Extremity Defects Research Articles

Optimization of surgical treatment of post-burn scar deformities of the lower extremities

The article presents the experience of surgical treatment of 172 patients with post-burn scar deformities and defects of the lower extremities. Based on the results obtained, practical recommendations on the optimal choice of methods of operations are given.

REVISITING ABDOMINAL FLAPS AND ASSESSING THEIR RELIABLITY FOR COVERAGE OF UPPER EXTREMITY DEFECTS

Abdominal aps have been a workhorse aps for complex upper extremity defects since last 5 decades. Since the evolution of microsurgery, free aps have revolutionised the upper extremity defect reconstruction and have invariably replaced abdominal aps as the primary option for reconstruction. Abdominal aps due to their reliablity still continue to be the lifeboat and primary surgical option in centres where microsurgery is not possible and in events of failure of free aps. It is documented in the literature that long term outcomes of successful pedicled aps are equal or even better than free aps. With their lesser learning curve, requiring lesser resources and very reliable outcomes abdominal aps will stay as a primary option for reconstruction in some centres and as a life boat for free ap failure in some

Reconstruction option in complex lower extremity defects where microsurgical repair is not possible: Randomized bipedicled flaps.

Lower extremity defects may occur due to many etiological causes such as trauma, peripheral arterial disease, diabetic foot infections, tumor resection, gunshot injuries, and burns. Lower extremity defects show a wide clinical presentation ac-cording to the affected anatomical localization, amount of tissue, and tissue content. In this study, it is aimed to present the use of bipedicled flaps as a simple and reliable salvage method in cases where microsurgical repairs such as free flaps are not possible. Patients with soft-tissue defect in their lower extremities between March 2018 and September 2021 were scanned retrospectively over the file. Among these patients, patients who were repaired with a bipedicle flap were included in the study. The patients were followed up regularly for at least 12 months. During the follow-ups, the patients were photographed, a physical examination was performed in terms of flap viability, wound dehiscence, and soft-tissue infection, and the data were recorded. In this study, 23 patients with a defect in the lower extremity who were repaired with randomized bipedicled flap were retrospectively analyzed. In four patients, the location of the defect was located in the middle 1/3 of the leg, while in 19 patients, it was located in the distal 1/3 of the leg. The flap design was done vertically in 22 patients, and the flap design was done transversely in one patient. One bipedicled flap was used for defect repair in 14 patients, and two bipedicled flaps were used for defect repair in nine patients. While skin grafts were used for donor site repairs in 16 patients, the donor site was primarily repaired in seven patients. In the post-operative period, local soft-tissue infection was detected in five patients and dehiscence at the wound site in three patients, and uneventful healing was achieved with antibiotic therapy, resuturation, and appropriate wound care. No major complications such as flap or graft loss were experienced in any of the patients. Randomized bipediculated flaps are a very reliable option for the reconstruction of middle and distal lower extremity defects. We think that it is a reconstruction option that can be safely applied in small and medium-sized defects of the lower extremity, since it can be used even in patients with comorbidities such as diabetes mellitus and peripheral arterial disease that adversely affect wound healing.

Application of infrared thermography in the study of the osteopathic correction results in patients with amputation defects of the lower extremities

Introduction. The main medical consequences of amputations are: phantom pain syndrome, degenerative changes in soft tissues, increased muscle tone of the stump, deterioration of microcirculation in the amputated limb. Methods of rehabilitation of such patients are physical therapy, physiotherapy, psychotherapy, mechanotherapy. The search for new methods of rehabilitation of patients with amputation of the lower limb is constantly underway due to the social significance of this disease. Osteopathic correction has proven effects of normalization of muscle tone, improvement of blood circulation, which can be assessed using infrared thermography.Aims: to evaluate the effect of osteopathic correction on blood circulation in the stump in patients with transtibial amputation.Materials and methods. The study includes 30 patients (21 men and 9 women) with transtibial amputation, undergoing diagnostic examination using infrared thermography on an outpatient basis in Albrecht Federal Scientific Centre of Rehabilitation of the Disabled. Patients were divided in two groups in random: main group (n=15), receiving osteopathic correction, and control group, receiving sham therapy. Both groups were divided in subgroups depending on amputation cause: cardiovascular diseases and trauma. Regardless the group infrared thermography was performed before and after first session of therapy or osteopathic correction and before and after second session. On thermograms, the temperature of the distal part of the stump was evaluated, the second limb — in the projection of the distal part of the stump.Results. The method of infrared thermography objectively confirmed the positive effect of osteopathic correction on blood flow in the lower leg stump: in patients with traumatic and vascular genesis of amputation — in the form of a decrease in the severity of distal hypothermia after the first, before the second and after the second session of osteopathic correction compared to the data before osteopathic correction. In the control group, there was also a statistically significant increase in the temperature of the distal part of the stump after the first session and the second sessions of sham therapy, which returned to its original values before the second session, which indicates the short-term nature of the changes.Conclusion. The study showed an improvement in blood circulation in the truncated limb, confirmed by an increase in the temperature of the stump in patients with transtibial amputation of traumatic and vascular genesis, which underwent osteopathic correction.

