Thin flaps are useful for reconstruction of exposed regions such as the face, neck and hand. However, the definition and classification of thin flaps differ among surgeons. Thus, we searched previous articles and discussed a new classification method for thin flaps. As a result, thin flaps can be classified anatomically, technically and temporally. These classifications can be mixed, and a new classification of “thin-type flap” and “thinned flap” was proposed. Moreover, “thinned flaps” can be separated into primary thinned flaps, secondary thinned flaps and multiple staged thinned flaps. For example, thin-type flaps include radial forearm flaps and SCIP (superficial circumflex iliac artery perforator) flaps. These flaps are naturally thin without the thinning procedure. The thickness of thin flaps is less than 1 cm. Primary thinned flaps have had fat tissues removed intraoperatively, and secondary thinned-flaps have been thinned before flap transfer, such as some delayed flaps and expanded flaps. Multiple staged thinned flaps include defatted flaps after transplantation.
Several techniques have been reported for smile restoration in patients with facial paralysis. When options in which a nerve other than the contralateral facial nerve is used, such as free muscle transfer with coaptation to the masseter nerve and lengthening temporalis myoplasty (LTM), the majority of these subjects can achieve a spontaneous smile without biting. The plasticity of the cerebral cortex, as well as the relative proximity of the motor centers of the smiling and chewing muscles have been considered; however, the mechanism behind this spontaneity is not well established. The aim of this study was to confirm the manifestation of spontaneity in patients who underwent LTM. The study included 13 patients aged 12 to 74 years (mean 51.3 years), comprising 6 males and 7 females. All 13 temporalis transfer patients developed voluntary movement within 6 weeks, and 7 patients (54%) learned to smile without biting. Age affected the manifestation of spontaneous smiling (p=0.007). Neither gender nor duration of facial paralysis before the operation significantly affected spontaneity; however, females developed spontaneous smile more often than males.
Sixty-four patients with functional disabilities of the upper extremities underwent wide-awake tendon transfer between 2003 and 2015. Forty-one patients were male, and the average patient age was 55 years (range: 17-84 years). Under local anesthesia (lidocaine with epinephrine), all transferred tendons were routed subcutaneously and woven into the recipient tendons. Restored hand function was confirmed in all patients before skin closure. During the operations, 59 patients who underwent tendon transfers using synergists (e.g. the extensor carpi radialis longus to the flexor digitorum profundus) or proximity donors (e.g. the extensor indicis proprius to the extensor pollicis longus), were immediately able to use the reconstructed hand without delay. The remaining five patients who underwent the brachioradialis transfer to the flexor pollicis longus, the palmaris longus transfer to the flexor pollicis longus, or the extensor digiti minimi transfer to the extensor pollicis longus were unable to perform thumb flexion or extension during surgery, but they all exhibited the full range of thumb motion at the final evaluation. We consider tendon transfer to be unaccompanied by immediate functional switching during surgery, but as it was later found to be successful, it may reflect brain plasticity.
Between 1996 and 2016, we treated 36 cases of fracture nonunion and bone necrosis using free vascularized bone grafts from the medial supracondylar region of the distal femur. The nonunion cases consisted of 16 in the scaphoid, 6 in the forearm (3 each for the radius and ulna), 4 talar necrosis cases, 3 tibial nonunion cases, 3 in the lunate (Kienböck's disease), 2 humerus, and 1 each for the finger phalange and trochanter of the femur. All nonunion cases except three scaphoid cases achieved bony union. Two cases of talar necrosis healed completely. One talus healed with small collapse. The other talar necrosis cases had moderate collapse with osteoarthritis. Two Kienböck's disease cases healed with small collapse. The other developed severe collapse with osteoarthritis. We suggest that this procedure is good for patients with scaphoid nonunion, long bone nonunion with small bone defects, or talus necrosis. However, we do not recommend this procedure for patients with Kienböck's disease.
The reverse digital artery flap (RDAF) is useful for skin coverage of the finger, but postoperative flap congestion is a serious problem. The degree of flap congestion varies with the type of injury and may affect the treatment for congestion. We examined the treatment outcomes of 24 fingertips by separating them by the type of injury based on the presence of a narrow skin bridge. There were 13 cases in the crush group and 11 cases in the avulsion group. Congestion was confirmed in half of the crushed skin bridge ( - ) group. In the crushed skin bridge ( + ) group, congestion was not observed. In the avulsion skin bridge ( - ) group, congestion was observed in all cases. In the avulsion skin bridge ( + ) group, low grade congestion was observed. A RDAF will adequately survive without the skin bridge in crush injuries, but congestion can be avoided by attaching the skin bridge. In the case of avulsion injury, the flap can survive, but congestion cannot be avoided only with a skin bridge, and it is likely that a wider skin bridge or subcutaneous venous network will be needed.
Background: The distal tibia is prone to open fracture with bone loss because of its anatomical characteristics. These injuries are commonly associated with complications such as non-union and bone necrosis. The pedicled vascularized bone flap harvested from the distal tibia is one of the alternative methods to overcome these complications. Methods: Seven fresh cadaveric lower extremities were dissected following injection of silicon compounds into the femoral artery. We investigated the number, location, and diameter of the nutrient communicating branches of the posterior tibial perforator and peroneal artery to the distal tibia. We elevated the bony flap (5 × 1 × 1 cm) from the medial distal tibia and measured the location it reached. Results: The mean number and diameter of nutrient branches to the tibia from the peroneal artery were 1 and 0.96 mm, respectively, and those from the posterior tibial artery were 1.1 and 0.83 mm, respectively. These branches constantly communicated and ran through the medial aspect of the distal tibia. The bony flap reached a mean of 16 cm from the proximal to distal edge of the medial malleolus. Conclusions: The posterior-medial aspect of the distal tibia was consistently nourished from communicating branches of the peroneal artery and posterior tibial artery. Vascularized bone grafts can be harvested from this region.
