. That is, there were unique variants in the descending branches of the lateral femoral circumflex artery, the major origin of the perforator artery, in 3 of the total 11 cases. Conclusion: Our results showed that (1) a perforator artery accounts for the high proportion of fasciocutaneous ones, (2) a perforator artery might not originate from the descending branch of the lateral femoral circumflex artery and (3) there might be unique variants in the descending branch. If considering this, surgeons would successfully elevate an ALT flap.

• Archives of Reconstructive Microsurgery
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• v.22 no.1
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• pp.29-32
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• 2013

Purpose: Reconstruction of scalp and calvarial defects should provide both aesthetic and functional aspects. The inelastic nature of the scalp and previous surgery or radiation preclude the use of primary closure or a local flap. With development of microsurgical technique, a free tissue transfer is a good option. We use the latissimus dorsi myocutaneous free flap for reconstruction. Materials and Methods: A review of all latissimus dorsi free flap reconstructions performed in nine patients from 2009 to 2012 was conducted. There were six males and three females, ranging in age from seven to 69 years, and nine different regions, including five temporal regions, two occipital regions, and two frontoparietal regions. The flaps ranged in size from $9.0{\times}10.0cm$ to $14.0{\times}15.0cm$. Recipient vessels available for microanastomosis were most often the superficial temporal vessels and two patients had anastomoses to the external carotid artery and internal jugular vein. Results: All flaps survived postoperatively. With a median follow-up period of 14 months, no major complications were noted. However, two patients developed minor wound dehiscence, and a hematoma was observed in one patient. Conclusion: We performed the latissimus dorsi myocutaneous free flap reconstruction, which is one of the most popular reconstructive methods. The latissimus dorsi myocutaneous free flap reconstruction has been proven successful in our patients with satisfactory results. During the long term follow-up period, even though depressions were observed on the defect area in some patients, they were treated successfully with cranioplasty. Therefore, we recommend the latissimus dorsi myocutaneous free flap for reconstruction of scalp and calvarial defects.