Compound Flap Research Articles

Pedicled thoracoacromial artery compound flaps for circumferential hypopharyngeal reconstruction.

Total laryngeal and hypopharyngeal resection remained to be the mainly treatment option for advanced hypopharyngeal cancer, which resulted in complicated reconstructive challenge for circumferential hypopharyngeal defect. The pedicled thoracoacromial artery compound flaps included Thoracoacromial artery perforator (TAAP) flap and pectoralis major myocutaneous (PMMC) flap. This study is to evaluate the clinical application of the pedicled thoracoacromial artery compound flaps for circumferential hypopharyngeal reconstruction. From May 2021 to April 2022, four hypopharyngeal cancer patients with circumferential hypopharyngeal defects were reconstructed by the pedicled thoracoacromial artery compound flaps. All patients were males. Patient age ranged from 35 to 62years (average, 50years). The Shoulder function were evaluated by SPADI. The average follow-up was 10.25months (range from 4 to 18months). All of the pedicled thoracoacromial artery compound flaps in our study survived. The defect length between tongue base and cervical esophagus ranged from 8 to 10cm after total laryngeal and hypopharyngeal resection. The TAAP flap size ranged from 6 × 7cm to 7 × 10cm, and the PMMC flap size ranged from 6 × 7cm to 9 × 12cm. The pedicle length of TAAP and PMMC flaps varied, respectively, from 5 to 8cm (mean 6.5cm) and 7cm to 11cm (mean 8.75cm). The mean time of TAAP and PMMC flaps harvest was, respectively, 82min and 39min. All patients were able to resume soft diet in the fourth week of postoperation, but one patient was operated by gastrostomy in the second month of postoperation because of pharyngeal cavity stenosis, and the patient successfully resumed oral soft diet by endoscopic balloon dilation after postoperation radiotherapy. All patients have resumed oral feeding at last. There were mild dysfunction for our patients according to SPADI during the mid-long follow-up. The pedicled thoracoacromial artery compound flaps have stable blood supply and provide adequate muscle coverage for greater protection during radiotherapy, and the microsurgical skills have no requirement. Therefore, the compound flaps provide a good choice for the reconstruction of circumferential hypopharyngeal defect, especially in the aged or patients with comorbidities who are not able to tolerate prolonged surgery.

Reconstruction of Soft-Tissue Defects of the Thumb Using Reverse-Flow Homodigital Flaps: A Systematic Review

IntroductionSoft-tissue thumb defects are common reconstructive challenges, the main goals being restoration of tactile sensibility, range of movement, pulp padding, length, and cosmesis. The reverse-flow dorsoulnar and dorsoradial collateral artery flaps are homodigital flaps used to cover both distal dorsal and volar thumb defects. These flaps can be used as compound flaps including skin, fat, and/or nerves. As there is no critical analysis of these studies, this study aims to create a synthesized comprehensive systematic review. MethodsSystematic review was performed using the databases PubMed, Embase, and Medline. Eligible studies followed the inclusion criteria: English language and all studies published to date. The primary outcome was flap survival. Other data collected included anatomical area of the defect, flap constituents and dimensions, donor-site closure and complications, transfer method, reoperation, revision, and functional outcomes. ResultsA total of 19 articles incorporating 189 flaps met the inclusion criteria. These flaps were categorized and analyzed as dorsoradial (50%), dorsoulnar (39%), and turnover flaps (11%). Dorsoradial flaps were used in fasciocutaneous fashion alone. Partial flap failures occurred in five cases. Dorsoulnar flaps were used as fasciocutaneous or as osteocutaneous flaps. Complete flap failure was reported in one patient alone, whereas partial necrosis was reported in four patients. Adipofascial turnover flaps had two partial flap failures reported but no complete failures. The overall complete and partial flap failure rates were 0.5 and 6.5%, respectively. ConclusionReverse-flow homodigital random or axial-based flaps provide a reliable means of reconstruction for soft-tissue defects with reasonable success rate and good functional outcomes. They have a consistent anatomy with a good potential for personalization and therefore increased versatility.

