Clinical Application and Outcome Assessment of a Novel Adhesive-Based Shoelace Wound Closure Device (EZip): A Retrospective Case Series.

Use of pedicled latissimus dorsi myocutaneous flap to reconstruct the upper limb with large soft tissue defects

To investigate the clinical efficacy of free latissimus dorsi musculocutaneous flaps in repairing large and deep skin and soft tissue defects around the knee joints. Twenty-five patients with large and deep skin and soft tissue defects around the knee joints were hospitalized from March 2005 to March 2014. The area of defects around the knee joints ranged from 10 cm × 8 cm to 43 cm × 23 cm. The free latissimus dorsi musculocutaneous flaps were used to repair the defects, with the area ranging from 12 cm × 10 cm to 45 cm × 25 cm. The thoracodorsal artery and its concomitant vein of the musculocutaneous flap were anastomosed to the descending branch of the lateral circumflex femoral artery and its concomitant vein respectively to reconstruct blood supply. Split-thickness skin grafts around the flap donor sites were harvested to cover the muscle surface of the musculocutaneous flaps. The flap donor sites were closed directly with suture, and the skin donor sites were healed by dressing change. All the 25 flaps survived without vascular crisis. The flaps were in satisfactory appearance. The flap donor sites were healed with linear scar. All the patients were followed up for 3 to 6 months. At last, they were able to stand up and walk. The free latissimus dorsi musculocutaneous flap transplantation is an effective treatment for the repair of large and deep soft tissue defects around the knee joints, and the descending branch of lateral circumflex femoral artery and its concomitant vein are the appropriate recipient vessels.

Objective To determine the outcome of the combined use of flaps transfer and ilizarov technique re-construct the large soft tissue defects and bone lose in the lower leg. Methods Sixteen patients were identified from a retrospective review from July, 2008 to July, 2013, who suffered the large soft tissue defects and bone lose in the lower leg and underwent single-stage soft tissue and osseous reconstruction using the flap technique and Ilizarov method. There were 12 males and 4 females aged from 22 to 62 years old (average 42.6 years old). The size of soft tissue defect ranged from 8 cm×9 cm to 30 cm×20 cm. The length of the bone discrepancy ranged from 2 to 14 cm. According to the local con-dition of the lower leg and the size of the composite tissue defects, 10 patients received the free flap covering, 6 patients repaired by the saphenous neurocutaneous perforator flap (3 cases) and sural nerve neurocutaneous flap (3 cases). Daily monitoring the skin temperature postoperative. Distraction was commenced on postoperative day 10 to 14 at the rate of 1 mm/day and continued in 4 equal increments. Results The follow-up time ranged from 18 to 36 months. Sixteen flaps survived completed, only 1 flap was observed the venous congestion in postoperative day 2. The duration of ilizarov appli-cation ranged from 3.5 to 18.0 months. All patients achieved final union. All patients were satisfied with the outcome of the surgery. Conclusion The combined use of neurocutaneous flap and Ilizarov technique for reconstruction of large composite soft tissue defect in the lower leg. Significantly reduce patient treatment time, improving traction osteogenesis of long bones and the ability of resistance to infection. Key words: Surgical flap; Ilizarov technique; Lower leg; Composite tissue defects; Reconstruction

