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Staged distant muscle flap transfer using a forearm carrier
British JournalofPlasric Surgery(l992). 45.618619 0 1992 The British Association of Plastic Surgeons
Letters to the Editor
Staged distant muscle flap transfer using a forearm carrier Sir, The jump flap concept for distant transfer of cutaneous flaps has deservedly been relegated as an historical curiosity, as have most multistaged flap procedures. However, in an extremely unusual situation, this principle was modified for the unique conveyance of a muscle flap, using the forearm as an intermediate carrier in a patient with open thoracic abdominal cavities from a gunshot wound (Figs 1, 2). This obsolete alternative was considered only as a last resort to obtain the known advantages of a muscle flap within a contaminated milieu (Chang and Mathes, 1982), as local flaps were unavailable due to the nature of the injury, and the risks of microsurgery were unacceptable in this moribund patient. Although the extracorporeal transfer of muscle flaps in two stages has been previously successful as an interpolation flap to immediately adjacent regions (Sadove et al., 1991), attachment of a muscle first to an extremity carrier as a jump flap requiring repeated episodes of neovascularisation, permits even more distant transfer. A skin component was included for monitoring the progression and perhaps enhancement of neovascularisation (Millican and Poole, 1985) required at each step in the transfer. The disadvantage of any multistaged flap transfer have been well documented, although most microsurgeons have little direct exposure. The extensive immobilisation, discomfort, prolonged hospitalisation, and economic factors that must be borne all justify the priority of the free flap. However, the constraints of an non-ideal situation someFig. 2 Figure 2-Ultimate result 6 months after injury, with successful cover of the visceral cavities and healed skin wounds, albeit requiring 3 surgical stages over a period of 50 days.
times demand less than satisfactory and perhaps even archaic solutions. Yours faithfully, Geoffrey G. Hallock, MD, Division of Plastic Surgery, William Hoff, MD, Trauma Fellow, Dept of Surgery, Lehigh Valley Hospital, Allentown, Pennsylvania, USA Fig. 1
References
Figure l--Satisfactory neovascularisation of a latissimus dorsi flap via the forearm, at 4 weeks. The thoracodorsal pedicle was divided with total survival of the latissimus dorsi muscle (arrow shows the interface of skin component of flap and that of forearm).
Chang, N. and Mathes, S. J. (1982). Comparison of the effect of bacterial inoculation in musculocutaneous and random-pattern flaps. Plastic and Reconstructive Surgery, 70, 1,
618
619
Letters to the Editor Milliean,
P. G. and Poole,
M. D.
(1985). Peripheral neovascu-
larisation of muscle and musculocutaneous flaps. Brifish Journal IJ/ Plaslic Surgery, 38. 369. H. C., Arthur, K. R., Draud, J. W. and (1991). Immediate closure of traumatic upper arm and forearm injuries with the latissimus dorsi island myocuta-
Sadove.
R. C., Vasconez,
Burgess, R. C.
neous pedicle Rap. Plastic and Reconslructive Surgery. 88. 115.
W. E. and James, J. H. (1992). Cancrum Oris: functional and cosmetic reconstruction in patients with ankylosis of the jaws. British Journal of Plastic Surger?. 45, 193.
AdamsRay,
Coleman, J. J., Jurkiewicz, M. J., Nahai, (1983). The platysma musculocutaneous
F. and Mathes,
S. J.
flap: experience with 24 cases. PInstic and Reconstructive Surger!, 72. 3 15.
Dijkstra, R., Abate-Green, C. and You, M. C. ( 1986). Noma. European Journal of Plastic Pwgery, 9. 46. Juri, J. and Juri, C. (1979). Advancement and rotation of a large cervicofacial flap for cheek repairs. Pla.vric md Remnvrructirv Surgery. 64. 692.
