Blood Supply Of Flap Research Articles

Indocyanine Green Angiography for Continuously Monitoring Blood Flow Changes and Predicting Perfusion of Deep Inferior Epigastric Perforator Flap in Rats

Background Deep inferior epigastric perforator (DIEP) flap approach has excellent outcomes and low morbidity. However, it is associated with high rates of perfusion-related complications. To observe the blood flow changes and the stages of the flap perfusion, as well as the necrosis formation, we used indocyanine green (ICG) to monitor its perforators before and after DIEP flap harvesting. Methods: Abdominal perforator flaps supplied by the right superior abdominal perforating arteries were generated from seven SD rats. Laser-assisted ICG angiography was applied for dynamical and continuous observation of changes in the blood flow and courses of flap perfusion. Areas of flap perfusion were quantitatively analyzed using ImageJ. Results: The average perfusion area of the seven flaps after surgery and at days 1, 2, and 3 after surgery were 23.06 ± 2.47, 22.48 ± 2.04, 28.34 ± 1.14, and 28.97 ± 2.44 cm2, respectively. Compared to values after surgery, no significant difference was observed on day one (p > 0.05); however, the flaps had significantly improved perfusion areas on day 2 (mean value of 5.28 ± 1.83 cm2, p < 0.01) and day 3 (mean value of 5.91 ± 2.60 cm2, p < 0.01) postsurgery. In addition, there were no significant differences between days 2 and 3 (p > 0.05). The blood flow changes in both arteries and veins, the stages of flap perfusion, and the development of necrosis at the distal end of the flap were also observed. Conclusion: We gained valuable knowledge on the dynamic of blood flow changes and the course of flap perfusion inside the DIEP flap. Dynamic and continuous observation with ICG angiography through an SPY system is a powerful method for monitoring of blood supply in flaps that can be used to predict flap perfusion with a strong positive predictive significance.

Efficacy of nasolabial flap in repairing inferior nasal defect

Objective To investigate the clinical effect of retrograde nasolabial fold flap pedicled with angular artery in the repair of inferior nasal defect. Methods According to the location and size of inferior nasal defect, the reverse island flap or axial flap pedicled with the inner canthus artery was designed to repair the defect at the nasolabial fold of the affected side. Results Eighteen patients were followed up for 6-36 months, of which 2 cases had partial necrosis at the distal part of the flap, healed by dressing change, and the rest of the flaps survived. The flaps were not bulky and the color and texture were similar to those of the surrounding skin. All patients were satisfied with the appearance improvement. Conclusions The blood supply of the retrograde nasolabial fold flap pedicled with the inner canthus artery is reliable, using flaps from the nasolabial sulcus is surgically convenient, flexible in design and covert in donor site. It is one of the ideal methods for the repair of inferior nasal defects. It is worthy of clinical application. Key words: Nose; Soft tissue injuries; Reconstructive surgical procedures; Angular artery; Retrograde nasolabial fold flap; Inferior nasal defect

The lateral thoracic vessels: A novel recipient site for breast reconstruction with DIEP flap

Adequate selection of recipient vessel to minimize recipient site morbidity is essential for a successful breast reconstruction. The authors explored the clinical use of the lateral thoracic vessels as recipient vessels in the deep inferior epigastric artery perforator (DIEP) flap breast reconstruction. This study included 63 patients with breast cancer. The age of patients ranged from 26 to 67 years (43.23±8.63). All patients received an immediate DIEP flap breast reconstruction using the lateral thoracic vessels as recipient vessels in the authors' department from 2014 May to 2018 September. The flap blood supply, complications, and outcomes were assessed. The patients were followed up for 6 to 29 months with satisfactory results. All the flaps had stable blood supply except for two cases, which had an event of partial skin necrosis and were repaired by debridement. Lateral thoracic vessels are not only easy to explore but also have reliable blood supply, which present a safe and reliable choice for immediate DIEP flap breast reconstruction.

