Complex Tissue Defects Research Articles

Reconstruction of complex tissue defects of the hand with humeral osteocutaneous lateral arm flap

Objective To investigate the clinical effect of the application of humeral osteocutaneous lateral arm flap in reconstruction of complex tissue defects of the hand. Methods Eight cases of complex tissue defects of the hand were treated. The location and size of the bone flap was designed first according to the defect of the metacarpal and phalangeal bones (the distal end of the bone flap was at the upper margin of the lateral epicondyle). Then the location and size of the cutaneous flap was designed according to the defects of the hand. The line between the insertion of deltoid muscle and the epicondylus lateralis humeri is the body projection of the posterior branch of radial collateral artery. It is the axis while designing the flap. The posterior antebrachial cutaneous nerve can be retained in the flap in order to restore sensation of the recipient site. The area of the skin flaps ranged from 4.0 cm× 8.0 cm to 6.0 cm× 8.0 cm, while the area of the bone flaps ranged from 4.0 cm× 1.5cm×1.0cm to 6.0cm×1.5cm×1.0cm. Results All 8 osteocutaneous flap survived uneventfully.The donor sites were closed directly in all 8 cases. Functions of the upper arm were not impaired. The patients were follow-up for 4 to 24 months. Flap sensation recovery was satisfactory. Bone healing was observed and hand appearance was satisfactory. Conclusion The humeral osteocutaneous lateral arm flap is ideal for reconstruction of complex tissue defects of the hand. Key words: Wounds and injuries; Arm; Humerus; Osteocutaneous flap

Spliting second toe for repairing more complex tissue defects in a hand

Objective To investigate a method of repairing complex tissue defects one stage in one finger or several fingers for more fine recipient site repairing and less donor area traum. Methods From August 2007 to August 2010,eight cases of 20 fingers were reconstructed according to the state of complex tissue defects in a hand,second toes (right or left side) were split into two or three parts as complex tissue flaps that may including joints,tendons,skin,nail beds,et al.These flaps then were translated to hand to repair complex tissue defects by anastomosing vessels.Results Twenty fingers in 8 cases were successfully reconstructed.Follow-up ranged from 3 months to 36 months,external appearance were fine.According to the Trial Evaluation Standard of Reconstructed Finger Function of Handsurgery Society of China,sixteen fingers were excellent,three fingers were good,one finger was fine.And there was no effect on foot.Conclusion Spliting single second toe is a good method for repairing more complex tissue defects in a hand. Key words: The second toe; Transplantation; Reconstruction; Microsurgery

Repair the complex defect of lateral side of ankle with free anterolateral thigh musculocutaneous flap

Objective To explore the long-time clinical results and effection of free anterolateral thigh musculocutaneous flap for repairing the complex defects involving lateral or medial malleolar of the ankle and heel,especially for reconstructing stability of the ankle joints. Methods Thirteen patients with complex tissue defects,involving lateral or medial malleolar of the ankle and heel,were treated by free anterolateral thigh fasciomusculocutaneous flap.The fascia lata which was involved in the flap was fixed with the adjacent tissue of the recipient area.The descending branches of the lateral circumflex femoral vessels were anastomosed with the vessels in the recipient area.The largest area of the flap was 20 cm × 12 cm.The ankle joint was fixed in functional position with plaster in the early 3 months post-operatively.The following time ranged from 1.5 years to 20 years.The stability of the ankle joint were evatuated with the patients' objective feeling and clinical symptoms and imaging study.Results The stability of the ankle should be protected by external fixation in the early 3 months postoperatively,and was restored at 6 months usually.In all cases,ten cases were followed over 10 years,six cases were followed over 6 years,three cases were followed over 15 years.Though radiological discovering suggesting traumatic esteoarthritis exited in 3 cases with a follow-up more than 5 years,the clinical manifestations were fair and no one need undergo arthredesis. Conclusion Using ant erolateral thigh musculocutaneous flap for reconstructing the complex defects involving lateral or medial malleolar of the ankle and heel repairing stability of the joint and ovoiding off early arthrodosis of the joint is one of the favorable choice,especially for the teen-agers. Key words: Foot; Ankle; Ankle joint; Anterolateral thigh musculocutaneous flap; Microsurgical operation

