Flow-through Flap Research Articles

The curative-effect observation for fibular flap synchronous repairing limbs composite tissue defects

Objective To explore the curative effect of fibular flap with limbs composite soft-tissue. Methods From February, 2013 to February, 2016, 13 cases with body severe trauma patients were treated, which including 5 cases of upper limbs and 8 cases of lower limbs,and all existed bone defect, soft tissue defect and trunk vessel defect. Three cases with limbs distal non blood supply were emergency treated with debridment and flow-through fibular flap transplantation renovation,peroneal artery repairing defective blood vessels to restore limbs distal blood supply, fibular flap repairing bone defect, skin flap repairing soft tissue defect. The limb blood supply for other 10 cases were in good condition, but one case with main artery defect did the second phase of fibular flap transplantation and repaired defective blood vessels, bone and skin soft tissue synchronously according to wound condition. According to the postoperative observation for flap survival and appearance, X -ray films to observe fracture healing after 6 weeks, three months and 6 months of operation as well as evaluating limb function recovery, then analyzed the results. Results Flaps survived successfully for 11 cases, and flaps for the other 2 cases were partial necrosis. One Case was edge flap necrosis, heal scabby after dressing, and the other case was necrosis for 1/3 of the area, but the deep fascia survival,and the skin graft healing after dressing. One case with forearm rolling was in vascular crisis after operation, but the crisis was relieved after detection, and fingers blood supply was recovered. All the patients were followed up for 6 to 36 months(mean,14 months ). All flaps were survived, fractures healed well and limbs distal blood supply was good. Bone healing time was 8 to 24 weeks, and patients with lower limbs injury could bear load after 3 to 8 months. Lower limbs restored walking function. Upper limbs and hands restored rotation function. Transplant flapshad good e-lasticity and satisfactory appearance. Conclusion Using fibular flap to repair defective blood vessels, bone and soft tissue synchronously, not only can rescue the limbs on the verge of amputation, but also can repair defective composite tissue and get a good prognosis. It is an effective method for open injuries severely treatment in clinic. Key words: Fibular flap; Limbs; Reconstruction; Microsurgical technique

The use of innervated radial artery superficial palmar branch perforator free flap for complex digital injuries reconstruction

Loco-regional flaps have been widely used for the reconstruction of digital injuries without requiring microvascular anastomosis, however, they result in scarring and compromised functional outcomes. This study demonstrates our experience utilizing the innervated radial artery superficial palmar branch (RASPB) perforator free flap for complex digital injury reconstruction. From May 2007 to March 2014, the innervated RASPB perforator free flap was used to reconstruct 79 distal complex hand and digital soft tissue defects of which 14 were used to re-vascularise the distal digit in a flow-through fashion. All free flaps were innervated by the palmar cutaneous branch of the median nerve. All 79 free flaps survived and all 14 digits re-vascularized successfully. One flow-through free flap developed distal skin necrosis which healed uneventfully without further procedure. The average follow-up was 21.5 months. Measurement of two-point discrimination ranged from 7 to 13 mm. All patients were satisfied with the aesthetic results. The innervated RASPB perforator free flap is a feasible and effective option for the reconstruction of complex digital defects and the flow-through concept, when utilized in cases with compromised vascularity, provides reliable re-vascularization. Level III, therapeutic study.

Emergency repair of hand wound with artery defect using anterolateral thigh flap

Objective To investigate the clinical application of flow-through anterolateral thigh perforator flap for repair of hand wound with artery defects. Methods From May 2013 to August 2015, 13 cases of hand wound with artery defects were treated by flow-through anterolateral thigh perforator flap. The flap areas ranged from 8 cm×7 cm to 21 cm×12 cm. Results All 13 flaps and donor sites survived uneventfully. All the patients were follow-up for 6 to 15 months with an average of 10 months. The texture and color of flaps were good. Partial protective sensation of flaps recovered. All the patients were satisfied with hand function. According to upper extremity function evaluation criteria issued by the Hand Surgery Society of the Chinese Medical Association, the results were graded as excellent in 7 cases, good in 4 cases and fair in 2 cases. Conclusion It may be an ideal method to use flow-through anterolateral thigh perforator flap for the treatment of hand wound with artery defects. It can bridge the vessel defects and repair the soft tissue defects in one stage. Key words: Hand injuries; Surgical flaps; Artery defects; Microsurgery

