Five recent examples of the cross-leg flap are presented. Its applications and design have been altered and its versatility widened by using muscle. In all cases the use of a Hoffmann apparatus facilitated not only fixation of the flap but also patient comfort, since ropes attached to side-arm rods can be put over pulleys and weights attached to take the strain off potential pressure points. The technetium scan was helpful in determining when flap division should be done. Flaps were rarely in place more than three weeks before division: often, especially in children, division is possible by two weeks. By clamping the flap with a soft clamp and giving an intravenous bolus of fluorescein, circulation can be ascertained unequivocally. Cross-leg flaps remain a useful and highly reliable tool for the reconstruction of difficult wounds of the lower limb.
Twenty-eight patients treated with free tissue transfer for soft-tissue coverage of the weight-bearing portion of the foot were investigated over a minimum follow-up period of 12 months. Seven were treated with a sensory innervated flap transfer, and 21 had a noninnervated skin or muscle flap transfer. Secondary procedures to debulk or sculpture the flap were necessary in seven patients. Complications occurred in six patients and were either related to lack of protective sensibility (in three) or excessive flap mobility (in three). Impaired flap sensibility was more common in noninnervated flaps, but excessive flap mobility was more typical of cutaneous flaps. The merits of an innervated cutaneous flap, which may be excessively bulky, must be weighed against those of a well-contoured muscle flap without sensory innervation.
It is necessary that the treatment of arteriovenous malformations in general be undertaken by a team that consists of a radiologist who is experienced in angiography and embolization and a plastic surgeon. The latter should be well versed in angiographic techniques and should be able to comprehend the dynamics of these malformations. In this report, three patients with high-flow, high-shunt arteriovenous intraosseous malformations of the head are presented. Two of these presented as emergencies with almost uncontrollable bleeding and were initially treated with embolization and then mandibular resection and reconstruction within the first 48 hours. In one patient, a further reconstructive procedure using free vascularized tissue was carried out. A third patient with involvement of the maxilla, again presenting with bleeding, was treated with embolization and because of the deformity that would be created by resection, was simply observed. However, this patient is to be reassessed in the future and may well come to maxillectomy. It is emphasized that the treatment of these patients requires careful assessment, embolization, and resection as indicated after discussion between radiologist and surgeon.
One hundred muscule flap transfers performed at the Mayo Clinic from 1975 to 1978 are reviewed and assessed as to the cause and location of the defects, muscles used, complications, and results. We found the muscle flaps very versatile for covering for a wide variety of difficult soft tissue and bony defects. The complication rate was very low, considering the severity and chronic nature of the problem. Ninety-two percent of patients showed healing after surgery, and 82% remained healed at the time of this follow-up survey.
A group of patients who underwent free skin or muscle flap transfer to the upper extremity are compared with a similar group who were treated by a conventional distant pedicle skin flap. The most frequent indications for using a free flap technique were the presence of an exoskeletal fixation apparatus at the recipient site which precluded a more conventional procedure, or the desire to obtain an innervated flap for sensibility. The free flap group generally had more massive defects. In this group, the mean initial surgical time was 5.37 hours and total cost was $7,692. An average of 1.58 general anesthetics was required, and the mean postoperative hospilalizalion was 13.08 days. In the conventional distant pedicle flap group, mean initial surgical time was 2.76 hours and total cost was $6,849. An average of 2.54 general anesthetics was required and mean postoperative hospitalization was 19.15 days. All cases had a successful outcome, although the complication rale was slightly higher in the free flap group. Overall, the economic advantage was slightly weighted toward the conventional pedicle flap group, although hospitalization time was longer. Therefore, for the management of soft tissue defects in the upper extremity requiring pedicle flap coverage, a free flap should probably be chosen only for specifìc indications and special circumstances.
Thirty-five patients with difficult wound problems underwent 35 reconstructive procedures using transposed greater omentum. The ages of the 28 female and 7 male patients ranged from 16 to 75 years, with an average of 50.5. At the time of omenlal transposition, 22 patients (63%) had evidence of radiation necrosis complicating their wounds, 24 (69%) had documented infections of their wounds before treatment, 30 (86%) had defects as a direct result of cancer, and 11 (31%) had recurrent carcinoma. The average duration of the defects, which were in the chest or abdominal wall, extremities, or pelvic floor, was 31.7 months. Small secondary revision procedures were occasionally required: however, the omentum remained the final solution to the problem for 26 (74%) of the 35 patients.