Clinical application of anterolateral thigh perforator flap pedicled with oblique branch in intramuscular of lateral circumflex femoral artery

To explore the characteristics and clinical application of the anterolateral thigh flap pedicled with the oblique branch in the intramuscular of lateral circumflex femoral artery. The clinical data of 25 patients with skin and soft tissue defects of extremities admitted between December 2020 and April 2021 were retrospectively analyzed, including 16 males and 9 females, aged 14-75 years, with the median age of 43 years. The defect site included 13 cases of hand, 2 cases of forearm, 2 cases of calf, and 8 cases of foot and ankle. The wound area ranged from 6 cm×4 cm to 35 cm×22 cm. Twenty-four patients with trauma were admitted to hospital immediately after injury, and 1 patient with diabetic foot infection was transferred to the hospital after ineffective treatment in other hospital. Flap surgery was performed from 0 to 56 days (median, 22 days) after admission. A total of 26 thigh flaps were harvested in 25 patients, with unilateral flaps in size of 7 cm×5 cm to 40 cm×10 cm. The type, caliber, and location of the perforating branch were recorded during the operation, and the anatomical characteristics of the oblique branch of the intramuscular trunk were mainly observed. The flap harvesting time was recorded; the flap survival and wound healing time were observed; at last follow-up, XIAO Feipeng et al. flap comprehensive efficacy evaluation table was used to evaluate the effectiveness of flap repair from three aspects of donor site, recipient site, and subjective satisfaction of doctors and patients. After the oblique branch in intramuscular of lateral circumflex femoral artery was sent out, it ran 2-3 cm obliquely laterally and inferiorly in the intermuscular septum and then entered the vastus lateralis muscle, and sent out perforating branches to nourish the skin. A total of 61 perforating branches were marked in 26 thighs of 25 patients before operation, and 70 perforating branches were found during operation, including 9 transverse branches, 29 descending branches, and 32 oblique branches, all of the oblique branches were musculocutaneous perforators. All 25 patients were followed up 6-10 months, with an average of 8 months. The time of unilateral thigh flap harvesting ranged from 13 to 90 minutes, with an average of 48 minutes. One patient with diabetes developed disturbance of blood supply and complete necrosis of the flap at 1 month after operation, and then the flap was repaired with skin graft; 1 case developed arterial crisis after operation, which survived after timely exploration; and the rest of the flaps survived smoothly. The wound healing time of the recipient site ranged from 10 to 44 days, with an average of 19 days, and the donor site of the thigh healed by first intention. At last follow-up, the color and texture of the flap was good and the sensation recovered to S 1-S 2. Only linear scar was left in the donor site, no scar contracture, pain, and other discomfort occurred, and no other serious complications occurred. Evaluated by flap comprehensive efficacy evaluation table, the score was 74-93, with an average of 88, of which 10 cases were excellent, 13 cases were good, and 2 cases were fair, with an excellent and good rate of 92%. The intramuscular trunk oblique branch is not uncommon, and its trunk course and perforators distribution are regular. To improve the understanding of this type of oblique branch and adopt appropriate methods during operation can improve the success rate of skin flap extraction.

Free Fibula Flap for Extremity Oncologic Defects: Factors Influencing Union and Functional Outcomes.