Клинический пример лечения пациента с посттравматическим комбинированным обширным дефектом тканей голени

Introduction Treatment of patients with open fractures of long bones with soft tissue defects remains one of the most difficult tasks of current traumatology. Material and methods We repor a clinical case of the treatment of a patient with an extensive purulent wound, a defect in the tibia, chronic damage to the anterior neurovascular bundle, tendons and muscles of the anterior and lateral groups of the lower leg, post-traumatic severe lymphedema of the right foot. The complex of the treatment process included debride-ment of the wound, orthoplastic surgery using Ilizarov transosseous osteosynthesis and elements of plastic surgery. The defect of the right tibia was managed using a non-free vascularized peroneal compound flap from the opposite tibia. Results The treatment of this patient resulted in the arrest of osteomyelitis, a significant reduction in foot lymphedema, restoration of weight-bearing and functional capacity of the right lower limb. This was achieved by replacing a significant defect in the tibia and soft tissues under conditions of long-term wound and scar processes and compromised main blood flow in the affected lower leg. Discussion The main operations for management of complex defects in the tissues of the lower leg are demonstrated. Among them, the main ones are transosseous osteosynthesis according to Ilizarov and microsurgical replacement with a vascularized complex of tissues.

Vascular iliac myofascial flap to repair compound defect of the jaw

The vascular iliac myofascial flap is a compound flap with the deep circumflex iliac artery (DCIA) as the vascular pedicle, carrying the iliac bone and parts of the internal oblique, external oblique and muscle-fascial tissue that cover the surface of the iliac crest and inside the iliac bone. The aim of this study was to advocate a feasible surgical strategy for maxillofacial surgeons through our review of clinical applications and to improve the quality of life of patients after the operation. In recent years, Stomatology Hospital of Wuhan University has performed dozens of vascularized iliac myofascial flaps, not only to repair jaw defects but also to complete the repair of intraoral soft tissue defects. 20 patients were followed up. These patients with jaw tumors who received a vascular iliac myofascial flap to repair compound defects of the jaw from 2018 to 2020. The Quality of Life Questionnaire-Head and Neck Cancer-37 (QLQ-H&N37) was used to evaluate their speech function (Z=-0.061, P>0.05) and postoperative aesthetics (Z=-2.824, P<0.05). All patients obtained good surgical results and satisfaction in terms of aesthetics and function. The successful reconstruction of these cases prove that the vascularized iliac composite flap with myofascial tissue is a reliable flap for the reconstruction of maxillofacial defects.

Clinical application of superior lateral genicular artery perforator propeller flap in repair of soft-tissue defects around knee joint

To explore the feasibility and effectiveness of using the superior lateral genicular artery (SLGA) perforator propeller flap to reconstruct soft-tissue defects around the knee joint. Between October 2013 and May 2019, 10 patients underwent repairing of soft-tissue defects around the knee joint using the SLGA perforator propeller flap. There were 6 males and 4 males, with a median age of 34.5 years (range, 6-66 years). Etiologies included radical tumor resection in 4 cases, post-burn scar contracture in 3 cases, post-burn hypertrophic scar in 2 cases, and prothesis exposure after knee arthroplasty in 1 case. Defects located on the lateral knee in 6 cases, proximal lateral leg in 2 cases, popliteal fossa in 1 cases, and infrapatellar region in 1 case. The size of soft-tissue defects was from 6 cm×4 cm to 14 cm×8 cm. The extraction range of the flap was from 10.0 cm×5.5 cm to 23.0 cm×7.0 cm; the length of the perforator pedicle was 2.5-5.0 cm, with an average of 3.65 cm; the flaps were rotated 180°, the large paddle of the propeller flap was used to repair the defect, and the small paddle was used to assist the closure of donor site. Blister was observed in the distal 3-cm of one flap and the flap survived after conservative management. All the flaps survived, and the wounds in the donor and recipient areas healed by first intention. There was no vascular crisis, incision dehiscence, infection, or other complications. All 10 patients were followed up 4 to 48 months, with an average of 12.6 months. The color and texture of the flap were similar to those of the recipient area, and there was no need for secondary operation for degreasing and thinning. Scar contracture was corrected; no tumor recurrence was found in tumor patients; the artificial knee joint was preserved, the knee joint flexion and extension activities were good, and all the patient and family members were satisfied with the appearance and function of the lower limbs after operation. The SLGA perforator propeller flap surgery is relatively simple without the need of microvascular anastomosis, has the minimal donor-site morbidities, and can provide a compound flap for the repairing of a complex wound. The SLGA perforator propeller flap is one of the optional methods to repair soft-tissue defects around the knee joint.