The reverse latissimus dorsi flap: An anatomical study and retrospective analysis of its clinical application

The segmental paraspinous and intercostal blood vessels form the blood supply and represent the pivot point for the reverse latissimus dorsi flap. Aim of this study was to confirm the exact location of the blood supply and the most caudal pivot point to assess the suitability of the reverse latissimus dorsi flap for pedicled reconstructions of the trunk as well as sacral area. Our study comprised a human cadaver study, where 30 latissimus dorsi flaps were assessed in 15 specimens, and a clinical study with 49 patients who underwent distally based latissimus dorsi flap reconstructions in our division. 74% of all perforators were located in a bilateral 7 cm broad area, which spread from the 6th intercostal space to the subcostal plane. In a second clinical part of this study we evaluated forty-nine patients, who underwent reconstruction with the reverse latissimus dorsi flap. We demonstrated that the pivot point can also be planned below the 12th rib, thus reaching tissue defects in the sacral area. To the best of our knowledge, this is the first study to define a caudal "hotspot" for the safest blood supply of the reverse latissimus dorsi flap.

Anatomic basis and clinical application of perforator flap thinning of posterior tibial artery

Objective To explore the anatomic basis of the thinning of the free posterior tibial artery perforator flaps and the clinical effect of repairing wound on hand or foot due to trauma. Methods From November, 2016 to December, 2017, 10 cases of lower extremity cadaver specimens perfused with red ralex were dissected, which were perfused through the amputated femoral artery. Five of them were left and the rest were right. All cases were males. The number, diameter, branches and distribution of the perforator was observed. From September, 2012 to September, 2017, there were 13 cases of clinical application, which were 5 cases of hand wound and 8 cases of foot wound. The size of the wound was 3.0 cm × 2.0 cm to 6.0 cm × 4.0 cm, and the flap area was 3.5 cm × 2.2 cm to 6.5 cm × 4.5 cm. The repairing procedure was suitable for the wound associated with tendon, bone, joint capsule exposure. Results The number of posterior tibial artery perforating branches that more than 0.50 mm in diameter was 4 to 6, and the mean diameter was (0.87±0.26) mm. The perforating branch penetrated into the fat layer and was divided into 3 layers of vascular network: deep fat vascular network, superficial fat vascular network and subdermal vascular network. The perforating branch was located according to the positional relationship from deep to shallow, and vessel diameter become smaller step by step. The perforating branch trunk gave off branches to the deep vascular network, and the superficial vascular network had the same origin or shared with the deep blood vessels. The subdermal vascular network issued from the superficial vascular network or directly from the perforating branch trunk. There was no or few communicating branch between the deep vascular network and superficial ones, besides the vessel pedicle. So trimming deep fat layer will not affect the blood supply of superficial vascular network and neither will affect the flap blood supply. Most of the deep fat tissue was trimmed in 13 cases. The superficial and subdermal fat vascular network was preserved, and the same to the trunk and branches of the pedicle. All the flaps survived. Of which, 1 appeared arterial crisis on the 2nd day after operation, and relieved by the local injection of papaverine. There was 1 case of venous crisis on the 3rd day, and improved by stitches, local release of congestion. Followed-up time was ranged from 2 to 12 months. All flaps were soft with good blood supply and good appearance, and did not need a second thinning surgery. Flaps restored the protective feeling 6 months later. Conclusion The microdissection of perforator flap of posterior tibial artery provides a theoretical basis for the perforator flap thinning, and the thinning of perforator flap is a good method to repair the appearance and function of the wound after foot and hand injuries. Key words: Posterior tibial artery perforator flap; Applied anatomy; Wound; Repair; Microsurgical operation

Clinical application of free latissimus dorsi lobulated musculocutaneous flap for repair of tissue defect of the shank