Versatility of Free Cutaneous Flaps for Upper Extremity Soft Tissue Reconstruction

The goals of upper extremity soft tissue reconstruction should go well beyond providing coverage and restoring function. As the field of reconstructive microsurgery has evolved, free cutaneous flaps (FCFs) are gaining wider application. The advantages of FCF include minimizing donor-site morbidity by preserving the muscle and fascia, improving versatility of flap design, and superior aesthetic results. This review highlights the application of anterolateral thigh, superficial circumflex iliac artery, deep inferior epigastric perforator, superficial inferior epigastric artery, and flow-through flaps for reconstruction of upper extremity defects. These flaps share several qualities in common: well-concealed donor sites, preservation of major arteries responsible of providing inflow to distal extremity, and potential for a two-team approach (donor and recipient sites). While the choice of flaps should be decided based on individual patient and defect characteristics, FCF should be considered as excellent options to achieve the goals of upper extremity reconstruction.

Single stage soft tissue and extensor tendon reconstruction of upper extremity with antero-lateral thigh free flap- A case report

Soft tissue coverage for traumatic soft tissue loss of upper extremity is challenging with limited local tissues availability. Hence, free tissue transfer is indicated. A patient presented to us with degloving injury of the right dorsum hand and forearm following a road traffic accident. There was large soft tissue defect on the dorsal lateral aspect of the hand and forearm, open comminuted fracture of distal end radius with segmental loss of extensor tendons. After adequate debridement and fracture stabilization with external fixator, soft tissue and extensor tendon reconstruction were performed with conjoined flow-through anterior-lateral thigh and tensor fascia lata free flap. At postoperative three months, there was non union of the distal end of right radius. Flap was re-elevated and non union was corrected with osteotomy, non vascularized bone graft and locking plate. Subsequently, at 1 year follow up revealed limited range of movement at wrist joint (flexion-extension 15 degree), acceptable at metacarpophalangeal of all fingers (hyperextension 15 degree, flexion 60 degree) and interphalangeal joints (PIP joint extension- flexion 0-45 degree, DIP joint extension-flexion 0-15 degree). Hand grip was weak and requires further hand therapy. Anterior lateral thigh flap is a versatile and reliable option for reconstruction of large soft tissue and composite defects of upper extremity with favourable outcome.

Free perforator flaps for soft-tissue coverage of the hand

Objective To evaluate the clinical outcomes of soft-tissue coverage of the hand using perforator flaps. Methods From May 2013 to September 2015, 10 cases of soft-tissue defects of the hand were treated with 12 free perforator flaps. These included 3 ulnar artery dorsal wrist perforator flaps, 1 proximal ulnar artery perforator flap, 2 dorsal interosseous artery perforator flaps, 1 medial arm perforator flap, 1 superficial iliac circumflex artery perforator flap, 2 anterolateral thigh perforator flaps and 2 medial sural artery perforator flaps. There were 3 cases of flow-through perforator flap, 2 cases of microdissected thin perforator flap and 1 case of lobulated perforator flap. The defects were located in the fingers in 6 cases, in the palm in 2 cases, and on the dorsum of the hand in 4 cases. The minimum size of the perforator flap was 5.0 cm×2.5 cm, while the largest was 11.0 cm×11.0 cm. Results All 12 perforator flaps survived uneventfully. No vascular crisis occurred. The color as well as texture of the flaps was satisfactory. There was no flap bulkiness. Only linear scar was seen at the donor site. Postoperative follow-up ranged from 3 to 15 months (8 months on average). Protective sensation was restored in some of these flaps. The function and appearance of the hand were good. Conclusion Free transplantation of perforator flaps causes less damage to the donor site and the hand, conforming to the principles of hand reconstruction. Perforator flaps of the upper limb are located close to the hand, with matching color and texture. It is an ideal option for repairing small to medium size soft-tissue defects of the hand. Key words: Surgical flaps; Hand injuries; Free transplantation; Soft tissue defects

