Free Your Mind, Not Your Flap

Abstract

The pedicled flap has been a mainstay of soft tissue reconstruction since the earliest days of plastic surgery. Advances in surgical technology and skill have led to an erosion in the use of pedicled flaps in favor of increasingly popular free tissue transfers. Still, regional flaps without microvascular anastomosis remain a valuable reconstructive tool. Although still requiring microsurgical skills, these flaps are of particular benefit in patients with few or poor quality recipient vessels, in those who cannot tolerate antiplatelet therapy, and in those who cannot tolerate the often-extended anesthesia time necessitated by microvascular anastomosis. Furthermore, pedicled flaps may significantly reduce total cost of a reconstruction procedure with similar outcomes. In this case series, we report challenging scenarios where microsurgical approaches may have been typical choices but were instead reconstructed by pedicled options with desired outcomes. Difficult soft tissue defects were successfully reconstructed with a variety of pedicled flaps. Soft tissue transfers to the abdomen, flank, shoulder, and back are presented. None of the reconstructions required microvascular anastomosis.

Fig. 1.

Pedicled scapula tip flap for shoulder arthrodesis. A, Isolated scapula tip flap on angular branch pedicle. B, Pedicled scapula tip flap after inset to shoulder fusion site.

Fig. 2.

TRAM reconstruction of flank defect. A, Defect following resection of flank sarcoma. B, Isolated bipedicled TRAM flap before rotation and inset.

Fig. 3.

Total thigh flap for recurrent flank defect. A, Marked total thigh flap. B, Isolated total thigh flap before rotation and inset. C, Total thigh inset into defect with split-thickness skin grafting to donor site. D, Two month follow-up with excellent healing of flap and donor site.

Fig. 4.

Seven-centimeter tibia defect with antibiotic spacer in place.

Fig. 5.

Reverse pedicled osteocutaneous fibula flap for mid-tibia defect. A, Markings for reverse pedicled fibula flap. B, Elevated reverse fibula flap before transfer. C, After fibula bone flap inset with skin paddle shown before inset.

Fig. 6.

Penile skin and urethral defect before urethral reconstruction.

Fig. 7.

Buried abdominal wall flap for penile reconstruction. A, Penis after placement within abdominal wall flap. B, Six weeks before elevation of flap. C, After elevation of penis and flap.

Fig. 8.

One-year follow up with excellent flap healing.

Fig. 9.

Maxilla defect following excision of invasive squamous cell carcinoma.

Fig. 10.

Prelaminated, expanded submental flap for midface reconstruction. A, Following flap elevation with tissue expander and full-thickness skin graft before placement. B, Following tissue expansion and flap prelamination just before rotation and inset.