A meta-analysis evaluating risk factors for compound free flaps for upper extremity defect reconstruction comparing complications and functional outcomes of compound free flaps with and without bone components.

Compound flaps offer the advantage of one stage defect reconstruction respecting all relevant tissues and early functional recovery by optimal vascularity of all components. Due to its specific vascular anatomy and the three-dimensional donor site, compound flaps with bone components may result in higher complication rates compared to soft tissue compound flaps. The meta-analysis summarizes the available evidence and evaluates whether bone components are a risk factor for periprocedural complications in upper extremity multidimensional defect reconstruction. PubMed and Embase were searched for all publications addressing compound free flaps for upper extremity defect reconstruction with bone or soft tissue components published between January 1988 and May 2018. The methodological quality was assessed with the American Society of Plastic Surgeons Evidence Rating Scale for Therapeutic Studies. Flap loss, thrombosis rate, early infection, hematoma, seroma, as well as donor site complications were extracted and analyzed. Twelve out of 1157 potentially eligible studies (evidence-III) comprising 159 patients were finally included with publication bias for all summarized complication rates. Complication rates for flaps with/ without bone components were: total flap loss 5%, 95% CI=3%-10% (6%/5%); partial flap loss 8%, 95% CI=5%-15%, (9%/8%); arterial/venous thrombosis 7%, 95% CI=4%-12%, (8%/5%)/14%, 95% CI=9%-21% (16%/6%, P< .05) with higher risk for flaps with bone components; infection 6%, 95% CI=3%-12% (6%/6%); hematoma 6%, 95% CI=3%-11% (6%/5%); seroma 5%, 95% CI=3%-10% (5%/5%); dehiscence 10%, 95% CI=6%-17% (11%/9%). Compound flaps for upper extremity defect reconstruction including bone components have a higher venous thrombosis rate compared to compound soft-tissue flaps.

The Versatility of the Superficial Circumflex Iliac Artery Perforator Flap: A Single Surgeon's 16-Year Experience for Limb Reconstruction and a Systematic Review.

The superficial circumflex iliac artery perforator (SCIP) flap is a versatile option of free tissue transfer for small to large defects. In this study, we examine the advantages of the SCIP flap, its cadaveric anatomy, and clinical subtypes. Ten cadavers were dissected and the corresponding pedicles of the SCIP and groin flaps were identified. A retrospective review of 20 clinical cases of free SCIP flap reconstruction was undertaken. The indication for reconstruction, flap dimensions, and survival were analyzed. A systematic literature review was conducted including articles that have previously reported the use of the SCIP flap. The SCIP pedicle was present in all our cadaveric dissections. The starting point of its pedicle ranged from 1.5 to 4.5 cm along the superficial circumflex iliac artery. The median diameter of the perforator and its concomitant vein was 1mm (range 0.8-2 mm). A cutaneous vein (1.3-2.3 mm) could be included in the flap if the concomitant vein was too small. Twenty consecutive patients had free SCIP flaps between 2002 and 2018. The indications were for finger defects (n = 8), thumb reconstruction (n = 1), lower limb compound fractures (n = 3), iatrogenic wounds (n = 2), upper limb large defects (n = 2), and scar contractures (n = 4). Flap dimensions ranged from 2 × 4 cm to 14 × 25cm, and the longest pedicle was 8cm. All flaps survived. The systematic literature review identified 34 previous reports using the SCIP flaps, most of these published by Asian units. The SCIP flap is useful for reconstruction throughout the body due to its ease of dissection, thinness, adjustable pedicle length, and flap dimension ranging from tiny to large, as well as the feasibility of raising a compound flap incorporating an adipofascial or vascularized bone component if necessary.This is a level of evidence therapeutic IV study.