Skin and soft-tissue defects around the knee are common and their reconstruction is still challenging and argued. Thin, pliable and well-vascularized tissues are required in order to restore the aesthetic appearance of the knee and facilitate joint function. Historically local muscle flaps were employed for the upper third of the lower limb reconstruction; however, since their introduction, different perforator flaps have been proposed for this purpose. The aim of this report is to share our clinical experience with the pedicled lower medial thigh perforator (p-LMT) flap for the reconstruction of skin and soft tissue defects around the knee. Between August 2013 and July 20, 2018, patients underwent pedicled LMT propeller flap reconstruction for defects around the knee. The subunits of the defects were the suprapatellar, the infrapatellar and patellar area and in two cases a full around the knee defect was reported. Cause of defects included trauma (13), tumor (4) and infection after knee operation (3) and defect sizes ranged from 4 × 3 cm2 to 7 × 8 cm2 . Flap sizes ranged from 4 × 9 cm2 to 6 × 16 cm2 . One to two perforators based on the superficial femoral artery or descending genicular artery were found between the septum of satorius and vastus medialis, or piercing the vastus medialis during dissection. All flaps were rotated 180° in propeller fashion. All the donor sites were primarily closed and no complication at the donor site was detected. In the two cases of the total knee soft tissue defect, a double pedicled flaps reconstruction was required. After a 6 months follow-up, all the patients in the series achieved a full range of motion. Fasciocutaneous flaps are currently the first reconstructive option for the soft tissue defects around the knee. The p-LMT flap reconstruction in this case series achieved good aesthetic and functional outcomes and this flap may be a valuable option for the reconstruction of the small to medium soft tissue defects around the knee.

Perceptions of Transvaginal Ultrasound by Patients Being Evaluated in the Emergency Department for Complications of First Trimester Pregnancy

The aim of this study is to evaluate the clinical outcome of flap transfer followed by delayed bone transport using external fixator on the soft tissue defect with segmental tibial loss. A total of 14 patients with soft tissue defects and bone loss were treated with flap transfer combined followed by delayed bone transport using external fixator from January 2010 to January 2017 and, successfully, follow-up were included. Demographic data and data on clinical outcomes and complications were obtained from hospital record. The mean age was 35.5 years, and the average time from injury to reconstructive surgery was 4.14 months. The average soft tissue and bone defect sizes were 33.57 cm and 7.04 cm, respectively. Local or free flap was created to reconstruct the soft tissue defects. The Ilizarov external fixator or Orthofix limb reconstruction system (OLRS) was used to reconstruct bony defects by bifocal or trifocal bone transport using delayed distraction osteogenesis. The functional results were evaluated by Association for the Study and Application of the Method of Ilizarov scoring system, and all postoperative complications were recorded. The mean duration of follow-up after removal of fixator was 29.49 ± 4.34 months (range, 24-38 months). All wounds healed after 1-stage operation, and all transferred flaps were survived. The average interval between flap coverage and bone transportation was 13.4 weeks (range, 8-24 weeks). Eight patients used bifocal, and 6 patients used trifocal approach for bone transportation. An average external fixation time was 208.5 days (range, 168-235 days) and external fixation index was 33.6 days/cm (range, 18.8-46.5 days/cm). Superficial necrosis of the flap edge was noted in 4 cases, after debridement and regular dressing, the flap healed successfully. Bone union was achieved in all patients except 4 cases that occurred with docking site nonunion which achieved satisfactory union after application of accordion maneuver and autografting of iliac bone. All patients achieved satisfactory functional recovery and were able to walk normally. The flap transfer followed by delayed distraction osteogenesis using external fixator which can be used for successful reconstruction of bone and soft tissue defects in lower leg.

The elbow is a challenging region to reconstruct functionally. Several closure methods for elbow wounds have been reported, including flap surgery. Here, we present the results obtained using a propeller flap pedicled by a posterior ulnar recurrence artery perforator (PURAP) or a radial collateral artery perforator (RCAP) for functional reconstruction of soft tissue defects in elbows. Twenty-four patients with an average age of 27.0years (range, 9-52years) underwent elbow soft tissue reconstructions between 2005 and 2015. Twenty-one patients were male and three were female. Among them, 18 patients received a PURAP flap transfer and six received a RCAP flap transfer. The frequent soft tissue defects were due to release of a postburn scar contracture in 12 patients, trauma in ten patients. Functional results were obtained by measuring range of motion (ROM). The mean follow up time was 10.1months (range, 4-22months). The flaps ranged in size from 3×5cm to 16×6cm. Nearly all flaps survived with only one showing partial necrosis. 16 and 8 patients achieved ranges of motions of 0-5 and 6-15 degree extension and 130-145 degree flexion. With the aims of easy flap harvest, primary donor site closure, skin texture match, and avoiding vascular anastomosis, both PURAP and RCAP were employed. Both flap transfer techniques were safe and effective for elbow soft tissue reconstruction. It is important to ensure that the skin defect and flap design are closely matched.

