Distally-based forearm flow-through flaps for emergency finger revascularization.

目的 探讨游离肩胛皮瓣在修复手腕部软组织缺损中的应用价值.方法 1997年1月至2002年6月,用游离肩胛皮瓣修复手腕部软组织缺损25例,其中单纯手背侧缺损14例,手背、腕背均缺损9例,手掌侧缺损2例.按常规切取游离肩胛皮瓣,面积最大23cm×12cm,最小8cm×6cm;以旋肩胛动脉为血管蒂,蒂长4～6cm,平均5.1cm.结果 25例皮瓣全部存活,其中1例术后出现动脉危象,手术探查证实为吻合口栓塞,取栓后重新吻合血管,皮瓣存活.术后随访6个月～3年,皮瓣色泽、质地良好,厚度适宜.结论肩胛皮瓣血供可靠,切取方便,是修复手腕部软组织缺损较理想的皮瓣,可作为修复手背部软组织缺损的首选皮瓣。

BackgroundSoft tissue necrosis following total knee arthroplasty (TKA) may be the cause of the devastating complication of deep infection. It necessitates an immediate operative intervention because it could potentially jeopardise the arthroplasty or even the limb.MethodsSixteen consecutive patients with a mean age of 73,8 years (range 47 to76 years) over a 6-year period (January 2003 to December 2008) with wound dehiscence after TKA were enrolled in the present study. Unilateral or bilateral fasciocutaneous V-Y flaps that are differently oriented, depending on the local conditions of the tissues were used to reconstruct the soft tissues defects.ResultsIn 15 of the 16 cases studied, the wound was successfully covered with the presented technique while in 1 patient a partial flap loss occurred, which was healed after surgical debridement and the application of vacuum system. No other complications occurred. Knee prosthesis was salvaged in all the patients with a good functional and esthetical outcome.ConclusionsThe presented reconstructive technique is a simple, quick, versatile and reliable solution for the coverage of soft tissue defects following TKA, more than 2 cm width and grade 1 and 2 according to Laing classification, provided the V-Y flaps are applied early in the postoperative period and no complex defects are involved.

Fasciocutaneous flaps are available anywhere in the body, literally from head to foot. Some hair-bearing flaps, the parasternal flap, and some forearm and lower extremity flaps may be useful for coverage of soft tissue defects when a relatively simple one-stage procedure is preferred. The fasciocutaneous flaps described here are long and narrow, with a length to width ratio of up to 5:1. Although these flaps are not the ultimate solution to all reconstructive problems, they are especially useful in the treatment of burn scar contractures and chronic ulcerations such as those that result from the extravasation caused by chemotherapeutic agents. Of particular importance is the fact that the use of these flaps does not preclude the use of other flaps later, should this be necessary. Specific indications for these flaps must always be kept in mind in relation to other reconstructive alternatives.

Sir: Danker’s team has recently published their valuable study of the recipient vessels in phalloplasty.1 Our plastic and reconstructive department had performed more than 300 phalloplasties in Shanghai since 1984,2 and we would like to share our experience on the topic regarding the article “Technical Description and Microsurgical Outcomes in Phalloplasty Using the Deep Inferior Epigastric Artery and Locoregional Veins.” Phalloplasty aims to construct a sensate phallus that can achieve sexual penetration and standing micturition. Although the donor-site injury is obvious for radial forearm free flap phalloplasty, it is still the most suitable technique for patients because of the stable blood supply, good sensation, and thin subcutaneous layer of fat, which can mostly be used to reconstruct the urethra through tube-in-tube technique in a one-stage operation.3 The cephalic vein provides the main backflow, and two venae comitantes are also necessary to keep sufficient blood flow balance of a reconstructed phallus. Previously, we have reported a new phalloplasty procedure in which a free forearm flap is combined with a dorsalis pedis flap. The deep inferior epigastric artery was used as the recipient vessel in these case series, and one of the 14 patients had partial flap loss in the distal part of the dorsalis pedis flap.4 We had a similar experience, namely, that most of the complications of free flaps were related to venous complications in phalloplasty. In our strategy, both for single forearm flaps and combined flaps, we usually dissect three veins, including the cephalic vein and the two venae comitantes of the forearm flap for anastomoses. In the recipient site, two venae comitantes of the deep inferior epigastric artery, together with the superficial epigastric vein, can be used to match the three veins from the forearm flap. We prefer the superficial epigastric vein over the greater saphenous vein because the superficial epigastric vein is closer to the deep inferior epigastric artery and the diameter is suitable for end-to-end anastomose. The deep inferior epigastric artery connected to the radial artery can provide a reliable arterial supply; meanwhile, a three-vein backflow system can minimize the risks of venous complications. In our experience, approximately 3 to 4 percent of patients had partial flap loss with this technique in radial forearm free flap phalloplasty. Last but not least, validated tools such as the SPY system (Novadaq Technologies, Inc., Richmond, British Columbia, Canada) are very helpful for observing the blood flow changes and the stages of the flap perfusion in the operation.5 For radial forearm free flap phalloplasty with tube-in-tube technique, the flaps fold twice for reconstructing the urethra and shaft, which would easily cause venous complications after surgery. Objective estimation of the flap perfusion after shaping would further decrease the rate of flap loss in phalloplasty. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Chen Cheng, M.D.Yingfan Zhang, M.D.Yang Liu, M.D., Ph.D.Department of Plastic and Reconstructive SurgeryShanghai Ninth People’s HospitalShanghai Jiao Tong University School of MedicineShanghai, People’s Republic of China