Clinical application of a large flow-through venous flap

To investigate the clinical effects of a large flow-through venous flap. Between January 2012 and January 2015,this flap was used in 9 patients with upper limb injury to reconstruct artery defect and large skin and soft tissue defect. The donor sites were covered with free skin grafts. The skin and soft tissue defects size ranged from 7.0 cm × 10.0 cm to 9.5 cm × 18.0 cm (average 9.2 cm× 12.0 cm). The flaps size ranged from 9.0 cm × 12.0 cm-11.5 cm × 20.0 cm (average 10.3 cm × 13.5 cm).Except 2 cases of small area necrosis occurred in the distal end of the flap, which healed after dressing change; the other 7 flaps survived completely. The donor wounds healed primarily. Postoperative patients were followed up for 12-26 months (mean 14.5 months). Flap appearance, texture and thickness were similar to the surrounding normal tissue. According to the sensory function evaluation standard formulated by the British Medical Research Council in 1954,the result of skin flap sensory evaluation was assessed as S2 in two cases,S3 in four cases,S3 in three cases, with excellent and good rate as 77.8％.According to the assessment standard for upper limb function issued by Chinese Medical Association of hand surgery, the limb function were assessed as excellent in 6 cases, good in 2 cases, poor in 1 case, with the excellent and good rate as 88.9％. The large flowthrough venous flap has the advantages of simple operation, minimal donor site morbidity and satisfactory appearance. It is a feasible method to repair the wound at upper limb with artery defect.

Omental Flow-Through Flap: Experimental Hemodynamic Study

The omental flow-through flap (OFTF) is based on the use of an anatomic unit composed of the right gastro-omental artery (bypass) with its omental branch or branches supplying the greater omentum (flap). The greater omentum flap is known for its capacity of resistance to infection, for its use in the treatment of ischemic lesions and as a high-flow tissue. Several hypotheses regarding the hemodynamic behavior of a distal bypass with a flap were discussed in the literature. We made the assumption that the OFTF was a low peripheral resistance flap and that the greater omentum did not induce a steal phenomenon. We demonstrated the anatomical feasibility of the experimental model with a morphologic study inthe pig. The mail objective of this study was to measure the blood flow to evaluate the hemodynamic effects of the OFTF. Twelve domestic pigs were used for this study. Four cadavers of pigs were dissected for the anatomic study of the OFTF, and 8 live pigs were used for the experimental surgery and hemodynamic measurements. Hemodynamic measurements were taken before transplantation on in situ arteries using periarterial ultrasonic flow transducers. After transplantation of the OFTF, flows were measured before, then during clamping and unclamping of the flap. OFTF was feasible in the porcine model. With the experimental model, the flow increased by 56.15% in the distal part of the bypass after the implantation of the flap with decrease of peripheral resistances. Our results suggest that the OFTF is a low resistance flap and that the greater omentum does not induce a steal phenomenon. This anatomic unit could be used to carry out simultaneously limb revascularization and cover a tissue loss.