Vacuum‐assisted closure improves the incorporation of artificial dermis in soft tissue defects: Terudermis® and Pelnac®

As a dermal scaffold, artificial dermal substitutes allow the body to accomplish its own tissue regeneration through infiltration of cells and neovascularisation. However, they show not only rather lower take rates compared to autologous skin grafts alone, but they also require more time for sufficient vascular ingrowth to overlay the skin graft. To accelerate this overlaying, we applied vacuum-assisted closure negative-pressure settings over the artificial dermis: Terudermis(®) and Pelnac(®) grafts. Fourteen patients with complex tissue defects were treated, including bone exposure in two cases, tendon exposure in seven cases and soft tissue defects in five cases. Nine cases had combined wound infections. The time interval between the first artificial dermis graft and the second split-thickness skin graft over it was 7·64 days on average. Dermal substitutes took place completely in all cases and there were no graft failures.

Clinical repairing complex defect of soft tissue and bone in limbs caused by traffic accident

Objective To report the clinical result of repairing complex tissue defect in limb caused by traffic accident using both tissue flap transplantation and external fixer. Methods The vascular tissue flap including bone flap and muscular flap to repair the complex tissue defection(soft tissue, bones, joints) in forearm, hand, leg, ankle and foot were applied in 36 cases. At the same time in surgery, injured bones and joints were fixed by external fixer for stabilizing and accelerating cure. Results All 56 eases were applied successfully with transplanted tissue combined with external fixation. The external fixers were moved away about 10-16 weeks(upper extremity) or 6-8 months(lower extremity) later and all the cases recovered satisfactorily. Conclusion It is a reliable method for repairing the complex tissue defection in the limb caused by traffic accident by external fixer of traumarology and microsurgery technique. And it is also characterized as a minor injury method on transplanted bones, enables early exercise for joints, convenient observation of flap circulation and easy nursing. Key words: Traffic accident; Limbs; Tissue flap; Transplantation; Microsurgery

Nursing on external fixator repairing defects of limbs caused by traffic accidents

Objective To report the clinical result of repairing complex tissue defect in limb caused by traffic accident using both tissue flap transplantation and external fixer. Methods The vascular tissue flap including bone flap and muscular flap to repair the complex tissue defection ( soft tissue, bones, joints) in forearm, hand, leg, ankle and foot were applied in 36 cases. At the same time in surgery, injured bones and joints were fixed by external fixator for stabilizing and accelerating cure. Results All 36 cases were applied successfully with transplanted tissue combined with external fixator. The external fixator were moved away about 10～16 weeks post - operation in upper extremity or 6～8 months post - operation in lower extremity and all the cases recovered satisfactorily. Conclusions It is a reliable method for repairing the complex tissue defection in the limb caused by traffic accident by external fixator with traumatology and microsurgery technique. And it is also characterized as a minor injury method on transplanted bones, enables early exercise for joints, convenient observation of flap circulation and easy nursing. Key words: Traffic accident; Complex defection; Tissue flap transplantation; External fixator; Nursing

The use of flow perfusion culture and subcutaneous implantation with fibroblast-seeded PLLA-collagen 3D scaffolds for abdominal wall repair

Highly cellularised 3D-tissue constructs designed to repair large, complex abdominal wall defects were prepared using poly (lactic acid) (PLLA)-collagen scaffolds i n vitro using a flow perfusion bioreactor. The PLLA-collagen scaffolds had a unique structure consisting of a collagen sponge formed within the pores of a mechanically stable knitted mesh of PLLA. The effect of the flow perfusion bioreactor culturing conditions was investigated in vitro for 0, 7, 14 and 28 days on scaffolds seeded with dermal fibroblasts. The cultured constructs were subsequently studied subcutaneously (SC) in an in vivo animal model. The results of in vitro studies demonstrated that the perfusion system facilitated increased cell proliferation and homogenous distribution in the PLLA-collagen scaffolds compared to static conditions. A highly cellularised 3D-tissue construct was formed by 7 days incubation under perfusion conditions, with increased cellularity by the 28 day time point. The in vivo model demonstrated that implanting constructs with high cellularity resulted in exceptional cell stabilisation, with the survival of implanted cells and expression of the phenotypically-relevant extracellular matrix proteins collagen types I and III, studied by fluorescence in situ hybridisation (FISH) and immunohistochemistry. The implantation of this porous PPLA-collagen scaffold seeded with dermal fibroblasts following in vitro maturation using a flow perfusion bioreactor system suggests a significant advance over current state-of-the-art procedures for the reconstruction of large, complex abdominal wall tissue defects.