Clinical study and prognostic analysis of composite flap transplantation combined with traditional Chinese medicine for the skin repair and bone defects of limbs

Objective To explore the clinical effect and prognosis of composite skin flap transplantation combined with traditional Chinese medicine for the skin repair and bone defects of extremities. Methods A total of 80 patients with extremities' bone defect were selected in our hospital between March 2016 and March 2015. The patients were randomly divided into two groups according to the orders of the alternaive medical treatment. The observation group (n=40) was treated with compound skin flap transplantation combined with Chinese traditional medicine steaming and washing. The control group (n=40) was treated with a single compound flap transplantation. The skin flaps, transplant survival rate, flap swelling, treatment effect and complications were observed. Results The survival rate of the observation group was 95% (38/40), and the survival rate of the control group was 75% (30/40). The survival rate between two groups was statitically significant difference (χ2=6.274, P<0.05). The proportion of degree Ⅰ of the skin flap in the observation group significantly higher than that in the control group (χ2=8.584, P=0.003), while the proportion of degree Ⅳ of the skin flap in the observation group significantly lower than that in the control group (χ2=4.210, P=0.040). The total effective rate in the observation group was 97.5% (39/40), the control group was 77.5% (31/40), and the difference between two group was significant (χ2=7.314, P<0.05). The incidence of complications in the observation group was 2.5% (1/40). The incidence of complications in the control group was 17.5% (7/40). The incidence of complications in the observation group was significantly lower than that in the control group (χ2=5.000, P<0.05). Conclusions The combination of skin flap transplantation and Chinese medicine could repair bone defect of the extremities, lower swelling degree of the skin flap after transplantation and improve curative effect, and the incidence of complications after treatment is low and the clinical value is high. Key words: Surgical flaps; Transplantation; Reconstructive; Steaming washing therapy; Extremities; Bone defect

Different mini skin flaps in repairing finger soft tissue with bone defect

To explore surgical methods and clinical effects of three different types of mini skin flap transplantation for repairing finger soft tissue with bone defect. Thirty-three patients with finger soft tissue or bone defect were treated from December 2014 to October 2016, including 24 males and 9 females aged from 21 to 52 years old with an average of (36.42±5.70) years old, and soft tissue defect area ranged from 1.3 cm×1.8 cm to 2.3 cm×4.2 cm. According to damage degree, nature and patients' options, 15 finger of 15 cases were adopted retrograde dorsal metacarpal artery perforators fascia flap, 10 fingers of 9 cases were treated with free foot artery descending branch wrist skin flap, 9 fingers of 9 cases were treated with free the second toe details phalanges compound flap. Survival rate, postoperative complications and finger function assessed by Dargan functional criteria at the latest follow up were observed. All flaps were survived, both of donor site and recipient site were without deep infected. The donor site of one patient occurred necrotic, and the distal donor site of one patient occurred surface necrotic, then healed by active dressing change. All patients were followed up from 6 to 16 months with an average of(8.34±1.28) months. Two points of finger recognition were restored between 8 and 12 mm with an average of (8.84±0.43) mm, and the appearance, texture and sensory functions of skin flap were restored. No obvious complications were observed on the donor site. According to Dargan function evaluation of finger joints, 18 patients got excellent results, 14 moderate and 1 good. Three kinds of mini skin flap could receive good results in repairing soft tissue of finger or bone defect. Reverse dorsal metacarpal artery perforator fascia flap is not necessary with anastomosing blood vessels and has advantages of safe, simple and high survival rate. Descending branch of superior cutaneous branch of free ulnar artery could cut multiple other perforator flaps simultaneously, and the scar is small and hidden. Dissociated the second toe combined metatarsal phalangeal flap could repair shape and function of finger to the maximum extent and donor site is hidden.

The Chimera Flap: A Quarter Century Odyssey.