The goal of this study was to evaluate outcomes after vascularized bone flap (VBF) reconstruction of oncologic bony extremity defects. A secondary goal was to compare union rates based on various insetting methods, including onlay, intermedullary, and intercalary. The authors conducted a retrospective review of consecutive patients who received an extremity reconstruction with a fibula flap after oncologic resection between 2001 and 2019. The authors identified a total of 60 fibular VBFs in 55 patients (67% lower extremity, 33% upper extremity). The overall union rate was 91.7% (55 of 60). For lower extremity reconstructions, the mean time to full weightbearing was 16 months (range, 4 to 44 months). Fibula VBFs were onlay in 65% of cases, intercalary in 23%, and intramedullary in 12%. Forty-three percent of patients required a reoperation as a result of a surgical complication. Immediate femur reconstruction subgroup analysis demonstrated that onlay fibula flap orientation was associated with a significantly increased risk for any complication (odds ratio, 6.3; 95% CI, 1.4 to 28.7; P = 0.03) as well as an increased risk for requiring conversion to endoprostheses because of nonunion (OR, 12.1; 90% CI, 1.03 to 143.5; P = 0.03) compared with intramedullary placement. The free vascularized fibula flap is a reliable option for functional reconstruction of any long bone extremity defect, but complications in these complex procedures are not uncommon. In patients with immediate femur reconstructions, intramedullary fibula placement was associated with significantly lower complication and lower metallic implant conversion rates and a trend toward a more rapid early union compared with onlay VBF. Therapeutic, III.

Customizing Anterolateral Thigh Flap With Magnetic Resonance Angiography Differential Subsampling With Cartesian Ordering Imaging for Individualized Reconstruction of Extremity Defects

IntroductionMagnetic resonance angiography (MRA) with the differential subsampling with cartesian ordering (DISCO) imaging technique is rarely used in anterolateral thigh (ALT) flap. In our series, MRA DISCO imaging technique is used as a tool to customize ALT flaps. The aim of this study was to report the accuracy of cutaneous perforators identified by the MRA DISCO imaging. MethodsNineteen patients underwent the MRA DISCO imaging for perforator mapping before the ALT flap transfer. A total of 38 ALT regions were studied on the MRA DISCO images. Flap thinning was performed under the guidance of MRA DISCO imaging. ResultsThe lateral circumflex femoral artery (LCFA) most commonly stems from the deep femoral artery (84.2%), followed by the common femoral artery (15.8%). The average number of perforator vessels per LCFA was 10.2 ± 1.7. The distinct oblique branch was observed in 16 out of the 38 ALT regions (42.1%). Among the 19 ALT flaps harvested, 5 were septocutaneous perforator flaps and 14 musculocutaneous perforator flaps. Ten were harvested based on the descending branch, and 3 used the oblique branch as the flap vascular pedicle. In addition, the displayed course and types of perforator vessels on the DISCO images of the 18 skin flaps were consistent with the intraoperative findings, with an accuracy of 94.7%. ConclusionsThe state of the cutaneous perforators of LCFA can be identified on the MRA DISCO images. The 3D-CE-MRA DISCO imaging is a practical method, which can ameliorate the design and customization of ALT flap for an individualized reconstruction.

Spare-parts free flap reconstruction in polytrauma with limb amputation: Pearls, pitfalls, and an illustrative case report