Composite flap transfer from the foot for treatment of multi-finger complex soft tissue defects

Objective To introduce the clinical application of composite flap transfer from the foot for treatment of multi-finger complex soft tissue defects. Methods This method was applied to treat 7 cases and 19 fingers. All the cases involved complex dorsal soft tissue defect of 2 to 4 fingers with extensor tendons missing and phalanx or interphalangeal joint exposed. The combined soft tissue defect area was 5.0cm×1.5cm to 9.0 cm× 2.5 cm. The flaps were designed along the axis extending from the fibular and plantar margin of the great toe to the interspace between the first and second metatarsal bones. The flap was slightly larger than the dorsal finger defect combined and the shape of the flap was the same as the combined defect. The greater saphenous vein, dorsal digital veins and dorsal metatarsal or plantar metatarsal artery and nerves were included in the flap. They were sutured with dorsal digital veins, digital artery and nerves, respectively. Extensor digitorum brevis tendons and extensor digitorum longus tendons were included in the flap to reconstruct the missing tendons. Results All the flaps survived with good texture and good appearance. Two-point discrimination recovered 6 to 8 mm. Finger extension function was restored, and active finger flexion and extension recovered satisfactorily. The donor feet were with slight scar, good appearance and normal function. Conclusion Combined dorsalis pedis,toe web and great toe fibular flap including extensor digitorum brevis and extensor digitorum longus tendon is a good option to treat multi-finger dorsal complex defects. Key words: Surgical flaps; Finger injuries; Tendon injuries; Transplantation

Emergency tissue flap transfer (transposition) for reconstruction of complex upper extremity tissue defects accompanied with severe vascular damage

Objective To report the surgical techniques and clinical outcomes of emergency tissue flap transfer (transposition) for one-stage reconstruction of complex upper extremity tissue defects accompanied with severe vascular damage. Methods Ten cases of complex upper extremity tissue defects accompanied with vascular injuries were involved. The vessels were repaired to restore blood circulation of the limbs. Meanwhile based on the type and extent of tissue defects, cutaneous flaps, myocutaneous flaps, osteocutaneous flaps or composite flaps were transferred for one-stage repair. In 3 cases there were lengthy defect of the humeral artery and vein, biceps muscle defect and large skin defect on the medial side of the arm. The latissimus dorsi myocutaneous flap was transferred for wound coverage and elbow flexion reconstruction immediately after vascular repair. In 2 cases the vascular injuries were accompanied by the large soft tissue defect around the elbow. The thoraco-umbilical flap was transferred for wound coverage following vascular repair. Anterolateral thigh flap transfer combined with vascular reconstruction was carried out in 3 cases with skin and muscle defects accompanied with ulnar and radial artery injuries. In 1 case there were ulnar artery damage and defect of forearm both bones. A fibular osteocutaneous flap was transferred to repair the ulna bone defect along with vascular reconstruction in the first stage. At the second stage, another fibular osteocutaneous flap was transferred to repair the radial defect. In 1 case with combined forearm radial and ulnar artery damages, radial bone defect and large skin defect, combined transfer of the anterolateral thigh flap and iliac osteocutaneous flap were carried out in addition to the vascular repair. Results Postoperatively all the limbs and transferred tissues in the 10 cases survived. The patients were follow-up for 3 to 6 months. The 3 patients with defects at the arm level recovered maximum flexion of the elbow joint to 105°. Muscle power of elbow flexion was M_3 to M_4. Hand function was near normal. For the 7 patients with injuries at the elbow or forearm level, bone healing was achieved for the transferred bone flaps. There was partial recovery of the hand function. Conclusion In the management of complex tissue defect and vascular damage of the upper extremity, emergency composite tissue transfer at the same stage of vascular repair can effectively cover the wound, increase the survival rate of the compromised limb,and provide good soft tissue bed for secondary functional reconstruction. Key words: Surgical flaps; Wounds and Injuries; Transplantation; Microsurgery