Incredibly complicated multidimensional defects have always strained the ingenuity of the reconstructive surgeon. Secondary perhaps to vascularized composite allotransplantation as a solution to this dilemma, the compound flap has been developed to be a more useful and available alternative. Their greatest versatility has been proven by its subtype, the chimera flap. The chimera flap itself consists of multiple flaps, the latter possibly composed of bone, skin, muscle, and so on, where each part has an independent vascular supply, and each part is independent of any physical interconnection whatsoever with the other components, except where joined ultimately only to a common vascular pedicle. An appellation for this concept was first introduced a quarter century ago in this very journal, a time frame now the impetus for a recapitulation of its origin and subsequent history that proves that it has eventually withstood the test of time and has been successfully assimilated into the reconstructive repertoire.

A Modified Approach to Extensive Oromandibular Reconstruction Using Free Fibula Flaps.

In select patients with advanced disease resulting in large composite tissue defects, consideration is often given to multiple flap reconstruction. The authors propose an alternative option. Using virtual surgical planning the authors demonstrate how modest sacrifice in projection translates into a substantial decrease in the volume and surface area of soft tissue needed, in turn maximizing soft tissue coverage with a single fibula free flap. The authors used 3-dimensional virtual surgery to simulate angle-to-angle reconstructions using free fibula flaps. The reference 3-segment reconstruction was done using symphyseal projection to the plane perpendicular to the anterior nasal spine, a customary landmark. Additional simulations were then performed using recessed projections 0.5 mm, 1 cm, 1.5 cm, and 2 cm posterior to anterior nasal spine plane. Program analytics were used to calculate the surface area and volume of the floor of mouth. With projection recessed by 1 cm, surface area decreased 22% to 14 cm. With projection recessed by 2 cm, surface area decreased 44% to 10 cm. With a 3-segment construct converted to a 2-segment construct, surface area decreased 22% to 14 cm. This demonstrates for the first time an official analysis of an intraoperative modification that sacrifices little and gains a lot. Ultimately, 1 compound flap can be used in extensive reconstructions with increased confidence that it will not be overly stressed.

Full-Length Finger Reconstruction for Proximal Amputation With Expanded Wraparound Great Toe Flap and Vascularized Second Toe Joint.

Most of the frequently used methods for finger reconstruction have their own limitations. Reconstruction of a full-length finger with normal appearance, in patients with proximal digital amputation, remains a challenge. Between January 2002 and November 2013, a total of 86 fingers (60 patients) with proximal phalanx amputation were surgically repaired. A compound flap comprising an expanded wraparound flap from the great toe and a vascularized proximal interphalangeal (PIP) joint from the second toe was harvested to reconstruct a full-length finger. The flap was used to reconstruct the nail, skin, and the distal phalanx; the PIP joint was used to reconstruct the PIP joint. To attain normal length of the finger and right PIP joint positioning, an iliac bone graft was inserted into the distal-middle or proximal phalanx. All reconstructed fingers retained their viability and natural appearance and were of near-normal length with a normal PIP joint positioning; 12.8% (9/86) of the procedures required re-exploration owing to compromised circulation. Secondary procedures were required in 71% (61/86) of the cases. With the exception of 1 case, the donor-site complications were mild; the average range of motion at the other PIP joints was 52 degrees (-15 to -5 degrees of extension, 25-90 degrees of flexion). Approximately 80% of the normal functionality and 93% of the normal appearance with respect to aesthetics were restored. The full-length finger reconstruction procedure allows for construction of natural-appearing full-length fingers with normal PIP joint positioning and a near-normal functional recovery for proximal digital amputation. The operation is technically complex and time consuming and demands a skilled operator for successful outcomes.