Spare-part free-flap reconstruction involves free tissue transfer from an unsalvageable extremity for reconstruction of a separate defect. In the setting of traumatic injury, spare-part surgery requires special attention to donor site zone of injury assessment and multidisciplinary coordination. Here we describe a case of upper extremity reconstruction using a free flap harvested from a lower extremity which was indicated for transfemoral amputation. Key pearls and pitfalls are reported in an effort to facilitate collaborative interdisciplinary reconstructive opportunities in cases where amputation is planned in the setting of multi-limb trauma. A 53-year-old male presented after a motorcycle collision with open fractures of the right elbow and tibia/fibula. After initial fracture stabilization and serial debridement, the upper extremity wound required flap coverage for the indication of exposed implants. Extensive bone and soft tissue loss of the lower limb indicated the patient for transfemoral amputation, and spare-part free flap reconstruction of the upper extremity defect was planned. Intra-operative venous pedicle thrombosis caused failure of an initial flap based on the posterior tibial artery. A second spare-part flap based on the anterior tibial artery was successfully transferred under the same anesthetic. When amputation is planned in the context of the multiply traumatized patient, coordinated orthopedic trauma and microsurgical care can facilitate spare-parts free-flap reconstruction. Though these cases require careful planning and intra-operative flexibility to accomplish flap harvest adjacent to a zone of injury, spare-part reconstruction worth pursuing as this strategy obviates the need for an additional donor site. • Spare-part free flaps are useful when amputation is planned in cases of polytrauma. • Collaboration and communication are critical to identify eligible patients. • Carefully assess the zone of injury adjacent to the donor site. • Harvest a large flap and assess with intraoperative fluorescence angiography. • Many unsalvageable limbs do not harbor an uninjured donor site.

Clinical application of free inguinal flaps with retrograde blood supply anastomotic to repair soft tissue defects of extremities.

To observe the clinical efficacy of free inguinal flaps with retrograde blood supply anastomosis to repair skin and soft tissue defects in the limbs. A total of 25 patients with soft tissue defects of the limbs treated from January 2019 to December 2021 were selected and repaired with free inguinal flaps anastomotic with retrograde blood supply. All 25 skin flaps survived; 1 patient had skin flap infection and the wound healed gradually after symptomatic treatment, and 1 patient had venous embolism and the skin flap survived after re-anastomosis. The patients were followed up for 6 to 18 months after the operation. After healing, the patient recovered satisfactorily, and the flap had a good appearance, texture, and flexibility; a reoperation was not required. The patient was satisfied with the effect of the treatment. Retrograde vascular anastomosis with the anterolateral femoral perforator flap is safe and reliable for repairing the soft tissue defects of the limbs. It is convenient for micromanipulation and can achieve satisfactory clinical results, and thus is an ideal repair method.

The clinical efficacy of pure-grind acellular dermal matrix without gelatin in lower extremity skin defect treatment: A prospective randomized study

Background: Acellular dermal matrix (ADM) is currently considered as a replacement for lost extracellular matrix. Trials have been conducted on dressing materials with high contents of ADM without any impurities, such as gelatin, which only undergo the grinding process. In this study, we aimed to investigate the clinical application and wound healing effect of pure-grind ADM in lower extremity skin defect treatment.Methods: Patients with skin defects in the lower extremities who did not achieve wound healing within 4 weeks with conservative treatment were enrolled in this study from March 2021 to July 2021. We randomized the patients into two groups. The patients in the experimental group were treated with pure-grind ADM and conventional negative-pressure wound therapy (NPWT), whereas the patients in the control group were only treated with NPWT. Every wound was followed-up for 7 weeks, and complete wound healing was confirmed when the skin defect was fully covered with epithelized tissue.Results: A total of 41 patients were enrolled in this study. Complete wound healing was observed in 73.2% of patients, and 26.8% had an unhealed status until the end of the follow-up. The pure-grind ADM did not promote complete healing (p = 0.796) and was not associated with epithelization time but promoted the velocity of epithelization (experimental 5.58 vs. 3.50 cm2/day, p = 0.020). Considering the time of healing, the decrease in wound depth was more extensive (p = 0.021), the speed of granulation tissue formation was higher, and this difference was more evident after 5 weeks of treatment in the experimental group.Conclusion: We demonstrated the clinical efficacy of pure-grind ADM in treatment of lower extremity skin defects. This new type of ADM, without any impurities, is important in wound healing. Its depth filling effect is powerful, and it can promote epithelization velocity and speed of granulation tissue formation.