Cancrum oris reconstruction Sir, I read the paper on cancrum oris by Mr Adams-Ray and Mr James with considerable interest (British Journal of Plastic Surger!,, 45, 193). I have had the occasion to operate on a number of cancrum oris patients in Ethiopia, 27 of whom had an ankylosis of the jaws. By trial and error I came to the same conclusion as the authors: cervical skin flaps are the first choice for reconstruction of oral lining in moderately sized defects, and pectoralis major flaps are best for large intraoral defects. However, it is not necessary to delay the cervical flap. This flap can be raised and transferred intraorally as a platysma island flap (Coleman et aI., 1983). In my cases 18 platysma flaps were used, of which one developed complete necrosis of the skin paddle and two resulted in partial skin loss of about 25%. As the authors mention partial loss of one of their 7 cervical flaps, there is no obvious advantage in the delaying procedure. Using the platysma flap for lining with the cervicofacial rotation flap (Juri and Juri. 1979) for cover, the reconstruction can in most cases be completed as a one stage procedure (Dijkstra et al., 1986). I was very pleased that the authors also have used this cervicofacial rotation flap which yields an astonishingly large surface area of skin, mostly without having to graft a donor defect. In my series I used 17 cervicofacial rotation flaps and only 6 DP flaps. It was stimulating to learn that, apart from minor variations, the authors had arrived at the same basic approach to cancrum oris reconstruction as 1 have. Yours fdithfully. R. Dijkstra, Plastic Surgeon. Centrum voor Plastische-. Reconstructievechirurgie. Sophia Ziekenhuis, Ziekenhuis De Weezenlanden. Zwolle. The Netherlands,
References
en Hand-
The Strangeness of Reversed Images Sir. Hearing the mother of a young man with a unilateral cleft lip say that the asymmetry of his nose looked much worse in a mirror. and having often heard patients with nasal asymmetry remark how much worse they look in photographs (compared to the mirror), the explanation falls neatly into place that in both cases the visual cortex becomes accustomed to the most commonly seen view (for the patient the mirror image, for the onlooker the correct image) but reversal of this it can’t discount so readily. Could we therefore, by restricting mirrors and photographs appropriately, reduce the need for surgery in mild asymmetry‘? (only joking!),
Tim Milward, The Leicester Royal Infirmary, Leicester, LEI 5WW
Brian Sommerlad, St Andrew’s Hospital, Stock Rd. Billericay, Essex, CM12 OBH. UK
Letters to the Editor
Staged distant muscle flap transfer using a forearm carrier Sir, The jump flap concept for distant transfer of cutaneous flaps has deservedly been relegated as an historical curiosity, as have most multistaged flap procedures. However, in an extremely unusual situation, this principle was modified for the unique conveyance of a muscle flap, using the forearm as an intermediate carrier in a patient with open thoracic abdominal cavities from a gunshot wound (Figs 1, 2). This obsolete alternative was considered only as a last resort to obtain the known advantages of a muscle flap within a contaminated milieu (Chang and Mathes, 1982), as local flaps were unavailable due to the nature of the injury, and the risks of microsurgery were unacceptable in this moribund patient. Although the extracorporeal transfer of muscle flaps in two stages has been previously successful as an interpolation flap to immediately adjacent regions (Sadove et al., 1991), attachment of a muscle first to an extremity carrier as a jump flap requiring repeated episodes of neovascularisation, permits even more distant transfer. A skin component was included for monitoring the progression and perhaps enhancement of neovascularisation (Millican and Poole, 1985) required at each step in the transfer. The disadvantage of any multistaged flap transfer have been well documented, although most microsurgeons have little direct exposure. The extensive immobilisation, discomfort, prolonged hospitalisation, and economic factors that must be borne all justify the priority of the free flap. However, the constraints of an non-ideal situation someFig. 2 Figure 2-Ultimate result 6 months after injury, with successful cover of the visceral cavities and healed skin wounds, albeit requiring 3 surgical stages over a period of 50 days.
times demand less than satisfactory and perhaps even archaic solutions. Yours faithfully, Geoffrey G. Hallock, MD, Division of Plastic Surgery, William Hoff, MD, Trauma Fellow, Dept of Surgery, Lehigh Valley Hospital, Allentown, Pennsylvania, USA Fig. 1
References
Figure l--Satisfactory neovascularisation of a latissimus dorsi flap via the forearm, at 4 weeks. The thoracodorsal pedicle was divided with total survival of the latissimus dorsi muscle (arrow shows the interface of skin component of flap and that of forearm).