Coverage of soft tissue defects in the thumb: Essential flaps in daily practice

Flap coverage of soft tissue defects on both surfaces of the hand or of nonadjacent defects in the hand is a challenge. Two flaps are needed or if a single flap is used, the intervening normal area or part of the flap must be deepithelialized or the flap tunneled under the normal bridge segment. We are presenting a new technique whereby the hypogastric flap based on the superficial inferior epigastric artery is split into 2 components for the coverage of such defects. The hypogastric flap is separated into a cutaneous component and an adipofascial component at the level of Scarpa fascia. The flaps are separated almost to the base to increase mobility. Now it can be used to cover 2 defects separated by 5 to 7 cm or for defects in the dorsum and the palm. We have used it in 3 patients, in 2 for the coverage of palmar and dorsal aspect of the hand and in one for the coverage of nonadjacent defects on the dorsum of the hand and distal forearm after postburn contracture release. We achieved good results with no flap-related complications.

Background: This study aimed to determine the reliability of perforator pedicled propeller flap for coverage of wounds around the ankle. Materials and Methods: This was a prospective study undertaken between September 2017 and November 2018 in the Division of Plastic and Reconstructive Surgery of our institution. Patients with soft-tissue defect of the ankle referred from the Division of Orthopedic Surgery were included. Those with a scarring in the region of calf in the area of proposed flap were excluded. A detailed history and examination were recorded. A complete blood count, kidney and liver function tests, coagulation profile, and hepatitis B and C and human immunodeficiency viral marker testing were performed following informed consent. Anteroposterior and lateral radiographs of the ankle were taken in all cases. Perforator pedicled propeller flaps were raised in all patients for coverage of soft-tissue defects around the ankle. All patients were followed up regularly. Results: Ten patients with soft-tissue defect around the ankle were referred to our division from the Division of Orthopedic Surgery or admitted through the outpatient department of the Division of Plastic and Reconstructive Surgery of our institution. Eight patients were male and two were female, with the age ranging from 10 to 50 years. The mean operation time was 58 min. Size of the flap varied from 21 cm × 8 cm (168 cm2) to 8 cm × 5 cm (40 cm2). Flaps were rotated through 110°–180°. Out of ten flaps, eight flaps survived completely without any complications. Partial flap loss was found in one patient (10%), marginal flap necrosis in one patient (10%), and none of the flap was lost completely. Thus, the overall success rate of perforator pedicled propeller flap in our study observed was 80%. Conclusion: The perforator-based propeller flap is a versatile and reliable flap for the coverage of soft-tissue defects around the ankle because its vascularity is predictable.

Objective. Hand injuries in children are quite common. Most challenging within plastic and reconstructive surgery/reconstructive microsurgery expertise were there traumatic hand defect and upper extremities open injuries sequels. There were wide variety of reconstruction techniques to deal with hand defects in general and with distal phalanx defects particularly. The core problem is how to make very choice of reconstructive method and technique from diversity of local, regional and distant flaps. Injuries of distal phalanges are the most common type of hand trauma in children. The problem of coverage of soft tissue defects of distal phalanges remains actual. A lot of methods of coverage of distal phalanges defects are developed. There is no generally accepted approach or an algorithm in the treatment of adults and children with such type of trauma.Material and methods. In the period from 2018 to 2021 at the Microsurgery Department of N.F. Filatov Moscow Clinical Hospital for Children 152 surgical operations using local (68), regional (72) and distant (12) flaps were performed.Results. All flaps in all patients within our clinical series have survived. There were neither major complication no secondary revisional procedures. Used different flaps in general provided transport of adequate viable donor tissues to recipient areas of critical functional significance. The selection of particular flap we have been making on individual basis mostly depending on type and injury severity, and functional requirement and prognosis.Conclusion. We are considering surgeon’s own experience is main defining factor to make selection of certain method from the diversity of different flaps.