Objective To investigate the methods and therapeutic effects of anterolateral thigh perforator free flaps for reconstruction of soft tissue defects around the ankle. Methods A retrospective case series study was made on 30 patients treated with anterolateral thigh perforator free flaps for traumatic soft tissue defects around the tibia between January 2010 and June 2016. There were 22 males and eight females, with the age range of 16-58 years [(41.5±1.2)years]. Dimension of the soft tissue defect ranged from 9 cm×4 cm to 23 cm×12 cm. Flap stabilization time, flap survival rate, postoperative complications, second plastic surgery rate, and ankle joint function by Baird-Jackson score were recorded. Results All patients were followed up for (13.0±5.4)months (range, 6-24 months). Time for flap stabilization was (6.5±1.1)days. All flaps survived except in one patients with flap loss due to postoperative arterial thrombosis. Postoperatively, one patient had arterial crisis, one had venous thrombosis, and one presented sinus formation due to infection. No second plastic surgery was carried out. According to the Baird-Jackson score, the results were excellent in 25 patients and good in five. Conclusion Anterolateral thigh perforator free flaps for reconstruction of traumatic soft tissue defects around the tibia has advantages of easy harvesting and survival, less postoperative complications, less second surgery, and good function recovery. Key words: Ankle injuries; Soft tissue injuries; Perforator flap

<b>Objective:</b> To explore the preoperative whole perforator evaluation and intraoperative eccentric design of anterolateral thigh flap (ALTF) based on superficial fascial perforators by modified computed tomography angiography (CTA), and the clinical effects were observed. <b>Methods:</b> A prospective observational study was adopted. Twelve patients with oral and maxillofacial tumors and 10 patients with open injury of the upper limb with large soft tissue defects were hospitalized in the Department of Hand & Microsurgery and Department of Oral & Maxillofacial Surgery of Affiliated Hospital of Binzhou Medical University from January 2021 to July 2022, with 12 males and 10 females, aged from 33 to 75 years, an average age of 56.6 years. The wounds of the patients with oral and maxillofacial tumors were reconstructed by ALTF after the extensive tumor resection and radical cervical lymph node dissection in the same stage; the wounds of the patients with skin and soft tissue defect on the upper limb were covered by ALTF in stage Ⅱ after debridement in stage Ⅰ. After debridement, the area of wound was 3.5 cm×3.5 cm-25.0 cm×10.0 cm and the area of the required flap area was 4.0 cm×4.0 cm-23.0 cm×13.0 cm. Modified CTA scan was performed on the donor site of ALTF before the operation, with the parameters of modified CTA being set to mainly reduce the tube voltage and tube current, and increase the contrast dose and the dual phase scan. The acquired image data were sent to GE AW 4.7 workstation and adopted the volume reconstruction function for visual reconstruction and evaluation of the whole perforator. The information of perforator and source artery was marked on the body surface before operation according to the above evaluation. During the operation, an eccentric flap centered on the visible superficial fascia whole perforator was designed and cut according to the desired flap area and shape. The donor sites of the flap were repaired by direct sutures or full-thickness skin grafts. The total radiation dose was compared between the modified CTA scan and the traditional CTA scan. The distribution of outlet point of perforator of double thighs, the length and direction of superficial fascia perforators based modified CTA were recorded. The type, number, and origin of the target perforator, distribution of of outlet point of perforator, and the diameter, course, and branch of the source artery observed before the operation were compared with those observed during the operation. The healing of donor site wound and the survival of flaps in recipient site were observed after operation. The texture and appearance of flap, oral and upper limb functions, and the functions of femoral donor sites were followed up. <b>Results:</b> The total radiation dose of modified CTA scan was lower than that of the traditional CTA scan. A total of 48 perforators of double thighs were observed, among which, 31 (64.6%) perforators went outward and downward, 9 (18.8%) perforators went inward and downward, 6 (12.5%) perforators went outward and upward, and 2 (4.2%) perforators went inward and upward, and the average length of superficial fascia perforators was 19.94 mm. The preoperative observed type, number, and source of the perforator, the distribution of the outlet point of the perforator, diameter, course, and branches of the source artery were basically consistent with the intraoperative exploration. The types of 15 septocutaneous (including musculoseptocutaneous) perforators and 10 musculocutaneous perforators observed before the operation was consistent with intraoperative exploration. The distance between the mark of the surface perforator point and the actual exit point of the perforator during operation was (0.38±0.11) mm. All flaps survived without vascular crisis. The donor site wounds of 5 cases of skin grafting and 17 cases of direct suturing wounds healed well. The postoperative follow-up was 2 months to 1 year, with an average of 8.2 months, the flaps were soft and slightly bloated; the function of diet and mouth closing was accessible in patients with oral and maxillofacial tumors, the speech function was mildly impaired in patients with tongue cancer, but they could complete basic oral communication; the wrist and elbow joints and forearm rotation function were not significantly limited in patients with upper limb soft tissue injuries; there was no obvious tightness in the donor sites, and the function of the hip and knee joints was not limited. <b>Conclusions:</b> The whole perforator and even the subcutaneous perforator of the donor site of ALTF can be evaluated by modified CTA, and the flap can be used in oral or maxillofacial reconstruction and repair of skin and soft tissue defects of upper limbs to achieve good results. By clarifying the type, number, and source of the perforator, the distribution of the outlet point of the perforator, diameter, course, and branches of the source artery before the operation, the eccentric design of the ALTF based on the superficial fascia perforator was realized. This study has strong guiding value.

