J Reconstr Microsurg 2018; 34(02): 103-107
DOI: 10.1055/s-0037-1606552
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Combined Direct and Indirect Cerebral Revascularization Using Local and Flow-Through Flaps

Beina Azadgoli
1   Division of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
,
Hyuma A. Leland
1   Division of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
,
Erik M. Wolfswinkel
1   Division of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
,
Joshua Bakhsheshian
2   Division of Neurologic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
,
Jonathan J. Russin
2   Division of Neurologic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
,
Joseph N. Carey
1   Division of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
› Author Affiliations
Further Information

Publication History

29 March 2017

31 July 2017

Publication Date:
25 September 2017 (online)

Abstract

Background Extracranial–intracranial bypass is indicated in ischemic disease such as moyamoya, certain intracranial aneurysms, and other complex neurovascular diseases. In this article, we present our series of local and flow-through flaps for cerebral revascularization as an additional tool to provide direct and indirect revascularization and/or soft tissue coverage.

Methods A retrospective review of a prospectively maintained database was performed identifying nine patients. Ten direct arterial bypass procedures with nine indirect revascularization and/or soft tissue reconstruction were performed.

Results Indications for arterial bypass included intracranial aneurysm (n = 2) and moyamoya disease (n = 8). Indications for soft tissue transfer included infected cranioplasty (one) and indirect cerebral revascularization (eight). Four flow-through flaps and five pedicled flaps were used including a flow-through radial forearm fasciocutaneous flap (one), flow-through radial forearm fascial flaps (three), and pedicled temporoparietal fascial (TPF) flaps with distal end anastomosis (five). The superficial temporal vessels (seven) and facial vessels (two) were used as the vascular inflow. Arterial bypass was established into the middle cerebral artery (six) and anterior communicating artery (three). There were no intraoperative complications. All flaps survived with no donor-site complications. In one case of flow-through TPF flap, the direct graft failed, but the indirect flap remained vascularized.

Conclusion Local and flow-through flaps can improve combined direct and indirect revascularization and provide soft tissue reconstruction. Minimal morbidity has been encountered in early outcomes though long-term results remain under investigation for these combined neurosurgery and plastic surgery procedures.

Level of Evidence The level of evidence is IV.

 
  • References

  • 1 Soutar DS, Scheker LR, Tanner NS, McGregor IA. The radial forearm flap: a versatile method for intra-oral reconstruction. Br J Plast Surg 1983; 36 (01) 1-8
  • 2 Bambakidis NC, Chowdhry SA. Cerebral revascularization for ischemic disease in the 21st century. J Neurointerv Surg 2010; 2 (03) 229-236
  • 3 Vajkoczy P. Revival of extra-intracranial bypass surgery. Curr Opin Neurol 2009; 22 (01) 90-95
  • 4 Newell DW. Superficial temporal artery to middle cerebral artery bypass. Skull Base 2005; 15 (02) 133-141
  • 5 Kim T, Oh CW, Bang JS, Kim JE, Cho WS. Moyamoya disease: treatment and outcomes. J Stroke 2016; 18 (01) 21-30
  • 6 Choi IJ, Cho SJ, Chang JC, Park SQ, Park HK. Angiographic results of indirect and combined bypass surgery for adult moyamoya disease. J Cerebrovasc Endovasc Neurosurg 2012; 14 (03) 216-222
  • 7 Houkin K, Kuroda S, Ishikawa T, Abe H. Neovascularization (angiogenesis) after revascularization in moyamoya disease. Which technique is most useful for moyamoya disease?. Acta Neurochir (Wien) 2000; 142 (03) 269-276
  • 8 Mukawa M, Nariai T, Inaji M. , et al. First autopsy analysis of a neovascularized arterial network induced by indirect bypass surgery for moyamoya disease: case report. J Neurosurg 2016; 124 (05) 1211-1214
  • 9 Patel NN, Mangano FT, Klimo Jr P. Indirect revascularization techniques for treating moyamoya disease. Neurosurg Clin N Am 2010; 21 (03) 553-563
  • 10 Macyszyn L, Attiah M, Ma TS. , et al. Direct versus indirect revascularization procedures for moyamoya disease: a comparative effectiveness study. J Neurosurg 2016; 29: 1-7
  • 11 Gazyakan E, Lee C-Y, Wu C-T. , et al. Indications and outcomes of prophylactic and therapeutic extracranial-to-intracranial arterial bypass for cerebral revascularization. Plast Reconstr Surg Glob Open 2015; 3 (04) e372
  • 12 Bernier C, Hsu Y-H, Ali R, Cheng MH. The plastic surgeon's role in extracranial-to-intracranial bypass using a reverse great saphenous vein graft. Plast Reconstr Surg 2009; 123 (02) 517-523 , discussion 524