The clinical application and type of anterolateral thigh flap

Objective To investigate the effect of anterolateral thigh flap for repairing soft tissue defects of extremities and the clinical meaning of blood vessel types. Methods From November, 2011 to December, 2014, 102 cases of limbs soft tissue defects were treated with anterolateral thigh flap, through retrospectively analyzed. Seventy-five cases for leg and ankle, 27 cases for forearm and hand. The wounds sized from 5.0 cm × 14.0 cm-14.0 cm × 36.0 cm. The type of blood vessel include type I, 90 cases (contain 21 flow-through anterolateral perforator thigh flaps) , type II, 8 cases, and type IIIa, 4 cases. All of this cases were applied with turbocharge. The flap area was 7.0 cm × 15.0 cm-7.5 cm × 28.0 cm. Flap combination tissues transplantation were 35 cases (contain latissimus dorsi muscle, second digiti pedis, free wrap-around flap, etc.) , 3 cases included 3 tissues. Simultaneously 9 cases were repairing for reconstruction circulation of extremities. Results Ninety-seven cases were survived completely, 2 flaps survived partially, mortification 3 cases. Finally, free skin grafting to repair wound surface. Sixty-two cases had a primary wound healing (stage I) , 24 cases had a delayed wound healing (stage Ⅱ). Three cases had infected, which had not be healed until 2-15 months after operation. Conclusion The method is definite effective for treatment of soft tissue defects of extremities. Anterolateral thigh flap can be incised in Ⅲ types, according to blood vessel. It is most clinical significant that the method of flap circulation establishment can alter the type of flap blood-supply. Key words: Anterolateral thigh perforator flap; Transplantation; Soft tissue defects; Extremity; Microsurgical operation

Arteriovenous Loop-Independent Free Flap Reconstruction of Sternal Defects after Cardiac Surgery.

Background Sternal defects following deep wound infections are predominantly reconstructed using local and regional flaps. The lack of appropriate recipient vessels after cardiac surgery may explain the minor role of free flaps. To date, arteriovenous loops have been the leading solution to enable microsurgical closure of these defects. However, the related surgical effort and the risk of flap failure are increased. We reviewed our experiences with the right gastroepiploic vessels as alternative recipient vessels for free flap reconstructions. Methods Between September 2010 and July 2015, 12 patients suffering deep wound infection after cardiac surgery underwent sternal reconstruction with free flaps anastomosed to the right gastroepiploic vessels. Gracilis flaps (n = 8) and anterolateral thigh perforator flaps (n = 4) were used for sternal reconstruction. Recipient vessels were harvested by laparoscopic dissection in five patients. Half of the free flaps were variably combined with omental flow-through flaps. Results Healing of all flaps was uneventful with no partial or total flap loss. Simultaneous interdisciplinary harvesting of recipient vessels by laparoscopy significantly shortened mean operative time from 313 to 216 minutes (p = 0.018). One incisional hernia was observed in the laparotomy group. Revision of a gracilis donor site was necessary in another patient due to postoperative bleeding. No recurrent sternal infection occurred during a mean follow-up of 20 months (range, 3-59 months). Conclusions The concept of gastroepiploic recipient vessels allows reliable free flap reconstructions of sternal defects in such high-risk patients without the need for arteriovenous loops.

Using the special type of free tissue flap based on radial artery superficial palmar branch from palmar wrist repairing complex soft tissue defects of the digitals

Objective To investigate the clinical outcomes of repairing complex soft tissue defects of the fingers with transplantation of the special type of free tissue flap based on radial artery superficial palmar branch from palmar wrist. Methods Thirteen cases with complex soft tissue defects of fingers were repaired with free tissue flap based on radial artery superficial palmar branch from palmar wrist between March, 2012 to January, 2015. Skin and soft tissue defect 1.5 cm × 3.0 cm to 2.5 cm × 6.0 cm, accompanied by bilateral segmental artery defect and injured finger blood circulation disorder in 4 cases; with unilateral finger artery and nerve defect in 2 cases; with extensor tendon defect in 4 cases; with of the artery, nerves or tendons. The size of the skin flap was 2.0 cm × 3.0 cm-3.5 cm × 6.5 cm, and the donor site was primary closed, finger flexor tendon defect, finger artery defect in 3 cases, respectively to radial palmar superficial branch of the transverse crease of the wrist portion of the flow-through flap, carrying the median nerve of the palmar cutaneous branch of the chimeric flap, carrying palm longus chimeric flap, carrying palm longus chimeric flow-through flap to repair the wound, and defect and reconstruction. Results All the flaps survived completely, the wounds and the donor sites were healed by first intention. All the patients were followed up from 6 to 15 months (average 9.5 months). The color and appearance of the flaps were satisfactory with tender texture. The scar of donor district was not conspicuous. The twopoint discrimination of the flap was 5.5-9.5 mm (mean, 7.2 mm). According to the Chinese Medical Association Society of hand surgery of thumb and finger reconstruction function evaluation standard trial evaluation, were excellent in 11 cases, good in 1 case, medium in 1 case. Conclusion Using the special type of free tissue flap based on radial artery superficial palmar branch from palmar wrist can repair of finger skin defect, and reconstruction of the defect of digital artery, nerve or tendon tissue in one stage. It is a method for repairing complicated soft tissue defects of finger, with the advantages of shortening the course of disease and satisfied recovering of the appearance and function of the finger. Key words: Superficial palmar branch of the radial artery; Perforate flap; Digitals; Soft tissue defect; Repair