To explore the effectiveness of limb shortening/re-lengthening technique combined with in situ tissue regeneration technique in limb salvage for patients with complex lower limb fractures and soft tissue defects. Between January 2021 and December 2024, 12 patients with complex lower limb fractures and soft tissue defects caused by trauma were admitted. There were 10 males and 2 females; the age ranged from 18 to 46 years, with an average of 36 years. Among them, 1 case of open comminuted tibiofibular fracture caused bone necrosis and soft tissue infection; 4 cases of open tibiofibular fractures developed bone and soft tissue infections after being fixed with a combined external fixator, resulting in defects; 7 cases of closed tibial fractures that underwent internal fixation developed soft tissue infections, leading to bone and soft tissue necrosis. The time from injury to the formation of bone and soft tissue defects was 2-9 weeks, with an average of 6 weeks. The length of bone defects was 5.0-10.2 cm, with an average of 6.8 cm; the area of soft tissue defects was 32-54 cm 2, with an average of 43.9 cm 2. After admission, all patients underwent thorough debridement. The limb shortening treatment was performed after the wound had filled with fresh granulation tissue, and an Ilizarov ring-shaped external fixator was placed or replaced. The limb was shortened at a rate of 1 mm/day to reduce bone defects. At the same time, the soft tissue defects were repaired using the in situ tissue regeneration technique. After the wound healed, osteotomy was performed, and limb lengthening was carried out at a rate of 1 mm/day. The lower limb full-length X-ray films were taken, and the lengthening was stopped when the lower limb alignment was restored. The healing condition of the wound was observed and the healing time was recorded. One patient died due to a traffic accident during limb lengthening. The remaining 11 patients completed limb shortening and re-lengthening treatment and were followed up 18-36 months, with an average of 20 months. All 11 patients successfully preserved their limbs. The wound healing time was 4-12 weeks, with an average of 8 weeks; the limb shortening time was 4-8 weeks, with an average of 6 weeks; and the limb lengthening time was 4-12 weeks, with an average of 8 weeks. One patient experienced delayed bone mineralization during bone lengthening, and one had pin tract infection. Both were treated symptomatically. The lower limb mechanical axis of all 11 patients was restored, and they were able to walk independently. The application of limb shortening/re-lengthening technique combined with in situ tissue regeneration technique in the treatment of large bone and soft tissue defects not only effectively avoids the occurrence of nonunion at the apposition ends and increases the stability of the lower limb, but also significantly shortens the wound healing time, avoids the risk of soft tissue infection and increases the limb salvage rate. It can be used as a treatment technique for patients with complex lower limb fractures combined with soft tissue defects.