The clinical application of arterialized venous flaps in repairing large area of soft tissue defects of extremities

Background The reconstruction of microsurgery emphasizes the low morbidity of donor sites. The arterialized venous flaps (AVFs) are tissue flaps harvested without conventional vascular pedicles. However, reports of high necrosis rates and poor understanding of physiology hindered the application of many surgeons in clinical practice. Recently, experimental and clinical studies have demonstrated the feasibility and relative reliability of various AVF techniques. This study aims to report the clinical results of the arterialized venous free flaps in reconstructing soft tissue defects of limbs and propose methods to improve flap perfusion, extending the indications for using the flaps based on the authors’ clinical experiences. Methods We retrospectively reviewed the records of 16 patients that underwent arterialized venous free flaps for limb wound reconstruction from January 2019 to June 2021. Following the venous network on the calf’s tibial side, large venous flaps can be designed. Results Of the 16 cases, 14 (87.50%) cases (including 8 cases significantly congested with tension blisters) showed complete survival, and 2 (12.5%) cases, which had only one vein performed anastomosis of the efferent vein according to the vascularity of the recipient bed, showed partial necrosis. In all cases, no infection or other specific complications occurred in the donor areas. Conclusion The rate of congestion and necrosis of arterialized venous flaps is still challenging, but it will be suitable for large soft tissue defects of limbs in the future.

The turbocharged wide anterolateral thigh perforator flap to reconstruct massive soft tissue defects in traumatized lower extremities: A case series.

Extensive traumatic soft tissue defects in the lower extremities typically require complete coverage of exposed bone because inadequate coverage, such as partial flap loss, may result in bony infection and ultimately lead to limb salvage failure. To achieve complete coverage of these defects, we used the wide anterolateral thigh perforator flap in which the turbocharging procedure augments the blood flow. Herein, we describe our turbocharging technique and discuss its effectiveness. From January 2014 to December 2020, the turbocharged wide ALTP free flaps were used to treat 13 patients with massive traumatic soft tissue defects in the lower extremities, ranging in size from 22 × 10 cm2 (220 cm2) to 21 × 17 cm2 (357 cm2) (mean, 270 cm2). All ALTP flaps were supplied by perforators from both the transverse branch of the lateral circumflex artery (TB-LCFA) and descending branch of the lateral circumflex artery (DB-LCFA) simultaneously. The turbocharging procedure by connecting the TB-LCFA to a side branch of the DB-LCFA was carried out in all these flaps. A retrospective review of medical records for each patient was performed. The size of the transferred ALTP flap ranged from 23 × 12 cm2 (276 cm2) to 23 × 19 (437 cm2) (mean, 331 cm2). The total number of perforators included in the flaps was three on average. All ALTP flaps survived completely without partial necrosis. The postoperative course was uneventful except for two cases with minor complications, including hematoma and partial necrosis of the recipient's skin. Free transfer of the turbocharged wide ALTP flap can be a reliable and effective reconstructive method to obtain complete coverage of extensive traumatic soft tissue defects in the lower extremities and achieve successful limb salvage.

Commentary: Standardization of patient reported outcomes in lower extremity reconstruction

Lower extremity defects cause significant morbidity to patients, both in form and function.1 Fortunately, there exists a wide range of options for lower extremity reconstruction (LER), with donor sites including the anterolateral thigh, latissimus dorsi, and gracilis, as well as a choice for myocutaneous versus fasciocutaenous tissue.2 Although outcomes such as complications, flap survival, and function are well described in the literature3, patient reported outcomes (PRO) are underreported and should be taken into consideration for flap selection.

Freestyle Anterolateral Thigh Flap and Perforator Variations

Introduction: Anterolateral thigh (ALT) flap has become an increasingly popular reconstructive option, especially for head-and-neck and extremity defects. In addition to the many advantages of the ALT flap, there are also some disadvantages such as individual variations in the number and location of cutaneous perforators. Doppler ultrasonography (USG) is one of the most frequently used methods to overcome variations in perforator anatomy. However, the Doppler device may obtain false results so some clinics use the “freestyle” harvesting technique for ALT flap. The aim of the study is to examine experience with freestyle ALT flap harvesting and to evaluate the perforator variations. Materials and Methods: Between 2018 and 2021, 59 ALT flaps were harvested by the same microsurgical team for head-and-neck reconstructions. Of 59 patients, 23 were female and 36 were male. Cases were performed without using preoperative or peroperative imaging techniques. Results: In 2 (3%) of 59 patients, different septocutaneous flap options were used because suitable perforators could not be found in both thigh regions. For 57 ALT flaps, the rate of descending branch of lateral circumflex femoral artery (LCFA) perforators was 73%, transverse/ascending branch was 17%, aberrant perforators other than classical branches of LCFA was 7%, and the perforator from medial circumflex femoral artery was 1%. Partial necrosis due to perfusion problem was experienced in one flap and total necrosis was in two flaps. Conclusion: The advantages of the freestyle technique, such as allowing the evaluation of all perforators and designing flaps according to the appropriate perforator, provide great flexibility and convenience to the surgeon. With this, surgical problems caused by inaccurate results obtained by devices such as Doppler USG are excluded.