A case series of flow-through free anterolateral thigh flap to augment the vascularity of ischaemic limbs with soft tissue defect.

Introduction:In a world of fast moving vehicles, heavy machinery and industries crush injury to limbs with vascular compromise and soft tissue defect is common. The traditional treatment is a 2 step one dealing with vascular repair and soft tissue cover separately, in the same operation. We report a series of single step vascular repair and soft tissue cover with flow through anterolateral thigh flap (ALT) flap for limb salvage.Materials and Methods:Ten patients with soft tissue defect and vascular injury were included in this study. A two team approach was used to minimise operative time, team one prepared the vessels and team 2 harvested the flap.Observations and Results:Of the ten patients operated (8 males), eight flaps were done for upper limb and two for lower limb salvage. Six anastomosis were done with ulnar vessels, two with radial and two with posterior tibial vessels. Nine extremities could be salvaged while one patient developed progressive thrombosis leading to amputation.Conclusion:The ALT flow-through flap is a versatile single step procedure that can be used to salvage an ischemic limb with soft tissue loss avoiding the need for interpositional vein graft.

Effects of preserving different veins on flow-through flap survival: An experimental study.

Flow-through skin flap grafting is becoming widely used for the reconstruction of skin and soft tissue defects, particularly for patients with poor blood supply around the defect. However, the treatment of the veins remains controversial. In the present study, 5×2-cm skin flaps were created on the left inner thighs of rabbits in order to investigate the effects of various treatments of the veins on the survival of a flow-through skin flap. A femoral artery perforator running through the flap was preserved. Five groups were established in which no veins, one superficial vein (SV), one accompanying vein (AV), one SV plus one AV, or all trunk veins (control) were retained. The percentage of flap area survival was determined on day 10. On days 3, 5, 7 and 9, tissues were harvested from the skin flaps and immunohistochemical analysis was performed in order to count the number of microvessels. Western blot analysis was subsequently completed in order to determine the expression levels of vascular endothelial growth factor (VEGF). The flap areas in which no veins were retained demonstrated significantly reduced survival rates on day 10, as compared with those in the other four groups (P<0.01). Furthermore, flaps with the retention of a SV also demonstrated reduced survival rates, as compared with the AV, AV plus SV and all veins groups (P<0.01); however, there no significant differences were detected between the latter three groups (P>0.05). Immunohistochemical analysis on day 3 detected a greater number of microvessels in the flaps of the control group, as compared with the flaps of the other groups. Furthermore, the AV and AV plus SV groups demonstrated a greater number of microvessels, as compared with the SV and no vein groups, and he no vein group demonstrated the fewest microvessels. No significant differences were found between the AV, AV plus SV and control groups on day 5, 7 and 9. Western blot analysis on day 5 demonstrated that the expression levles of VEGF were significantly increased in the flaps of the AV, AV plus SV and control groups, as compared with those in the SV and no vein groups. No significant differences were detected between the former three groups, and increased VEGF expression levels were detected in the flaps of the SV group, as compared with the no vein group. The flow-through flap grafts with no retained veins barely survived. Anastomosing one AV was adequate for flap survival; however, further studies are required in order to investigate the survival of flow-through flaps in more detail.

Use of Flow-Through Anterolateral Thigh Perforator Flaps in Reconstruction of Complex Extremity Defects.