Facial contour deformities are a very challenging issue for aesthetic and reconstructive surgeons. Free dermal fat graft is a composite graft used for the reconstruction of soft tissue defects in the maxillofacial region. The free dermal fat graft is easily adapted and contoured intraoperatively and provides a soft, natural, and favorable appearance after augmentation of the soft tissue defects. To assess the use of free dermal fat graft for reconstruction of soft tissue defects in the maxillofacial region in regard to graft success, percentage of overcorrection, any associated complications, and cone beam computed tomography scan linear measurements for defect's depth. This is a prospective study that included a patients were grafted with free dermal fat graft for correction of facial soft tissue defects from November 2017 to July 2019. All patients possess a depression defect and facial asymmetry due to congenital facial deformities, post-traumatic deformities, and post-ablative surgical deformities. Eleven patients (8 males and 3 females) with a mean age of 33.7 years were enrolled in this study. Five regions in the maxillofacial area were grafted in 11 patients. The mean of the postoperative follow-up was 6 months. The percentage of graft overcorrection was 15%. The mean for graft survival was 94.4% with no serious complications reported. The autologous FDFG is a versatile and less invasive method in the reconstruction of facial soft tissue defects with a very good survival rate.

Rationale:Large soft tissue defects on the lower back represent a treatment challenge. Among a variety of reconstructive procedures, the latissimus dorsi (LD) muscle or musculocutaneous flap is one of most frequently used pedicled flaps. However, the pedicled LD flap carries a bulky pivot point and a short arc of rotation. If a pedicled LD muscle flap is transferred using a reverse turnover pattern, theses drawbacks can be avoided.Patient concerns:The first patient was a 56-year-old man with hepatocellular carcinoma and multiple bone metastases involving D11-L4 vertebral bodies. A chronic ulcer was developed on his lower back area after palliative radiation therapy for bone metastases. The second patient was a 41-year-old man with a soft tissue mass on his lower back, which was diagnosed as dermatofibrosarcoma protuberans via previous incisional biopsy. A large soft tissue defect was developed on his lower back as a result of a wide resection.Diagnosis:Both patients were referred to our department for the treatment of a large soft tissue defect on lower back.Interventions:They underwent the reverse turnover pedicled LD muscle flap and split-thickness skin graft.Outcomes:At postoperative 6-month follow-up, both patients remained free of wound problem.Lessons:The reverse turnover pedicled LD muscle flap is quite straightforward. Even if a soft tissue defect in the lower back is large or complicated by infection or radiation therapy, perfusion of LD by posterior intercostal arteries is likely to be preserved. We recommend the reverse turnover pedicled LD muscle flap as an effective alternative for reconstruction of soft tissue defects involving the lower back.

Extensive soft tissue defects present a dif!cult problem to the plastic surgeon as they are usually associated with exposed important structures such as vessels, nerves, tendons, joint cavity or bone. Reconstruction of soft tissue defects have a wide range of therapeutic options. We reconstructed soft tissue defect in many areas using free anterolateral thigh flap (ALTF). From Februari 2009 - 2010, 9 cases of soft tissue defects in the face, neck, leg and foot of various etiologic factors were admitted to the plastic and reconstructive surgery unit, Cipto Mangunkusumo general hospital. Trauma is the commonest cause of soft tissue defects of the lower extremity, followed by tumours. The cruris was the commonest site (4 cases, 44,4%). Flap success rate was 66,67 %. Failure was reported 1 cases in this study due to vein compromise. In our hospital, we are quite familiar with Anterolateral thigh flap (ALTF) even though the case is limited. Anterolateral thigh flap (ALTF) is used for reconstruction of various simple and complex soft tissue defects, for big and small defects with cavity (orbita).