Objective To explore the clinical outcomes of free latissimus dorsi lobulated musculocutaneous flap for repairing the soft tissue defects of the shank. Methods From January 2011 to December 12, free latissimus dorsi lobulated musculocutaneous flap was transferred to repair soft tissue defects of the shank in 22 cases. There were 16 males and 6 females retrospectivelyanalyzed, with an average age of 37.5±2.5 years. The wounds all had tendon,bone and/or internal fixation exposed. The size of the defect area was 18 cm×10 cm to 28 cm×15 cm. At first, the site of perforator vessels was determined by Doppler as the center, then the lobulated flaps were designedaccording to the wound shape and size. During the operation, the thoracic and dorsal nerves and part of latissimus dorsi muscle were preserved, and the myocutaneous flap was formed into lobulated myocutaneous flap. Finally, the pedicle was dissociated to the appropriate lengthwhen only the vascular pedicle was connected with the flap. After the combination of the two lobulated myocutaneous flaps, the skin flap was trimmed, and the subcutaneous fat was removed in a step-like way from the peripheral to the point of perforation of vascular cutaneous branches. Only the dermis was retained around the integral skin flap, and the blood supply of the skin flap was observed at the same time to prevent the injury of perforating vessels. The transplantation of musculocutaneous flap was performed to repair the leg wound. All donor sites were sutured directly. The flap survival was observed according to the comprehensive evaluation standard of hand surgery. Results All the 22 flaps survived, and the size of lobulated musculocutaneous flap was 20 cm×12 cm to 30 cm×16 cm. No vascular crisis happened, and all skin grafts survived in donor sites. 22 cases were follow-up for 6 to 24 months. The flaps were supple and elastic with nearly normal color. There was no bulkiness. Sensory function recovered well and two-point discrimination (2-PD) was about 3.5-5.0 cm. The function and appearance of the foot and ankle was good. According to the operative hand surgery function evaluation of flap, the results were excellent in 13 cases,good in 8 cases, fair in 1 case, with excellent and good rate of 95.45% (21/22). 1.0 cm×0.5 cm of the distal of flap was necrosis in 1 case and healed by dress changing. Conclusion The free latissimus dorsi lobulated musculocutaneous flap is an improvement of the traditional latissimus dorsi flap. The survival rate of musculocutaneous flap is high and the clinical effect of repairing soft tissue defect of lower leg is satisfactory. Key words: Leg; Soft tissue injuries; Surgical Flaps; Treatment outcome

A Systematic Study of Vascular Distribution Characteristics and Axis Design of Various Flap Types.

BackgroundThe aim of this study was to define blood flow characteristics of multiple types of flaps and the theoretical basis of flap axis design.Material/MethodsSixty Sprague-Dawley (SD) rats were randomly divided into 6 groups: a normal skin group, and 5 groups with different types of flap: abdominal flap group, dorsal flap group, single-perforator flap group, double-perforators flap group, and delayed cutaneous nerve flap group. The vascular distribution characteristics of normal skin and various flap types were observed by gross morphology of specimens and X-ray after perfusion.ResultsThere were distinct differences in vascular anastomosis and density in dorsal and ventral SD rats. The area of flap survival in the dorsal flap group was superior to that in the abdominal flap group, but the flap axis of the 2 groups passed straight through the middle of the pedicle. The flap surviving area in the double-perforators flap group was remarkably larger than in the single-perforator flap group, while the flap axis in the single-perforator flap group passed straight through the perforators, and in the double-perforators flap group there was a linking vessel between the 2 perforators. There were linking and reticulate vessels, in addition, linking vessels and cutaneous nerves were concomitant in the delayed cutaneous nerve flap group. The flap axis was the travel route of the cutaneous nerve.ConclusionsVariations in flap blood supply patterns and axes with alterations based on flap types have implications for flap survival. Understanding blood flow characteristics within each flap type and accurately designing the flap axis is essential for flap survival.

Repair of large area of soft tissue defect of calf by the retrograde anterolateral thigh flap with single high cutaneous perforator

Objective To explore the clinical effect of repairing the large area of soft tissue defect of the calf by the retrograde anterolateral thigh flap with single high cutaneous perforator. Methods From January, 2014 to July, 2017, 9 cases of large area of soft tissue defects were repaired by the retrograde anterolateral thigh flap with single high cutaneous perforator. There were 7 males and 2 females, aged 24-48 years. Soft tissue defects area of the calf was 10.0 cm×7.0 cm to 35.0 cm×15.0 cm, including skin grafting and skin stretch to repair the area. The perforating point of the high cutaneous artery branches was designed at the proximal end of the flap, which was used as the single nutrient vessel of the flap. The rotation point of the flap was moved upward to the proximal thigh, which not only increased the blood supply of the flap, but also made the flap repair range to the distal calf. The flap range was 15.0 cm×10.0 cm to 22.0 cm×12.0 cm. Results All flaps were cut smoothly, and no vascular crisis occurred. All flaps survived smoothly. All patients were followed-up for 6-12 months. The appearance of flaps was plump, slightly bloated, and their color was similar to the recipient area. The texture was soft, and no active disorder in the donor site. Conclusion The retrograde anterolateral thigh flap with single high cutaneous perforator can be designed at a high rotation point. By increasing the number and caliber of the anastomotic branch between the pedicle and lateral superior genicular artery, the blood supply and reflux of flap can be improved, and the survival rate is not affected. Compared with the traditional anterolateral thigh flap, it has great advantages. Key words: Anterolateral thigh flap; High cutaneous perforator; Lower leg; Soft tissue defect