Ultrathin Oblique Volar-to-Dorsal Reverse Turnover Radial Artery Perforator-Based Adipofascial Flap

Adipofascial flaps used in reconstruction of various tissue defects have been described by many authors and have several advantages. A clinical report of an extensive dorsal hand traumatic soft tissue injury where a new ultrathin oblique volar-to-dorsal adipofascial reverse turnover flap based on radial artery distal perforators is presented. Its width-to-length ratio was 1:4 (the longest ever reported), designed to cover primary free tendon grafts and exposed metacarpal bones. The technique has provided very good hand function and cosmetic outcome, minimum donor site morbidity, shortened rehabilitation, and no complications. Adipofascial flaps constitute a functional and an aesthetic refinement in the reconstructive surgical techniques managing complex tissue defects of the dorsum of the hand, a new surgical strategy reported here.

Poly-N-Acetyl Glucosamine Nanofibers

In several fields of surgery, the treatment of complicated tissue defects is an unsolved clinical problem. In particular, the use of tissue scaffolds has been limited by poor revascularization and integration. In this study, we developed a polymer, poly-N-acetyl-glucosamine (sNAG), with bioactive properties that may be useful to overcome these limitations. To develop a scaffold-like membrane with bioactive properties and test the biologic effects in vitro and in vivo in diabetic wound healing. In vitro, cells-nanofibers interactions were tested by cell metabolism and migration assays. In vivo, full thickness wounds in diabetic mice (n = 15 per group) were treated either with sNAG scaffolds, with a cellulosic control material, or were left untreated. Wound healing kinetics, including wound reepithelialization and wound contraction as well as microscopic metrics such as tissue growth, cell proliferation (Ki67), angiogenesis (PECAM-1), cell migration (MAP-Kinase), and keratinocyte migration (p 63) were monitored over a period of 28 days. Messenger RNA levels related to migration (uPAR), angiogenesis (VEGF), inflammatory response (IL-1beta), and extracellular matrix remodeling (MMP3 and 9) were measured in wound tissues. sNAG fibers stimulated cell metabolism and the in vitro migratory activity of endothelial cells and fibroblasts. sNAG membranes profoundly accelerated wound closure mainly by reepithelialization and increased keratinocyte migration (7.5-fold), granulation tissue formation (2.8-fold), cell proliferation (4-fold), and vascularization (2.7-fold) compared with control wounds. Expression of markers of angiogenesis (VEGF), cell migration (uPAR) and ECM remodeling (MMP3, MMP9) were up-regulated in sNAG treated wounds compared with controls. The key mechanism of the bioactive membranes is the cell-nanofiber stimulatory interaction. Engineering of bioactive materials may represent the clinical solution for a number of complex tissue defects.

The application of external fixator for complex tissue defect in the forearm

To discuss the curative effect of the external fixator for complex tissue defect in the forearm. From May, 2005 through December, 2008, the external fixators were used in 17 patients to treat the complex tissue defect in the forearm caused by trauma. There were 11 male and 6 female, with a mean age of 25.6. All patients were accompanied with the exposure of tendon, muscle or screw. The skin defect ranged from 7 cm x4 cm to 19 cm x9 cm. All patients underwent pedicle flap repair. The flap ranged from 10 cm x 6 cm to 20 cm x 15 cm. The proximal pedicle of the flap was sutured into a tubular. The position of the pedicle was fixed by the external fixator. The pin was at the ulnar and the iliac (n=5), and the radius and the iliac (n=12). The immobilization lasted 3 to 8 weeks, 5.1 weeks in average. All patients were followed up for 3 to 20 months, 11.3 in average. All pedicle flaps survived with no pressure ulcer, or no erosion in the axilla. No compartment syndrome or osteomyelitis occurred. Four to six week after surgery, the pedicle was cut. Infection occurred at the cutting end in 1 patient. The wound healed after addressing. The wound in the other 16 patients healed successfully. The fracture of the ulnar and the radius healed 8.5 or 15 weeks after surgery, 13.5 weeks in average. Eleven patients underwent second stage reshape and function restoration. The function of the hands and forearms recovered satisfactorily. Eleven patients returned to their work. Six patients can live with basic function for living. The external fixator used for complex tissue defect in the forearm can keep the position of the pedicle, replacing plaster fixation. It can reduce the incidence of flap and vessel spasm, and get good outcomes.