The leg consisted of a tight skin envelope directly covering bone and musculotendinous structures. Soft tissue defects in this area were difficult to repair because of the poor blood supply to the skin and the limitations imposed in designing reliable flaps. Several kinds of new reconstructive procedures for coverage of the leg were introduced.11 patients were treated with different flap transfers for soft tissue defects of the leg, between 1980 and 1983 at the Yamaguchi University School of Medicine.There were 5 free flaps, 4 pedicle skin flaps and 2 muscle flaps. All patients were male and their ages ranged between 20 and 65 year-old. Types of the free flaps used included free latissimus dorsi (2), free groin flap (2), and free peroneal flap (1), The pedicle flaps consisted dorsalis pedis flap (1), peroneal flap (1), bipedicle gastrocnemius M-C flap (1) and cross leg fasciocutaneous flap (1). The muscle flaps used the peroneus longs, brevis and the abductor hallucis (1), and the gastrocnemius (1). All flaps survived and any sequelae of the skin and tibia bone did not occur.The authors emphasized the superiority of the free latissimus dorsi, free peroneal flap, pedicle peroneal flap and cross leg fasciocut aneous flap for coverage of soft tissue defect of the leg.

Coverage of soft tissue defects following surgery at the trochanteric area is challenging. Revision surgery in case of compromised wound healing may lead to soft tissue defects requiring reconstruction with pedicled or free flaps. Previous access to the hip joint may jeopardize neurovascular structures relevant to the flap. In this study, we evaluated if the use of a pedicled anterior lateral thigh (ALT) flap is a valuable option for soft tissue reconstruction. In this retrospective study, seven patients were included. Defect etiology was tumor resection in one case, screw osteosynthesis in another case and total hip arthroplasty in three cases. All patients underwent reconstruction by proximal pedicled anterior lateral thigh (ALT) flap. Pedicled ALT flap was a safe procedure in all cases. One patient showed delayed wound healing with need for additional surgery. No further complications were observed. Pedicled ALT flap transfer represents a reliable option for soft tissue coverage in the trochanteric area after primary surgery such as hip arthroplasty, osteosynthesis or tumor resection.

Deep soft tissue injuries and defects in the digits such as pulp amputation and degloving injuries are relatively frequent in hand surgical practice. Injuries around the thumb constitute a specific subtype, because their fitting requires the use of techniques that are different from standard. Many different surgical options have been described for the treatment of these serious lesions, depending on site and size of the defect, as well as on bone exposition. The "kite flap" is one of the most popular and frequently used. Results of the treatment of 14 of the 22 patients whose defects in the thumb were fitted with the kite flap are presented. The flaps healed in all patients. At the mean follow-up of 3 years all patients declared satisfaction with the result of surgery. Most of them had slightly limited mobility of the operated thumbs but with no significant translation to the function of the hands, which was very good. The results of this study show that the kite flap is useful in reconstruction of soft tissue defects around the thumb, which are difficult to cover by more conventional techniques.

Perforator flap: A novel method for providing skin cover to lower limb defects

This article aims to introduce a technically easy and reliable flap design for the coverage of soft tissue defects in areas where traditional flap options are limited by trauma or scarring. We applied the boomerang design in cases with defects around the knee and also extrapolated it to other regions like the wrist and sacrum. Patients with soft tissue defects in regions with scarred tissues or limited flap reconstructive options were recruited. The procedures resulted in uneventful recovery and excellent cosmetic outcomes for the patients. The authors of this article recommend the usage of this uncomplicated flap design in areas with otherwise limited flap options due to restricted vascularity or surrounding scar tissue.

目的 应用前臂游离皮瓣修复口腔内软组织缺损.方法搜集2001年12月至2003年12月20例应用前臂游离皮瓣即刻修复口腔内软组织缺损患者的临床资料进行分析和经验总结.结果20例皮瓣,19例完全成活,1例皮瓣因动脉栓塞经二次手术后坏死,创面经换药后愈合.结论前臂皮瓣适合于口腔局部各个解剖区域软组织缺损的修复.对于粥样硬化患者,慎用该皮瓣。

目的 探讨应用桡动脉掌浅支皮瓣游离移植修复手指指腹软组织缺损的手术方法及治疗效果。 方法 自2013年10月至2016年1月，我们采用桡动脉掌浅支皮瓣游离移植修复手指指腹软组织缺损患者28例。皮瓣切取面积为1.8 cm×2.2 cm~2.2 cm×2.8 cm。 结果 本组28例皮瓣全部成活，其中1例出现皮瓣远端表皮坏死，经创面换药治疗后愈合，供受区均未并发深部感染。腕部皮瓣供区全部直接缝合。术后随访时间为5~18个月，平均9个月，皮瓣质地优良，外形满意，两点分辨觉达8~11 mm，患指功能根据中华医学会手外科学会上肢部分功能评定试用标准评定：优17例，良9例，可2例。皮瓣供区无疼痛，无严重瘢痕增生，腕关节屈伸活动良好。 结论 应用桡动脉掌浅支皮瓣游离移植修复手指指腹软组织缺损，皮瓣外形满意，供区相对隐蔽且损伤小，是一种较为理想的手术方式。