The one-stage microscopic repair of soft tissue defect caused by excision of malignant tumour

Objective To explore the method and clinical efficacy of microsurgical reconstructive surgery after malignant tumors radical resection on the surface. Methods From June, 2015 to March, 2017, a total of 32 patients in this group underwent radical resection of malignant tumors. All of them resulted in a large area of soft tissue defect with loss of function. The average defect area was 10.0 cm×12.0 cm. All types of free flap and pedicle flap were selected. Myocutaneous flaps or local flaps were used to repair large areas of soft tissue defect on the basis of microsurgical techniques to protect the blood supply of the flaps and to reduce the damage to the donor area by evaluating the defect size, surrounding anatomical characteristics, and other factors. Results Thirty-two flaps survived completely. After 4 to 18 months of followed-up, the color of flap was close to that of the surrounding skin. The texture was good. There was no bloated swelling, and the skin protective sensation was restored. There was no obvious scar hyperplasia, no chills, no pain and no other complications in the donor site. Conclusion After the radical mastectomy of the body surface, different types of flaps can be selected for the first-stage microsurgery according to the characteristics of the different parts and the tumor excision wounds to obtain a good clinical efficacy. Key words: Malignant tumour of body surface; Soft tissue defect; Surgical flaps; Repair; Microsurgical technique

Location of Vertical Limb of Extensile Lateral Calcaneal Approach and Risk of Injury of the Calcaneal Branch of Peroneal Artery.

The extensile lateral calcaneal approach is a standard method for accessing a joint depression calcaneal fracture. However, the operative wound complication rate is high. Previous studies showed a calcaneal branch of the peroneal artery contributing to the calcaneal flap blood supply. This study focuses on the location of the vertical limb in this approach correlating to the aforementioned artery and flap perfusion. Ten pairs of fresh-frozen cadaveric lower extremities were used. Extensile lateral calcaneal approach (ELCA) was carried out on both calcanei, where the vertical limb was placed at the line between the posterior border of lateral malleolus and lateral edge of the Achilles tendon for the right side (standard ELCA; sELCA) and at the lateral edge of the Achilles tendon for the left side (modified ELCA; mELCA). The identified vessel in the vertical limb incision was ligated and cut, and the horizontal limb of the incision was carried out as usual. After completion of flap elevation, 80°C water was injected into the popliteal vessel. In addition, thermal images were taken pre- and postinjection. Dye was injected subsequently, and perfusion was recorded in video format. Mean pre- and postinjection skin flap temperature difference was significantly higher in mELCA (5.36°C vs 0.72°C, P = .0002). Dye perfusion patterns were significantly better in mELCA ( P = .0013). The calcaneal branch of peroneal artery was found in the vertical incision in 9 of 10 sELCA, with average distance 22.04 mm anterior to the calcaneal tuberosity and 8.22 mm proximal to superior border of the calcaneus, whereas one was found in mELCA, in which perfusion tests still appeared normal. The vertical limb of incision during extensile lateral calcaneal approach should be placed at the lateral edge of the Achilles tendon to avoid injuring the calcaneal branch of peroneal artery, which supplies the lateral calcaneal flap. However, further clinical research might be needed to confirm the results of this study. This study demonstrates a likely safest position for the proper incision for exposing the lateral calcaneus.

Indocyanine green fluorescence/thermography evaluation of intercostal muscle flap vascularization.

