Closure of Sacral Pressure Sores with Bilateral V-Y Advancement Flaps

Hernia Reconstruction with Component Separation and Tensor Fascia Lata Flap

Massive hernias of the abdominal wall may require multiple stages to repair. When repairing hernias, stable soft tissue coverage is important. In patients who have developed a loss of domain because of prior open wounds, a component separation may be employed to recruit more tissue to facilitate closure. Occasionally, in large tumors of the abdominal wall, the plastic and reconstructive surgeon will use the tensor fascia lata muscle from the thigh to close the wound.

The tensor fascia lata is harvested and exposed and then rotated towards the abdomen. The upper border of the abdominal fascia can be closed and the inferior portion can be closed as an underlay with the tensor fascia lata.

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Gastrocnemius Flaps for Coverage of Antibiotic Spacers for Internal Total Knee Replacement

Gastrocnemius flaps are commonly used flaps to cover the proximal aspect of the tibia or distal knee joint. Gastroc flaps have become one of my favorite flaps over the years as they can be readily harvested through an extension of a previous incision.

Care should be taken when harvesting the flap to preserve the saphenous vein as this can significantly help the edema that is often present in the re-operative lower extremity. Furthermore, appropriate preservation is helpful as it may be used as a back-up for venous outflow if free tissue transfer is needed.

I find that one of the most helpful maneuvers in the gastroc flap is to remove the fascia from the under surface of the muscle. This allows for the exposure of a raw surface to adhere to the bone or antibiotic spacer. The raw muscle allows greater contact and exposure of surface area to the underlying object.

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Gastroc Flaps for Coverage of Total Knee Replacements

 



 

 

Knee replacement surgeries are common procedures. Total knee replacement infections can occur between 0.3% and 12.4% for primary TKR and between 1-15% for revision TKR. When total knee infections occur, a multi-stage reimplantation is emerging as the gold standard for the treatment of infected total knees.



The first stage includes the removal of the infected prosthesis and the stabilization of soft tissues. Common flaps that are used around the knee joint include the gastrocnemius muscle flap and occasionally it is appropriate to jump directly to free microvascular tissue transfer.

At the time that the prosthesis is removed, a temporary antibiotic spacer is placed that elutes an antibiotic. Usually the antibiotic is tobramycin and often vancomycin is placed in the cement.

Typically, clinical examinations are followed and laboratory results such as CRP, ESR, and white blood cell count are monitored. Usually after a period of 6-12 weeks when all soft tissues have stabilized and are no longer hostile and an antibiotic course has been completed, then the antibiotic spacer is removed and permanent knee prosthesis is placed.



 

 



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Free Latisimus Muscle Anastomosis to Popliteal Artery

Large radiation wounds or defects of the posterior aspect of the leg require vascularized tissue to heal. The free latisimus flaps offer long vascular pedicles, a significant amount of muscle for coverage.

When no vessels are available in the lower extremity, free tissue transfer can be performed by anastamosing the latisimus muscle flap to the popliteal artery and a saphenous vein branch for arterial outflow.

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Repair of Urethral Fistulas with Free Buccal Mucosal Graft and Gracillis Muscle Flap

Urethral fistulas can be a result of trauma or infection and can be a challenge to close for both the physician and patient. Closure of the wound requires urinary diversion and well vascularized tissue to close the wound. Of paramount importance when repairing urethral fistulas, is that there should be no downstream obstruction, so that a decreased resistance allows closure.

 

When there is a stricture of the urethra, a free buccal mucosal graft from the mouth can be used to substitute for the urinary epithelium. Buttressing of the buccal mucosal graft requires well vascularized tissue. The gracilis muscle is an excellent choice, for bringing in well vascularized tissue into the perineum. Hyperbaric oxygen can be a useful adjunct to faciliate wound closure.

 



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Rectus Muscle Free Flaps for Coverage of Radiated Skull Bone and Cranioplasty Plates

Superficial Temporal Artery and Vein for Recipient Vessels.

The superficial temporal vessels are excellent recipient vessels when planning for free microsurgical tissue transfer of muscle flaps to the skull. The superficial temporal vessels can be easily palpated crossing the zygomatic arch just superior to the root of the ear. The superficial temporal vessels are frequently quite toruous as one dissects proximally. It is perfectly fine to leave the vessel in it's native configuration and anastamose distal to the corkscrew of the artery.



Typically the rectus abdominis muscle provides adequate bulk and surface area to cover plates that are placed on the skull in cranioplasties. The bulk of the muslce helps to obiterate any dead space that may be present after bony debridement.

Once adequte flow is confirmed in the muscle through adequate bleeding and appropriate doppler flow, a skin graft is usually harvested from the lower extremity and then placed on top of the muscle.

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