Sixteen proper digital nerves in 14 patients who underwent nerve repair surgery using autologous nerve grafts between July 2012 and September 2017 were investigated retrospectively. For the autologous nerve graft, the posterior interosseous nerve was used in 4 cases, the lateral antebrachial cutaneous nerve in 4, the medial antebrachial cutaneous nerve in 1 and the sural nerve in 7. The mean distance from the fingertip to the nerve repair site was 68.1 mm, and the mean length of the nerve graft was 23.4 mm. After a mean 20.5 months (6-56 months) of follow-up, 4 nerves were red, 9 were purple and 3 were blue on the Semmes-Weinstein test, and the mean static 2PD and moving 2PD were 11.0 mm and 9.2 mm, respectively. On statistical analysis, there was a strong correlation between the duration from injury to operation and both 2PD values (p<0.01), a moderate correlation between the length of the nerve graft and static 2PD (p<0.05), and a moderate correlation between the distance from the fingertip to the nerve repair site and static 2PD (p<0.05). For a good postoperative outcome, shorter and earlier nerve graft reconstruction was performed, which improved sensory recovery.
There is currently no effective adjuvant therapy for chondrosarcoma, and the operations are basic and only therapeutic. For surgical treatment, wide resection is required, but this leads to marked functional loss and requires reconstruction surgery. For malignant bone tumors located around the glenohumeral joint, total shoulder arthroplasty, resection arthroplasty or amputation is selected. Recently, there have been many reports of reconstruction using autogenous bone devitalized with liquid nitrogen after wide resection of malignant soft and bone tumors. Moreover, the combination of autogenous bone treated by liquid nitrogen and vascularized bone graft has been reported. Vascularized bone grafts are more effective for bone union and regeneration of devitalized bone treated by liquid nitrogen. We used this combined technique for a chondrosarcoma located in the coracoid process. Two years after the operation, the shoulder function was excellent. There were no effects on activities of daily life. This case demonstrated that vascularized iliac bone grafts combined with autogenous bone devitalized by liquid nitrogen for the reconstruction of wide bone and joint defects after resection of bone tumors can provide good postoperative function.
Defects of finger dorsal skin often include defects of the extensor tendon, and adhesion is a severe problem during reconstruction. We consider vascularized tendons able to reduce adhesion and improve the recovery of motor function. Therefore, we reconstructed defects of finger dorsal skin and the extensor tendon using dorsal metacarpal flaps with extensor indicis proprius (EIP). We report two cases of dorsal metacarpal flaps with EIP for defects of finger dorsal skin and the extensor tendon. The clinical course and findings are presented. In one case, the patient was a 31-year-old male who had right index finger injuries. In the other case, the patient was a 72-year-old male who had right middle finger injuries and infection. All of the flaps survived completely and recovery of motor function was satisfactory in both cases. We conclude that the dorsal metacarpal flap with EIP is useful for patients with defects of finger dorsal skin and the extensor tendon.
A 27-year-old woman was injured on her right forearm by a conveyor belt. The distal part of her radius, ulna, a part of her skin and adipose tissue were absent, and tendons and nerves remained but were severely damaged. Four days after the injury, we performed bone reconstruction with a free vascularized fibula flap. However, adhesion of the flexor tendons and median nerve occurred despite aggressive rehabilitation. Three months after the injury, tenolysis and neurolysis were performed, and the peeled tendons and median nerve were wrapped by a double-layered free temporal fascia flap. 54 weeks after the operation, the flexor tendons had good excursion, but paresthesias remained in a part of the median nerve region. Adhesions are a frequent complication after trauma in the distal part of the forearm. Several methods to treat this complication have been reported such as wrapping the nerves and tendons with thin and well-vascularized tissue. We report a case in which free vascularized double-layered adipofascial tissue from the temporal region was wrapped. Although the patient continued to experience paresthesias, we consider this procedure to be useful in cases in which the adhesions occur over a wide area.
A 48-year-old, right-handed man sustained a degloving injury to the middle finger. He lost the bone distal to the distal part of the middle phalanx and the soft tissue distal to the proximal interphalangeal (PIP) joint. We planned to use two regional flaps to reconstruct the wide skin defect. To cover the volar loss of skin, the cross finger flap from the dorsal index was selected. For the dorsal loss of skin, we devised an extended dorsocommissural flap, which was harvested with the pivot point at the radial neck of the proximal phalanx as an axial pattern flap nourished by the dorsal metacarpal artery between the second and third metacarpals. The flaps survived after surgery. The patient returned to work three months after the injury. His Quick Disabilities of the Arm, Shoulder, and Hand score was 6.82. The extended dorsocommissural flap from the dorsum of the hand with the cross finger flap from the neighboring finger was suggested to be effective to cover the wide circumferential loss of skin in the distal region of the finger.
The free radial forearm flap is the main flap for head and neck reconstruction. However, it is associated with considerable morbidity at the donor site. A skin graft is a common way of closing the donor site, but complications, such as tendon exposure, occasionally occur. Several techniques for avoiding these donor site complications have been reported. We herein report the first use of a superficial circumflex iliac artery perforator (SCIP) flap to close the donor site defect after radial forearm flap elevation. In the present case, a SCIP flap was elevated above the superficial fascia as a thin flap, and the pedicle diameter was 0.5 mm. The SCIP flap was transplanted to the defect and anastomosed using a supermicriosurgical technique. The flap survived completely, and neither tendon exposure nor skin contraction have occurred. These findings suggest that a SCIP flap is a good option for closing the donor site of a free radial forearm flap.