BackgroundDuring anatomical lung resection in high‐risk patients, the bronchial stump is covered with tissue flaps (e.g. pericardial fat tissue and intercostal muscle) to prevent bronchopleural fistula development. This is vital for reliable reinforcement of the bronchial stump. We evaluated the blood supply of the flap using indocyanine green fluorescence (ICG‐FL) and thermography intraoperatively in 27 patients at high risk for developing a bronchopleural fistula.MethodsBefore reinforcing the stump with a flap, the fluorescence agent was intravenously injected and the blood supply was evaluated. The surface temperature of the flap was measured with thermography. The two modalities were then compared.ResultsICG‐FL intensity and surface temperature on the distal compared to the proximal side of the flap decreased by 32.6 ± 29.4% (P < 0.0001) and 3.5 ± 2.0°C (P < 0.0001), respectively. In patients with a higher ICG‐FL intensity value at the tip than the median, the surface temperature at the tip decreased by 2.7 ± 1.7°C compared to the proximal side. In patients with a lower ICG‐FL value at the tip, the surface temperature decreased by 4.6 ± 1.7°C (P = 0.0574). The bronchial stump reinforced the part of the flap with adequate blood supply; none of the patients developed a bronchopleural fistula.ConclusionsICG‐FL confirmed variation in the blood supply of the intercostal muscle flap, even if prepared using the same surgical procedure. Thermography analysis tends to correlate with the fluorescence method, but may be influenced by the state of flap preservation during surgery.

Anatomic feature of the adjacent perforator fasciocutaneous flap of plantar and its clinical application

Objective To study the anatomic basis and its clinical effects of the adjacent perforator fasciocutaneous flap in planta. Methods From October, 2010 to December, 2017, the work was on two fronts:① The blood supply of the flap was studied by the dissection of 5 adult lower limbs which were perfused with red emulsion. Under the magnifying glass, the source of blood supply to the pedicle perforator fasciocutaneous flap near the foot was observed, and the caliber of perforating vessels was measured by vernier caliper. ② Methods based on the anatomic study, the adjacent perforator fasciocutaneous flap was designed to repair plantar defect. Eleven cases with defects in planta were treated with the flap including 5 malignant melanoma, 5 refractory wound and 1 pigmented nevus. The size of defects ranged from 1.5 cm×2.0 cm to 4.0 cm ×5.0 cm with the size of the flaps ranging from 7.0 cm×3.0 cm to 13.0 cm×7.0 cm. Results Anatomical studies showed that the supply vessels of the fasciocutaneous flap near the perforator of the plantar space were plantar medial arteries. The external diameter was greater than or equal to the 0.5 mm perforating number of about 7, the average outer diameter was (0.85±0.19) mm. The medial plantar artery emits multiple branches along the running direction and forms anastomotic branches in the arch of the foot to ensure the blood supply of the flap. Eleven cases of perforator fasciocutaneous flaps survived, including 1 case of distal necrosis of small area and healed after change dressings. The follow-up results during 6-24 months showed that all patients were walking normally, with full texture and no localized dull pain. Conclusion On the basis of the extent of diseases, projected the adjacent perforator fasciocutaneous flap, the wear resistance and abrasive resistance are improved resulted from flaps with similar skin texture of defects. The donor site can be closed directly without skin graft. It is an simple and reliable method to repair medium and small- sized plantar defects. Key words: Plantar; Perforator flap, fasciocutaneous flap; Applied anatomy; Repair

Design and clinical application of postoperative marker system of perforator flap

Objective To investigate the design of the postoperatively marker system based on the perforator flap and its clinical application. Methods According to the basic anatomy and blood supply characteristics of perforator flap, the observation points were marked on the flap surface and recipient area postoperatively, and judge flap blood flow changes with hand-held Doppler(HHD) and clock-face measurement based on perforators. From November, 2015 to November, 2017, prospectively conducted a control study evaluating the incidence of vascular crisis, accuracy rate, reoperation rate and survival rate of flaps between simple traditional flap monitoring group (n=100) and traditional flap monitoring combine with postoperatively marker system monitoring group (n=100). Results Vascular crisis was mostly concentrated with in 48 h postoperative in traditional flap monitoring group and combined group. There was no significant difference in the incidence, positive rate and negative rate of vascular crisis in the two groups (P>0.05). The reoperation rate in the traditional flap monitoring group (87.5%) was higher than the combined group (27.8%)(P<0.01). The survival rate of flap of combined group (99%) was higher than the traditional falp monitoring group (90%) (P<0.05). Conclusion The postoperatively marker system of perforator flap can effectively guide the medical staff to observe the blood supply of the flap, detect and judge the vascular crisis in time, and It is simple and easy to do without increasing the patient’s trauma and medical expenses as well as no additional equipments. Key words: Perforator flap; Postoperatively marker; Hand-held Doppler ultrasound; Vascular crisis

