|Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.|
| The Groin Flap
Cutaneous flaps were among the first generation of microvascular transplants to be moved from the experimental laboratory to the clinical arena.1,2 The early models set up by Milton,3 Goldwyn, Lamb, and White,4 Kreizek et al.,5 Daniel and Williams,6 and Buncke and Schulz 7 all stress the importance of including a direct cutaneous artery in the pedicle. Unfortunately, many of these key vessels are small and do not have a predictable origin or course. Their elevation and dissection can be tedious, particularly in young individuals. Loupe magnification is imperative to allow careful visualization of the vessels and to prevent damage. One should always try to do several preliminary dissections of each proposed flap in the anatomic laboratory or morgue before a clinical attempt. This exercise, more than anything else, helps one to appreciate the variability of a flap's vascular supply.
Cutaneous flaps are indicated in reconstructive problems when simpler techniques such as local flaps, direct closure, or free skin grafting are not possible or desirable. The indications for cutaneous free flaps are the same as for pedicled flaps, although factors such as the patient's age and general health, the location of the defect, the nature of the defect, and available facilities influence the decision of whether to use a free or pedicled flap. Free-cutaneous-flap transplantation should be considered in the following
1. When coverage of exposed bone, tendon (if paratenon is lost, nerve, or other vital structure is necessary, or in reconstruction of an area in which further surgery is anticipated.
2. When conventional pedicled skin flaps have failed or are too unreliable, or when the period of immobilization with a pedicled flap would be detrimental to the joints or general health of the patient.
3. When the donor defect from an adjacent or distant traditional flap would be unacceptable.
4. When sensation is required, cutaneous flaps such as the lateral arm, radial forearm, dorsalis pedis, groin, first-web space of the foot, and toe neurovascular-island flaps can be used.
Cutaneous free flaps are probably less often indicated than highly vascular muscle transplants in patients with infection because of poorer vascularity of the subcutaneous fat. Our clinical experience, supported by the experimental work of Chang and Mathes,8 has been that cutaneous flaps seem to be less resistant to infection and subsequent necrosis.
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