Deep vein thrombosis in donor or recipient veins encountered during lower extremity reconstruction with a free anterolateral thigh perforator flap: How do we deal with it?

BackgroundThe free anterolateral thigh perforator (ALTP) flap has been successfully adopted to reconstruct traumatic soft tissue defects in the lower extremities. However, the occurrence of deep vein thrombosis (DVT) in donor or recipient veins has been overlooked, and there has been no reliable guideline to manage it. Therefore, in this study, we review our cases where the ALTP flaps were transferred to traumatic lower limbs even though DVT was found in the pedicle or recipient veins. Furthermore, based on our experiences, we suggest an algorithmic approach for dealing with DVT.Patients and methodsThis study included 108 patients who underwent lower extremity reconstruction using a free ALTP flap between January 2014 and January 2021. All medical records were reviewed, including preoperative assessment data, intraoperative findings, and postoperative complications. Notably, when DVT was found in both the donor and recipient veins, we thoroughly assessed operative findings, surgical solutions, and final outcomes.ResultsSixty-one of 108 (56.4%) patients underwent computed tomographic venography (CTV) preoperatively, revealing DVT in 11 of these 61 (18%) patients. Three of these 11 patients had iliofemoral DVT, and surgery was delayed more than two weeks after detection. The remaining eight patients had calf DVT and underwent free ALTP flap transfer as scheduled. Conversely, 47 of 108 (43.6%) patients did not undergo CTV, and an occult DVT was found in five of these 47 (10.6%) patients. In two of these five patients, free flap surgery was replaced with amputation and local flap coverage. In the remaining three patients and one patient with an occult DVT that was not found on CTV, the free ALTP flap transfer was carried out. In 15 patients with DVT, free ALTP flap transfer was performed using various alternative methods for venorrhaphy. Consequently, all flaps survived, with partial necrosis occurring in two patients.ConclusionIf DVT-affected veins are appropriately managed, the free ALTP flap can be successfully transferred to the traumatic lower limb even when DVT occurs in donor or recipient veins. The author's algorithm can help surgeons overcome the insufficiency of veins for pedicle anastomosis due to DVT and avoid postoperative thromboembolic complications.

Free superficial circumflex iliac artery flap combined with deep inferior epigastric perforator flap for repair of large soft tissue defects of upper extremities

To investigate the effectiveness of free superficial circumflex iliac artery flap (SCIP) combined with deep inferior epigastric perforator flap (DIEP) in repairing large soft tissue defects of upper extremities. Between February 2017 and January 2021, free SCIP combined with DIEP was used to repair 15 patients with large soft tissue defects of upper extremities. There were 12 males and 3 females, aged from 34 to 52 years, with a median age of 41 years. The causes of injury were mechanical injury in 11 cases and traffic accident injury in 4 cases. There were 9 cases of circular skin defect in the forearm and 6 cases of skin defect around the upper arm and elbow joint, with the defect in size of 15.5 cm×10.5 cm to 26.5 cm×15.5 cm, accompanied by exposure of deep tissues such as tendons and bones. There were 7 cases with open fractures and 8 cases with vascular and nerve injuries. The time from injury to operation ranged from 7 to 14 days, with an average of 7.5 days. The flaps in size of 16.0 cm×11.0 cm to 27.0 cm×16.0 cm were harvested; the thickness of the flaps was 0.8-1.3 cm, and the excess fat tissue was removed under the microscope after harvesting. The length of proximal vascular pedicle was 5.0-7.0 cm, and of distal vascular pedicle was 3.0-5.0 cm. The donor site was closed and sutured directly, and the navel was reconstructed. The flaps survived successfully in 14 cases, and the arterial crisis occurred in 1 case at 10 hours after operation, and the flap survived after surgical exploration. All the wounds in the donor and recipient sites healed by first intention. All 15 patients were followed up 3-14 months, with an average of 10.5 months. The appearance, elasticity, and texture of flap were good without obvious bloat, contracture, or adhesion. The donor site healed well, no abdominal wall hernia was found, and the appearance of reconstructed navel was good, only linear scar left. At last follow-up, 12 cases were evaluated as excellent and 3 cases were good according to the evaluation criteria of flap function of the Chinese Medical Association Microsurgery Branch. The sensation recovered to in 7 cases and in 8 cases. Free SCIP combined with DIEP has a large excision area and excellent skin ductility. It is an effective clinical method for repairing large soft tissue defects of upper extremities.