Vacuum sealing drainage with anterolateral thigh perforator flap for repair foot soft tissue defect

To investigate clinical effect of vacuum sealing drainage(VSD) with anterolateral thigh perforator flap for repair foot soft tissue defect. From September 2014 to September 2016, 45 patients with foot soft tissue defect repaired by VSD with anterolateral thigh perforator flap, including 31 males and 14 females aged from 17 to 55 years with an average of 36 years old. Thirty patients were dorsal soft tissue defects, and 15 patients were plantar soft tissue defects. Sizes of soft tissue defect ranged from 7 cm×10 cm to 11 cm×18 cm, the wound was contaminated seriously and assisted with deep soft tissue exposure. Emergency surgical wound debridement with VSD treatment were performed, and wound surface was cleaned after 5 to 7 days, free anterolateral thigh flap were repaired. Sizes of flap ranged from 9 cm×12 cm to 13 cm×21 cm. Appropriate method was used to repair flap donor area. All 45 free propeller flap were survived without skin edge necrosis, ulcerative infection. Forty patients were followed up from 3 to 24 months with an average of 13 months. Flap showed good color, beautiful appearance, good elasticity, soft texture, but without obvious bloated, the wood of leg healed well. VSD with anterolateral thigh perforator flap for repair foot soft tissue defect could effective control wound soft tissue infection, receive reliable flap blood supply and skin flap could repaired at stage I. It is an effective method for repairing foot soft tissue defects.

Effect of 810 nm Near-Infrared Laser on Revascularization of Ischemic Flaps in Rats.

To investigate the effect of 810 nm near-infrared (NIR) laser on the revascularization of ischemic flaps. It has long been proved that photobiomodulation therapy (PBMT) improves the blood supply of flaps. NIR laser improves the treatment of hypodermis-located lesions and of flap survival, but basic research on the use of 810 nm NIR laser for ischemic flap revascularization is still lacking. We prepared two symmetrical long random-pattern flaps on the backs of 60 rats. Each flap was 6 cm long, 1 cm wide, and 1 cm to the middle line. The flaps were divided into an irradiated flap group and an internal control group. The irradiated flaps underwent postoperative 810 nm laser therapy with the energy density of 11.30 J/cm2 daily. The control flaps were covered by stainless steel to avoid laser irradiation. We observed the viability of the flaps. The flaps underwent Hematoxylin and Eosin (H&E) staining for the observation of histomorphology, immunohistochemical staining of factor VIII for the capillary count, α-smooth muscle actin for the small arterial count, and vascular endothelial growth factor for the integrated optical density (OD) of the positive stained color. The irradiated flaps showed significantly better flap survival than the control flaps. H&E staining showed that the irradiated flaps had clear tissue structure and little inflammatory cell infiltration. The control flaps demonstrated comparatively worse results. Vascular endothelial growth factor staining showed that the difference in integrated OD between the irradiated flaps and the control flaps was not statistically significant. α-smooth muscle actin and factor VIII staining showed significantly greater numbers of arterioles and capillaries in the irradiated flaps than the control flaps after 4 days of irradiation. PBMT with 810 nm NIR laser could enhance ischemic flap revascularization and increase flap viability.

Application of skin stretcher for repair of postoperative skin and soft tissue defects in tibial fractures