Is the ratio of functional fibrinogen to platelets as measured by thromboelastography a predictive parameter for thrombotic complications in free tissue transfer surgery?

The risk of total flap loss after free microvascular tissue transfer is estimated to be between 2 and 6%. Flap failure is most frequently due to anastomotic thrombosis, occurring in the early postoperative period. The exact causes of events leading to thrombotic occlusion still are not clearly elucidated, although authors have observed detrimental effects of increased platelet counts, platelets aggregation, and elevation of fibrinogen levels on flap survival. In patients with hyperfibinogenemia related to oral cancer, the safety of performing a successful microsurgical procedure for complex tissue defects has been debated, and the correlation between hyperfibrinogenemia and vascular thrombosis in microsurgery remains unclear.

Transplantation of the cutaneous fibular flap combined with anterolateral thigh flap for the repair of complex tissue defect of the leg

Objective To explore the clinical application and effect of the transplantation of the cutaneous fibular flap combined with anterolateral thigh flap for the repair of complex tissue defect of the leg. Methods The cutaneous fibular flap combined with anterolateral thigh flap in series connection or parallel connection transfer were applied to repair complex tissue defect of the leg in 36 cases. 10 cases were fresh non-infectious wound 26 cases were delayed infectious wound. The area of wound ranged from 25 cm × 18 cm to 45 cm × 13 cm (36 cm × 16 cm on average). The area of anterolateral thigh flap ranged from 12 cm × 13 cm to 32 cm × 18 cm. The area of the cutaneous fibular flap ranged from 2.0 cm × 1.5 cm to 18.0 cm × 16.0 era. The length of fibular transplantation ranged from 10 cm to 24 cm. 30 cases were combined in parallel connection transfer, 6 cases were combined in series connection transfer, 5 cases were repaired in emergency, 5 cases were repaired in subemergency, 26 cases were repaired in delay. Results All cases were successfully repaired in 36 cases.35 cases were followed up. A mean follow-up was 29 months. Arterial crisis occurred in 1 case, venous crisis occurred in 2 cases 34 flaps survived completely and 2 cutaneous fibular flap survived partially in parallel connection which were later healed by skin transplantation.32 cases were healed in first stage, 4 cases were healed in second stage, (healing time ranged from 12 to 18 days), Bone healing time ranged from 3 to 6 months in fibula transplantation. The Enneking score system was applied to evaluate the leg function. Of the 35 cases, the mean scores was 26 (their scores ranged from 23 to 28).The functions of all supplied regions were not found malfunctional. Conclusion Transplantation of the cutaneous fibular flap combined with anterolateral thigh flap is an optimal method to repair the complex tissue defect of the leg. Key words: The cutaneous fibular flap; Anterolateral thigh flap; Transplantation; Microsurgery

Concept and Anatomical Basis of Microdissected Tailoring Method for Free Flap Transfer

For a refined microsurgical reconstruction, it is desirable to adjust the flap to fit the three-dimensional details of the defect. Essentially, each vessel arborized in the subcutaneous adipose tissue supplies axial blood flow to an individual small area surrounding the vessel. Therefore, free alteration of the flap would be possible if the anatomy of these branches could be identified during surgery. The microdissected tailoring method is a new procedure for alteration of the flap, observing the branches of the perforator directly after microdissection. By means of this procedure, three flaps were transferred to complex tissue defects. In addition, among intraadipose branches of 59 perforators, 90 cases of three types of microdissected thin perforator flap transfer were measured to classify the anatomical variations relating to microdissected tailoring of the flap. All flap transfers were uneventful and no circulatory failure of the flaps was observed. Statistical analyses reveal that the intermuscular septum perforator branches at the deeper layer of the adipose tissue and then spreads more widely in the adipose layer than that of muscle perforator, regardless of the type of flap and the length of the intraadipose vessel. Microdissected tailoring of the flap provides the best solution for flap alteration in the reconstruction of a complex-shaped tissue defect. It represents a change in the concept of free flap transfer, because the flap is prepared according to the individual anatomy of the intraadipose vessel.