Reconstruction for Dysplastic Radial Polydactyly With an Island Compound Flap

Purpose: To investigate the necessity and possibility of digit fusion with an advanced island flap in thumb dysplasia of radial polydactyly. Methods: We collected the patients with radial polydactyly, whose nail width or thumb girth was less than 80% of contralateral side, from February of 2007. Among them, some patients were also associated with radial deviation deformities in two thumbs or a shorter radial thumb compared with ulnar thumb. In these cases,the proper palmar digital artery island flap was harvested and advanced to eliminate the tension between the radial and ulnar duplicate. Besides the island compound flap containing a part of the distal phalanx and nail bed was harvested from the accessory radial duplicate to augment the retained ulnar duplicate. The patients only with a smaller thumb girth were treated by an island flap to augment the thumb size. There were 26 patients, including 29 sides. Preoperative Doppler ultrasonic examination was assigned to observe the amount and distribution of princepspollicisartery (PPA)and proper palmar digital artery (PPDA). Appearances were evaluated by Wang-Gao scoring system and functions were evaluated by Tada scoring system. Results: There were two basic artery forms through preoperative ultrasonography and surgical exploration in 29 hands: both thumbs only had one PPDA which was observed in 82.76% (24 hands); the main thumb had two while the extra thumb still had one which was observed in 17.24% (5 hands). All cases were operated according to preoperative design using an island compound flap. 26 hands in 23 patients were followed up more than 6 months. Flap results included survival in 22 patients, tension vesicle in 2 patients and tip necrosis in 2 patients. The incision was infected in one patient with the treatment of changing dressing regularly. The function results were excellent in 21 patients, good in 4, fair in 1. In terms of aesthetic, there were 13 excellent results, 4 good and 1 fair. Conclusion: There is one developed PDAA, which can be used to design a flap, in the accessory radial duplicate. The longitudinal advanced flap can also eliminate the tension caused by unequal length in two thumbs. Using an axial or island flap to reconstruct a new thumb can not only change the appearance, but also make the reconstructed thumb acquire two sets of blood supply and nerve system.

Reconstruction for dysplastic polydactyly of thumb with an island compound flap

To investigate the necessity and feasibility of digit fusion with an advanced island flap in thumb dysplasia of radial polydactyly. From February 2007 to January 2015,we collected the patients with radial polydactyly, whose nail width or thumb girth was less than 80％ of contralateral side. Among them, some patients were also associated with radial deviation deformities in two thumbs or a shorter radial thumb compared with ulnar thumb. In these cases, an island compound flap, which was based on proper palmar digital artery (PPDA) in radial thumb and contained nail, part distal phalanx and skin, combining with ulnar side of ulnar thumb was used to reconstruct a new thumb. Only the patients with a smaller thumb girth were treated by an island flap to augment the thumb size. There were 26 patients, including 29 sides.Preoperative Doppler ultrasonic examination was assigned to observe the amount and distribution of princepspollicisartery(PPA) and PPDA. Appearances were evaluated by Wang -Gao scoring system and functions were evaluated by Tata scoring system. There were two basic artery forms through preoperative ultrasonography and surgical exploration in 29 hands: both thumbs only had one PPDA; the main thumb had two while the extra thumb still had one. The former was responsible in 82.76％ (24 hands).All cases were operated according to preoperative design using an island compound flap.26 hands in 23 patients were followed up more than 6 months. Flap results included survival in 22 patients, tension vesicle in 2 patients and tip necrosis in 2 patients. The incision was infected in one patient with the treatment of changing dressing regularly. The function results were excellent in 21 patients, good in 4,fair in 1.Aesthetic results were excellent in 13 patients, good in 4 and fair in 1. There is always one developed PDAA in extra thumb, which can be used to design a flap. The longitudinal advanced flap can also eliminate the tension caused by unequal length in two thumbs. Using an axial or island flap to reconstruct a new thumb can not only change the appearance, but also make the reconstructed thumb acquire two sets of blood supply and nerve system.

Simultaneous Reconstruction of Forefoot and Hindfoot Defects with a Thoracodorsal-Axis Chimeric Flap.

Simultaneous Reconstruction of Forefoot and Hindfoot Defects with a Thoracodorsal-Axis Chimeric Flap.

Reconstruction of upper and lower eyelids with auricular, postauricular, and retroauricular scalping flap with cartilage flap.