Objective To investigate the clinical efficacy of free anterolateral thigh flap transport combined with tibia bone transport in reconstruction of large segmental bone and soft tissue defect of lower extremities. Methods This retrospective case series review included 27 patients sustaining large segmental bone and soft tissue defect of lower extremities admitted between August 2006 and April 2016. There were 22 males and 5 females, with a mean age of 36 years (range, 16-56 years). Eleven patients were identified with Gustilo ⅢB type open injury, 14 Gustilo ⅢC type open injury, and 2 large bone and soft tissue defects after internal fixation of the closed lower extremity fractures. Size of soft tissue defect was 10.0 cm×5.5 cm-21.0 cm×10.0 cm. Size of the flaps was 13.0 cm×7.5 cm-23.0 cm×11.0 cm. Length of bone defect was 5.5~18 cm and length of bone transport was 6~21 cm. Anterolateral thigh flaps were employed for limb salvage. After wound healing, bone transport with the use of an Ilizarov ring external fixator was done to treat tibial bone defect. Flap survival, wound healing time, bone transport time, bone healing index and time of external fixator removal were recorded. Mineralization of regenerate bone was assessed using the bone healing index. Results were evaluated using the Paley scoring system. Results Mean follow-up period was 4 years (range, 1-8 years). All flaps survived and the wounds were healed without ulceration or infection. Mean time for wound healing was 4.5 months (range, 1-18 months). Time interval between wound healing and bone transport was 1-4 days (mean, 1.5 months). Mean bone healing index was 55 days (range, 45-65 days), demonstrating good bone mineralization. Mean time of external fixator removal was 24.5 months (range, 10-39 months). Shape of the tibia was satisfied. All patients were able to ambulate without use of an aid. According to the Paley scoring system, results were excellent in 21 patients and good in 6 patients. Conclusion Combined free anterolateral thigh flap and tibial bone transport provides enough bone and soft tissue and satisfactory recovery of limb function and morphology, indicating an effective treatment for large segmental bone and soft tissue defect of lower extremities. Key words: Surgical flaps; Ilizarov technique; Tibial fractures; Soft tissue injuries; Bone defect

Objective To explore the clinical effects of the flap pedicled with superior malleolus perforator of anterior tibial artery in reconstruction of the soft defects in foot and ankle. Methods A retrospective study was carried out to analyze 19 patients with soft tissue defects in foot and ankle. Ninteen patients, which were 11 males and 8 females and aged 21-75 (mean, 39) years, received the surgery between April, 2018 and June, 2019. According to the anatomy of superior malleolus perforating flaps and the size and shape of the soft tissue defects in foot and ankle, flaps were designed and harvested in the anterolateral side of the shank. The sizes of flaps were 6.0 cm×5.0 cm-14.0 cm ×8.0 cm. Evaluation of clinical effects included flap survival, infection control, the elasticity, color, appearance and scars of the donor sites, skin sensations and patient satisfaction. The swelling of flap was also took into an account. Results All 19 flaps survived after the surgery. The soft tissue defects and exposure of tendon, bone and steel plate were repaired very well. Both the donor and recipient sites healed at stage I. Duration of out-patient clinic followed-up was 2-16 months. All flaps survived very well with good shape, and the color and elasticity were very close to the nearby normal skin. Scars at donor sites were small and the functions of ankle and foot were satisfactory. Conclusion The flap pedicled with superior malleolus perforator of anterior tibial artery in reconstruction of the soft tissue defect in foot and ankle delivered satisfactory clinical effects. This flap has reliable perforating blood vessels hence reliable blood supply with high survival rate of flaps. It is one of the simple, safe and optimal methods to repair soft tissue defects in foot and ankle. Key words: Anterior tibial artery perforator flap; Superior malleolus perforator; Foot and ankle; Soft tissue defects; Repair