To discuss the efficacy of skin stretcher applied for repair of postoperative skin and soft tissue defects in tibial fractures. Between April 2016 and March 2017, 15 cases with skin and soft tissue defects after tibial fractures fixation were treated with the skin stretcher. There were 11 males and 4 females with an age of 24-59 years (mean, 37.5 years). The causes of injury included traffic accident in 7 cases, bruise in 3 cases, falling from height in 3 cases, and falling in 2 cases; without nerve and vascular injury in all patients. These cases were followed up 1-3 months after their first surgery, consisting of 3 closed fractures treated with open reduction and plate and screw fixation, 12 open fractures treated with external fixation after debridement. The area of skin defects ranged from 14 cm×5 cm to 20 cm×7 cm, all of which were stripped or spindle shaped skin defects. First, the skin was penetrated by two Kirschner wires which were locked by skin stretchers on both sides of the skin defect longitudinally. Then, the tension of skin stretchers was timely adjusted according to the skin flap blood supply and muscle compression. Finally, Kirschner wires and skin stretchers were removed when the edge of skin contacted and been sutured. All skin and soft tissue defects were covered after stretching for 6-13 days. The interrupted sutured wounds healed at 12 days. Clinical scores of wound healing decreased from 3.40±0.51 at immediate postoperatively to 1.27±0.46 at 12 days postoperatively, showing significant difference ( t=12.911, P=0.000). All the patients were followed up 4-12 months (mean, 6.5 months). After stretching, the skin color, elasticity, and pain and touch feeling were similar with the normal skin, and the hair growth was normal. After operation, 1 case of nail tract infection and 2 cases of calf discomfort occurred, and all were relieved after treatment. It is an effective method for repairing postoperative skin and soft tissue defects in tibial fractures with the application of skin stretchers.

Repair of large area skin defect of forearm with overlength thoracic umbilical conjoined perforator flap with double blood supply

Objective To explore the surgical method and clinical effect of repairing the large area skin defect of forearm with the perforator flap pedicle with the inferior epigastric artery perforator and the lateral cutaneous branch of the posterior intercostal artery. Methods From January, 2006 to January, 2016, 14 cases of forearm large area of skin defects were treated with the overlength flap at one stage. The proximal flap to the inferior epigastric artery umbilical perforation and the flap distal to the posterior interphalangeal artery perforation were used for the blood supply of superficial flap. The length of the flap was 25-43 cm (average, 36 cm) . The width of the flap was 5-14 cm (average, 9 cm) . All patients were followed-up regularly. The content of the follow-up included three aspects: appearance, hand function and the recovery of the donor site. Results Twelve cases of postoperative flaps successfully survived. Arterial crisis was seen in 1 flap 28 hours after surgery. The re-surgical exploration was adopted after conservation treatment for 1 h without remission and the proximal anastomotic flap embolization was confirmed. The flap survived. Venous crisis was seen in 1 case. The flap survived with the help of removing the suture, smoothing drainage and bleeding for 5 d. The wounds and the donor site of the thoracic and abdominal region healed at the first stage. The follow-up time was 8-72 months, with an average of 31 months. The flaps had no obvious bloated, the skin texture was close to forearm skin and the flaps were restored protected sensation. There was no ulceration, infection and other complications. The healing of skin graft was satisfactory in 2 cases in abdominal donor site. No skin graft contracture occurred. The remaining 12 cases had linear scar in the abdomen of the donor site. The edge of the scar was soft and no obvious contracture occurred. Conclusion Super long thoracic umbilical conjoined perforator flap can repair the lager area skin defect of forearm with double blood supply. The length of flap is significantly longer with enough-blood-supply of distal part of the flap. The clinical efffect is satisfactory. Key words: Conjoined flap, perforator flap; Inferior epigastric artery; Posterior intercostal artery; Forearm; Defects

The clinical application of various forms of transverse rectus abdominis musculocutaneous flap in breast reconstruction and chest wall radiation ulcer repairment-Lessons learned and countermeasures