Sir: The postauricular and retroauricular scalping flap (PARAS), described by Dias and Chhajlani,1 has a profuse circulation from the contralateral superficial temporal vessels. The PARAS flap is described as a skin flap. Our modification adds preauricular skin and a portion of helical cartilage and combines conchal cartilage with postauricular skin. It is called an auricular, postauricular, and retroauricular scalping flap with cartilage flap (APARASC flap) (Fig. 1). Fig. 1. The APARASC flap was elevated. The upper eyelid was reconstructed with the auricular skin and helical cartilage compound flap, and the lower eyelid was reconstructed with postauricular skin and conchal cartilage and retroauricular skin compound flap. A 66-year-old man had developed a tumor on his left cheek 10 years back but received no treatment. The tumor spread slowly and widely and became ulcerated. A biopsy revealed basal cell carcinoma. The ulcerative lesion spread to the upper and lower eyelids. CT scan and MRI showed no cervical metastatic lymph nodes or other metastatic lesions. The ulcerative cancer was resected with a 10-mm tumor-free margin in the cheek and a 5-mm margin in each eyelid. A 15-mm-wide full-layer defect resulted in the upper eyelid and a 20-mm-wide full-layer defect in the lower eyelid. The APARASC flap was elevated. The upper eyelid was reconstructed with the auricular skin and helical cartilage compound flap and the lower eyelid with the postauricular skin and conchal cartilage and retroauricular skin compound flap (Fig. 1). The cartilage with perichondrium remained exposed without covering to allow mucosal migration. The hair-bearing area of the flap was returned back 15 days after the first operation. The cheek and the donor site of the ear region were reconstructed with full-thickness skin grafts from the medial side of the left upper arm. Later, defatting for flap reduction was performed several times. Two and a half years later, the tumor has not recurred. The patient has not complained of dryness of the left eye and can open and close the left eye very easily (Fig. 2). The donor site of the flap has an acceptable appearance. Fig. 2. Appearance of the flap 2½ y after operation. This patient had full-layer defects of his left upper and lower eyelids. For reconstruction, a malar flap could not be used because the skin tumor had spread widely over his cheek. Dias and Chhajlani1 reported their use of a PARAS flap for reconstruction of the facial skin. In their report, the flaps were used in the reconstruction of the frontal region, the cheek, alar defects (2 cases), and the eyelid. In their eyelid repair, ear cartilage was not used. For our patient, we modified their method. The retroauricular-temporal flap can be used to transfer tissue from behind the ear for reconstruction of limited defects of the nose, cheek, and lower eyelid.2 Washio and coworkers3,4 have shown ample anastomoses between the superficial temporal artery and the retroauricular artery. Guyuron5 reported an eye socket reconstruction using a postauricular fasciocutaneous island flap that provided an adequate amount of skin and soft-tissue bulk for reconstruction of a missing eye socket and orbital tissue.

Limb salvage surgery

The threat of lower limb loss is seen commonly in severe crush injury, cancer ablation, diabetes, peripheral vascular disease and neuropathy. The primary goal of limb salvage is to restore and maintain stability and ambulation. Reconstructive strategies differ in each condition such as: Meticulous debridement and early coverage in trauma, replacing lost functional units in cancer ablation, improving vascularity in ischaemic leg and providing stable walking surface for trophic ulcer. The decision to salvage the critically injured limb is multifactorial and should be individualised along with laid down definitive indications. Early cover remains the standard of care, delayed wound coverage not necessarily affect the final outcome. Limb salvage is more cost-effective than amputations in a long run. Limb salvage is the choice of procedure over amputation in 95% of limb sarcoma without affecting the survival. Compound flaps with different tissue components, skeletal reconstruction; tendon transfer/reconstruction helps to restore function. Adjuvant radiation alters tissue characters and calls for modification in reconstructive plan. Neuropathic ulcers are wide and deep often complicated by osteomyelitis. Free flap reconstruction aids in faster healing and provides superior surface for offloading. Diabetic wounds are primarily due to neuropathy and leads to six-fold increase in ulcerations. Control of infections, aggressive debridement and vascular cover are the mainstay of management. Endovascular procedures are gaining importance and have reduced extent of surgery and increased amputation free survival period. Though the standard approach remains utilising best option in the reconstruction ladder, the recent trend shows running down the ladder of reconstruction with newer reliable local flaps and negative wound pressure therapy.