Composite Tissue Transplantation: A Rapidly Advancing Field

Composite tissue allotransplantation (CTA) is emerging as a potential treatment for complex tissue defects. It is currently being performed with increasing frequency in the clinic. The feasibility of the procedure has been confirmed through 30 hand transplantation, 3 facial reconstructions, and vascularized knee, esophageal, and tracheal allografts. A major drawback for CTA is the requirement for lifelong immunosuppression. The toxicity of these agents has limited the widespread application of CTA. Methods to reduce or eliminate the requirement for immunosuppression and promote CTA acceptance would represent a significant step forward in the field. Multiple studies suggest that mixed chimerism established by bone marrow transplantation promotes tolerance resulting in allograft acceptance. This overview focuses on the history and the exponentially expanding applications of the new frontier in CTA transplantation: immunology associated with CTA; preclinical animal models of CTA; clinical experience with CTA; and advances in mixed chimerism–induced tolerance in CTA. Additionally, some important hurdles that must be overcome in using bone marrow chimerism to induce tolerance to CTA are also discussed.

Current Status of Composite Tissue Allotransplantation

Composite tissue allotransplantation (CTA) is emerging as a potential treatment for complex tissue defects. A major drawback for CTA remains the requirement of lifelong immunosuppression. Up to date numerous experimental CTA models have been introduced to the transplantation literature. After the first hand transplantation in 1998, the clinical applicability of CTA has attracted a lot of attention. This article will outline the historical background of CTA and our experience in different CTA models.

Free triceps lateral head myocutaneous flap transfer for repair of major complex tissue defect in the forearm

目的 探讨应用游离肱三头肌外侧头肌皮瓣修复前臂软组织缺损的方法.方法采用吻合血管的肱三头肌外侧头肌皮瓣移植修复6例前臂软组织缺损.肌皮瓣面积最大为14cm×8cm,最小9cm×5cm.结果6例肱三头肌外侧头肌皮瓣全部存活.术后1例发生血管危象,经手术探查重新吻合血管后存活.6例病人均得到随访,皮瓣外形及功能满意.结论肱三头肌外侧头肌皮瓣具有解剖位置恒定,血管蒂较长,口径粗,血运丰富,抗感染能力强和其皮肤与前臂皮肤组织结构相近等特点,是一种修复前臂软组织缺损的有效方法。

Second toe transplantation to repair complex tissue defect of the thumb and fingers

目的 介绍应用第二足趾部分组织移植修复拇、手指复合组织缺损的方法.方法对12例拇、手指缺损的骨、肌腱、神经及软组织采用部分第二足趾移植修复.结果 12例游离部分第二足趾全部存活.术后4个月～2年随访,手功能按中华医学会手外科学会上肢部分功能评定试用标准评定,优良率达到75%.结论游离部分第二足趾移植具有一期修复拇、手指复合组织缺损的较理想手术方法。

Plastic solutions for orthopaedic problems.

Infection and exposure of the implant may occur in 1-12% of patients operated on for arthroplasty or osteosynthesis. Variables such as tissue viability, presence of infection, exposure of osteosynthesis material and patient-related factors contribute to the lack of general consensus regarding the management of these defects. Between January 1999 and January 2001, six patients were treated for complex soft-tissue defects following various orthopaedic procedures at the Department of Plastic Surgery in the Slotervaartziekenhuis in Amsterdam, a rheuma-orthopaedic orientated hospital. All patients were initially treated by radical debridement and vacuum-assisted closure (VAC) system of the wound. After 1 week, this was followed by transplantation of a pedicled or free flap to cover the defect. We studied the medical history, initial orthopaedic procedure, wound treatment, transplanted flap and outcome of plastic surgery in this group. Plastic surgical intervention led to wound closure in all cases. In only one case was the osteosynthesis material removed because of osteomyelitis. We conclude that the earlier coverage with vital tissue is obtained, the lower the incidence of infection. Early consultation by a plastic surgeon will increase a positive outcome of treatment of complex tissue defects.