Reconstruction of upper extremity soft tissue defects with free flaps

Amaç: Çeşitli etiyolojik nedenler sonucu ortaya çıkabilen üst ekstremite defektlerinin rekonstrüksiyonu için literatürde pek çok yöntem tanımlanmıştır. Bu yöntemler arasında lokal veya bölgesel flepler oldukça sık kullanılmakta olup çoğu defekt başarılı bir şekilde rekonstrükte edilebilmektedir. Bununla birlikte bazı büyük ve kompleks defektlerde, teknik olarak daha zor olan serbest flep seçenekleri
 kaçınılmaz olabilmektedir. Çalışmamızda serbest fleplerle üst ekstremite rekonstrüksiyonu hakkındaki tecrübelerimizi sunmayı planladık.
 Gereç ve Yöntem: 2015 - 2021 yılları arasında 9 hastada (3 Kadın, 6 Erkek) serbest fleplerle üst ekstremite rekonstrüksiyonu uygulandı. Hastaların yaşları 22-68 arasında değişmekteydi. Serbest flep tercihlerimiz arasında 4 hastada anterolateral uyluk flebi, 4 hastada latissimus dorsi serbest flebi ve 1 hastada radial ön kol serbest flebi yer almaktaydı. Hastaların defektleri; 3 hastada el dorsumu, 1
 hastada amputasyon güdüğü, 2 hastada ön kol ile birlikte el dorsumu ve 3 hastada ön kol ile birlikte dirsekte bulunmaktaydı.
 Bulgular: Bütün hastalarda alıcı arter olarak radial arter seçildi. Alıcı ven olarak, radial arterin konkomitan veni veya yüzeyel venöz sistem kullanıldı. 6 hastada uç-uca, 3 hastada uç-yan anastomoz yapıldı.1 hastada arteriyel tromboz ve 1 hastada venöz tromboz gözlendi. Vasküler komplikasyon görülen bu hastalarda serbest latissimus dorsi flebi tercih edilmişti. İki hasta da erken dönem kurtarma cerrahisine alınarak anastomoz hatları yenilendi ve flepler kurtarıldı. Diğer hastalarda ek komplikasyon izlenmedi. Klinik serimizde flep kaybı yaşanmadı.
 Sonuç: Uygun vakalarda, üst ekstremite yumuşak doku rekonstrüksiyonları için serbest flepler güvenle kullanılabilir. Teknik deneyim gerektirmekle beraber, minimal donör saha problemleri nedeniyle perforatör tabanlı serbest fleplerin oldukça avantajlı olduğu ve uygun hastalarda ilk yöntem olarak güvenle seçilebileceği kanaatindeyiz.

Simultaneous reconstruction of septic composite defects in lower extremities: Combination of fasciocutaneous perforator flap and Masquelet technique.