Clinical application of the compound muscle flap combined by the lateral sural artery perforators and the nutrient vessels of the lateral sural cutaneous nerve

Objective To observe the anatomic relationship between the lateral sural artery perforators and the nutrient vessels of the lateral sural cutaneous nerve that were combined to design a compound muscle flap.And to observe the effect of this flap clinical application.Methods Ten adult and fresh cadaver lower limbs were observed the anatomic relationship between the lateral sural artery perforators and the nutrient vessels of the lateral sural cutaneous nerve,and were combined to design a compound muscle flap.Clinically applied in 5 cases,and the flap sizes ranged from 6 cm × 9 cm to 9 cm × 12 cm.Results After into the muscle,the lateral sural artery issued 3-5 perforating branches (OD:0.2-1.8 mm) along the way,which provided nutrition for the lateral head of the gastrocnemius and the surrounding skin and involved in the formation of shallow and deep fascia vascular network with the nutrient vessels of the lateral sural cutaneous nerve.From Feburary 2009 to November 2011,the compound pedicled muscle flap were clinically applied in 5 cases to repair the skin defects of the anterior knee and proximal tibia.Flaps in 4 cases completely survivedand 1 case had partial superficial necrosis on the distal part of the flap,which healed after dressing change.Conclusion The compound pedicled muscle flap has two sets of blood supply that could expand the area of the flap,which could guarantee its feeling.This kind of flap could repair the complicated skin and soft tissue defects around the knee joint. Key words: Lateral sural artery; Perforators; Lateral sural cutaneous nerve; Compound flap

Using flap or musculocutaneous flap by anatomosis repairs soft tissue defects of serious traumatic shank

Objective To summary and discuss the curative effect and experience of repairing serious and complicated soft tissue defects of traumatic shank by flap or musculocutaneous flap by anatomosis.Methods From October 2009 to December 2011, the wounds of 59 patients suffering from serious and complicated soft tissue defects of traumatic shank were covered by VSD after repeated debridement,when the conditions of the whole bodies were stable and the local acute infection was controlled in the main. Fifty-six patients were repaired by a single flap or musculocutaneous flap attributing to the fresh granulation, three patients were repaired by compound tissue flaps because a single flap was insufficient. Five patients who had no available blood vessels at recipient site were repaired by flaps with bridge cross vascular anatomosis. The compound flaps were no more than 2 pieces, the maximum area of flap was 32 cm × 13 cm, the minimum was 15 cm × 8 cm. Results The flaps of all of 59 cases survived, fifty-seven cases were healed in one stage, two in two stage, one case had complication of infection at donate site due to the hematocele, and was cured by debridement and skin graft. Serious and complicated soft tissue defects of shanks were repaired by reconstruction,damaged limbs were salvaged,the functions of the legs were reserved. Conclusion It is the most effective and irreplaceable way that using flaps and musculocutaneous flaps,by anatomosis with the microsurgery technique, repairs the serious and complicated soft tissue defects of shank, which can shorten course and salvage the damaged limbs. Key words: Leg; Surgical flap; Musculocutaneous flap; Trauma; Microsurgery

Reconstruction of penetrating injuries of the hand with dorsalis pedis composite free flaps: A series of 23 patients

Reconstruction of severe hand injuries remains a challenge. We herein report the use of dorsalis pedis composite free flaps (DPCFFs) for the reconstruction of penetrating injuries of the hand. From July 2001 to February 2009, 23 patients (15 males and 8 females), mean age of 26 years (range, 17-48 years), with penetrating wounds of the hand were treated with DPCFFs. A second toe composite flap was used in cases of bone, joint, tendon and skin defects, and combined flaps were used for patients with only soft-tissue defects. Total joint transplantation using the proximal interphalangeal joint of the second toe was used in 10 cases, compound flaps using the metatarsophalangeal joint of the second toe were used in six, and combined dorsalis pedis flaps were used in seven cases of soft-tissue loss. All flaps survived, no bone nonunion or malunion occurred, and primary healing was achieved at all recipient and donor sites. Mean follow-up was 11 months (range, 6-27 months). In all cases, hand function was satisfactory and aesthetic outcome was good. Sensory recovery ranged from S2 to S3. In six cases with transplanted metatarsophalangeal joints, the mean range of flexion and extension was 45° (range, 30-70°). In 11 cases with transplanted proximal interphalangeal joints, the mean range of flexion and extension was 65° (range, 35-90°). No patient experienced difficulty walking. DPCFFs are useful for the repair of composite tissue defects of the hand. III.