Objective To review outcome and experience in application of various forms of transverse rectus abdominis musculocutaneous flap in breast reconstruction and chest wall radiation ulcer repairment. Methods From January 2008 to February 2016, 61 cases (included 58 female patients and 3 male patients) were admitted, the age ranged from 39 to 57 years old. Among these cases, 37 cases received mastectomy and one-staged breast reconstructive operation and multiple chemotherapy preoperatively. The other 24 patients suffered from chest wall radiation ulcer, all occurred after mastectomy and radiotherapy, the course ranged from 12 to 56 months, all received long-time conservative therapy but the patient′s condition worsened. Of those patients 8 cases suffered radioactive bone injury , involved clavicle, rib and sterum; 3 cases suffered pleura injury; 2 cases suffered lung injury; 2 cases suffered brachial plexus injury and upper extremity lymphedema, resulted in upper extremity dysfunction. The patients were treated with pure pedicled transverse rectus abdominis musculocutaneous flap (TRAM) musculocutaneous flap in 31 cases, free TRAM musculocutaneous flap in 3 cases, pedicled TRAM musculocutaneous flap plus superficial inferior epigastric vein anastomosis in 13 cases, and pedicled TRAM musculocutaneous flap combined with contralateral free deep inferior epigastric perforator (DIEP) flap in 14 cases. Results The area of flap for chest wall reconstruction ranged from 22 cm×10 cm to 38 cm×15 cm, the size of flap for breast reconstruction ranged from 16 cm×10 cm to 22 cm×13 cm. The donor site was closed directly in all cases. Distal part necrosis and fat liquefaction were noted in 3 cases used pure pedicled TRAM musculocutaneous flap, in 1 case the defect was closed directly after radical debridement, in other 2 cases free anterolateral thigh flap was applied after debridement. All other 58 flaps survived uneventfully. All patients were followed up for 12-108 months with satisfied esthetic and functional results in reconstructed chest wall and breast. No local recurrence or ulcer happened. Only linear scar left in the donor sites, no hernia occurred. Conclusions Transverse rectus abdominis musculocutaneous flap is one of the first choice for breast reconstruction and chest wall radioactive ulcer.To ensure the operation success, it is efficient to apply different forms of transverse rectus abdominis musculocutaneous flap according to the flap size and blood supply. Key words: Surgical flaps; Rectus abdominis/SU; Epigastric arteries/SU; Mammaplasty; Skin ulcer/SU; Radiation injuries/SU; Thoracic injuries/SU

Thin anterolateral thigh perforator lobulated flap for repair of hand wounds

Objective To explore the curative effect of thin anterolateral thigh perforator lobulated flap for repairing hand skin and soft tissue defects. Methods From January 2009 to January 2016, 26 cases with hand skin and soft tissue defects were treated by free thin anterolateral thigh perforator lobulated flap. Anterolateral thigh perforator lobulated flap was harvested first. After the perforators were separated, the subcutaneous fat fascia was trimmed. The flap was lobulated and transplanted to repair the wound. The donor site was sutured directly. Results Postoperative follow-up period ranged from 6 to 24 months with an average of 13 months. One-leaf necrosis occurred in 1 case which achieved healing after skin grafting. The rest of 25 flaps survived uneventfully. The flaps were not bulky with satisfactory appearance. The donor site achieved primary healing. There was no obvious effect on walking. Conclusion Thin anterolateral thigh perforator lobulated flap is one of the ideal skin flaps to repair hand wounds. The shape and size of leaves can be adjusted according to the blood oozing from the dermis after thinning, which guarantees the lobulated flap blood supply and improves the success rate without secondary debulking. Key words: Surgical flaps; Treatment outcome; Anterolateral thigh perforators lobulated flap; Wound repair

A Possible Technique for the Complex Reconstruction of Exposed Breast Implant: Applicability and Microcirculation of the Capsule Flap

Aim of the Study: Immediate breast reconstruction is often applied after mastectomy. However, inappropriate surgical technique, postoperative radiotherapy and infection may lead to tissue necrosis and implant protrusion. Traditional therapies frequently fail. However, previous data suggested that capsule flaps may be appropriate for the salvage of implants. Our goal was to investigate the usefulness of capsuloplasty in patients with exposed breast implant and to monitor the blood supply of capsule flaps during the operation. Materials and Methods: Capsuloplasty was performed in 19 patients with exposed implant. After removal of necrotic tissue, capsulotomy was performed, the planned flap was dissected free, the implant was covered with the flap and the wound was then closed. During operation, the blood flow of the flap was determined by means of laser Doppler flowmetry. Moreover, tissue samples were taken for histology and immunostaining for CD34. Results: The postoperative follow-up showed that capsule flaps survived in each case: no complications were found. The blood flow of the flaps did not change significantly during the intervention as compared with the baseline values. The histology and the immunohistochemistry revealed considerable vascularization and angiogenesis in the flap. Conclusions: Capsule flaps seem to be appropriate for the salvage of exposed implants and for enhancement of implant cover in the case of thin and injured tissue.