Chang, N. and Mathes, S. J. (1982). Comparison of the effect of bacterial inoculation in musculocutaneous and random-pattern flaps. Plastic and Reconstructive Surgery, 70, 1,
618
619
Letters to the Editor Milliean,
P. G. and Poole,
M. D.
(1985). Peripheral neovascu-
larisation of muscle and musculocutaneous flaps. Brifish Journal IJ/ Plaslic Surgery, 38. 369. H. C., Arthur, K. R., Draud, J. W. and (1991). Immediate closure of traumatic upper arm and forearm injuries with the latissimus dorsi island myocuta-
Sadove.
R. C., Vasconez,
Burgess, R. C.
neous pedicle Rap. Plastic and Reconslructive Surgery. 88. 115.
W. E. and James, J. H. (1992). Cancrum Oris: functional and cosmetic reconstruction in patients with ankylosis of the jaws. British Journal of Plastic Surger?. 45, 193.
AdamsRay,
Coleman, J. J., Jurkiewicz, M. J., Nahai, (1983). The platysma musculocutaneous
F. and Mathes,
S. J.
flap: experience with 24 cases. PInstic and Reconstructive Surger!, 72. 3 15.
Dijkstra, R., Abate-Green, C. and You, M. C. ( 1986). Noma. European Journal of Plastic Pwgery, 9. 46. Juri, J. and Juri, C. (1979). Advancement and rotation of a large cervicofacial flap for cheek repairs. Pla.vric md Remnvrructirv Surgery. 64. 692.
Cancrum oris reconstruction Sir, I read the paper on cancrum oris by Mr Adams-Ray and Mr James with considerable interest (British Journal of Plastic Surger!,, 45, 193). I have had the occasion to operate on a number of cancrum oris patients in Ethiopia, 27 of whom had an ankylosis of the jaws. By trial and error I came to the same conclusion as the authors: cervical skin flaps are the first choice for reconstruction of oral lining in moderately sized defects, and pectoralis major flaps are best for large intraoral defects. However, it is not necessary to delay the cervical flap. This flap can be raised and transferred intraorally as a platysma island flap (Coleman et aI., 1983). In my cases 18 platysma flaps were used, of which one developed complete necrosis of the skin paddle and two resulted in partial skin loss of about 25%. As the authors mention partial loss of one of their 7 cervical flaps, there is no obvious advantage in the delaying procedure. Using the platysma flap for lining with the cervicofacial rotation flap (Juri and Juri. 1979) for cover, the reconstruction can in most cases be completed as a one stage procedure (Dijkstra et al., 1986). I was very pleased that the authors also have used this cervicofacial rotation flap which yields an astonishingly large surface area of skin, mostly without having to graft a donor defect. In my series I used 17 cervicofacial rotation flaps and only 6 DP flaps. It was stimulating to learn that, apart from minor variations, the authors had arrived at the same basic approach to cancrum oris reconstruction as 1 have. Yours fdithfully. R. Dijkstra, Plastic Surgeon. Centrum voor Plastische-. Reconstructievechirurgie. Sophia Ziekenhuis, Ziekenhuis De Weezenlanden. Zwolle. The Netherlands,
References
en Hand-
The Strangeness of Reversed Images Sir. Hearing the mother of a young man with a unilateral cleft lip say that the asymmetry of his nose looked much worse in a mirror. and having often heard patients with nasal asymmetry remark how much worse they look in photographs (compared to the mirror), the explanation falls neatly into place that in both cases the visual cortex becomes accustomed to the most commonly seen view (for the patient the mirror image, for the onlooker the correct image) but reversal of this it can’t discount so readily. Could we therefore, by restricting mirrors and photographs appropriately, reduce the need for surgery in mild asymmetry‘? (only joking!),
Tim Milward, The Leicester Royal Infirmary, Leicester, LEI 5WW
Brian Sommerlad, St Andrew’s Hospital, Stock Rd. Billericay, Essex, CM12 OBH. UK