BackgroundManagement of composite defects with deep infection is a challenge to reconstructive surgeons. This study aimed to demonstrate the versatility, safety, and complications of simultaneous reconstruction of infectious composite defects with fasciocutaneous perforator flap combined with the Masquelet technique.MethodsThis study presents 10 patients in whom a fasciocutaneous perforator flap combined with the Masquelet technique was used to restore soft tissue and bone defects of the lower extremity, and were admitted in two level 1 trauma centers in Shanghai. The first stage included debridement of necrotic bone and infected tissues, implantation of a polymethylmethacrylate cement spacer to cover the void; bridging fixation of the osseous defect using external or internal fixators, and soft-tissue reconstruction with a fasciocutaneous perforator flap. The second stage included cement spacer removal with membrane preservation, refreshing bone edges, and grafting the cavity with bone morphogenetic proteins and autologous iliac bone graft.ResultsThe mean follow-up duration after autologous bone graft was 17.5 months. The average bony defects and average flap dimensions were 7.1 cm and 44.9 cm2, respectively. All flaps survived uneventfully. No recurrence of infection was detected in either the second stage of surgery or follow-up period. The mean duration of bone consolidation was 31.9 weeks. One patient had a 2 cm leg length discrepancy, and one patient had mild foot drop. No residual deformity requiring a secondary procedure occurred.ConclusionFasciocutaneous perforator flap combined with Masquelet technique provides a reliable and versatile alternative for patients with composite defects resulting from lower extremity infection.

Algorithms for perforator-based flaps in different anatomical locations

Introduction: Perforator-based flaps can be planned in any anatomic location in the body when there is a detectable perforator. Although preoperative perforator mapping ensures safety and versatility of these flaps, there is no consensus yet about flap planning in different anatomical locations.
 Material and Method: 28 patients underwent perforator-based flap surgery for different anatomical locations as face (5), sternum (3), back (5), lomber (4), sacral (4) and scrotal (4) areas, leg (2) and foot (1). 19 of the patients were male while 9 were female. The mean age was 58.1±13.5 (22-80 years).
 Perforator-based flaps were planned as V-Y design in face, sacral and scrotal areas while as perforator plus transposition flaps for lomber area, leg and sternum. On the other hand, for foot the flap was planned as subcutaneous-pedicled turnover flap.
 Results: The mean follow-up time was 10 months (3-36 months). Partial flap necrosis is seen in all 3 patients who had underwent flap surgery on the lower extremity. There were no other complications seen in short- or long-term follow-ups. Comorbid diseases were not statistically significant on complications rates (P>0.05).
 Conclusion: V-Y flap for the face and the sacral area; and perforator plus transposition flap for back ,lomber area and sternum are suggested as the ideal flap modifications for these anatomical locations. On the other hand, perforator-based flaps should not be used as a first choice in reconstruction of lower extremity defects.

Application of deep inferior epigastric perforator flap for repair of extreme defects around knee

To investigate the effectiveness of the deep inferior epigastric perforator (DIEP) flap for extreme defects around the knee. Between June 2017 and December 2018, 15 patients with the extreme defects around the knee were admitted. There were 9 males and 6 females with a median age of 36 years (range, 23-51 years). The etiology was the traffic accident in 7 cases, tumor in 5 cases, and burn in 3 cases. The injured location was left knee in 8 cases and right knee in 7 cases. The size of soft tissue defects ranged from 15 cm×10 cm to 30 cm×20 cm, and all defects complicated with exposure of blood vessels, nerves, tendons, and other tissues. Transverse DIEP flaps with 1-2 vascular pedicles were prepared according to the size of the defect, including 6 cases of single-pedicle flaps and 9 cases of double-pedicle conjoined flaps. According to the depth of the defect, 10 cases of skin flaps were thinned under microscope. The size of the DIEP flaps ranged from 16 cm×10 cm to 32 cm×20 cm; the average thickness was 1.5 cm (range, 0.8-1.8 cm); the average pedicle length was 7.5 cm (range, 5.0-9.0 cm). The donor site was directly sutured. One single-pedicle flap developed distal necrosis after operation, and healed after skin grafting; the other skin flaps survived, and the wounds at the donor and recipient sites healed by first intention. All patients were followed up 16-28 months (mean, 24 months). The shape and texture of the flap were satisfactory, and there was no abnormal hair growth or obvious pigmentation. There was only linear scar at the donor site and no complication such as abdominal hernia. The appearance and function of the knee were satisfactory. No recurred tumor was observed, and the scar contracture was released. At last follow-up, 13 cases were excellent and 2 cases were good, according to the Knee Society Score (KSS) criteria. The DIEP flap is an ideal alternative for repairing the extreme defects around knee, with a concealed donor site, easy dissection, flexible design, as well as less complication.