The flow-through flap has been widely utilized for reconstruction of complex defects of the extremities as it can be used for arterial reconstruction and soft-tissue coverage simultaneously. This study describes our clinical experience with the application of the flow-through anterolateral thigh perforator (ALTP) flap for reconstruction of complex defects of the extremities. From January 2008 to June 2011, we retrospectively analyzed 16 patients with complex defects in the limbs. In two patients the defects occurred after undergoing wide excision of chronic ulcer, while 14 defects were due to trauma. All patients in this series underwent reconstruction with the flow-through ALTP flap. Applications of flow-through performed include preserving the recipient artery flow, rebuilding the major artery gap, bridging the artery and concomitant vein simultaneously, and combining the ALTP with another free flap. Flow-through ALTP flaps were used to preserve recipient flow (n = 5), rebuild the vessel gap (n = 2), bridge the artery and concomitant vein simultaneously (n = 2), and in combination with another free flap (n = 7). Follow-up ranged from 3 to 36 months (mean, 12 months). All flaps were successful; only two combination flaps required reexploration because of vessel crisis, and two patients suffered minor degrees of wound-edge necrosis. The donor sites healed well in all cases, without any complications. Our experience showed that the flow-through ALTP flap is reliable and suitable for reconstruction of complex defects of the extremities, as well as for various other clinical purposes.

Flow-through forearm flaps in palmar finger reconstruction

Objective To report the treatment and outcome of two kinds of flow-through forearm flaps in repairing palmar digital skin and artery defects. Methods The study included 15 patients (15 fingers) with palmar digtial skin combined with digital artery defects hospitalized from September 2011 through February 2014. Cut injuries were noted in 6 patients, crush injuries in 5 patients, and chain saw in 4 patients. There were 11 fingers with poor blood supply to the distal area and 4 no blood supply. One-stage reconstruction of the finger composite tissue defects was performed with flow-through free flaps including arterialised venous flaps (AVF) in 9 patients and superficial palmar branch of the radial artery (SPBRA) flaps in 6 patients. Discriminative sensation on the flap and active range of motion of the injured finger were analyzed and compared between the two groups. Results All the flaps survived and blood circulation in the finger restored. In AVF group, blister developed in 4 patients but healed within 5-10 days with no special care. Other than this the wound healed by the first intention. At a follow-up of 8-12 months, all the flaps that survived exhibited good restoration of the appearance, texture, thickness and protective sensation and the finger function was restored. According to the replanted finger function scoring system of Society of Hand Surgery of Chinese Medical Association, there were 6 excellent, 2 good, and 1 poor results in AVF group, with the excellent-good rate of 89%; there were 4 excellent, 1 good, and 1 poor results in SPBRA group, with the excellent-good rate of 83%. At postoperative 12 months, the two-point discrimination of the flaps was 6-9 mm[(7.6±1.3)mm] in AVF group versus 7-11 mm [(8.5±3.1)mm] in SPBRA group (P>0.05). Total active motion (TAM) of the injured fingers was (196.9±0.6)° in AVF group and was (196.2±0.5)° in SPBRA group (P> 0.05). Conclusion SPBRA flaps and AVF are both effective to cover digital wounds and restore blood circulation by flow-through technique. Key words: Surgical flaps; Soft tissue injuries; Fingers; Flow-through technique

Thumb reconstruction via a pedicled flap based on the superficial palmar branch of the radial artery from the wrist crease area

The free flap based on the superficial palmar branch of the radial artery (SPBRA) has been extensively reported. A reversed pedicled flap based on the SPBRA, harvested from the wrist crease area, can be a potential candidate for the reconstruction of the soft-tissue and artery defects in the thumb. Between January 2012 and October 2013, this flap was used in seven patients to reconstruct soft-tissue defects in the thumb. In three patients, blood circulation of the thumb was reestablished using flow-through flaps. The Michigan Hand Outcomes Questionnaire was used for patient self-evaluation. In one patient, the surgery was abandoned due to blood vessel variation. All the flaps and thumbs survived in the other six patients. The wounds healed primarily. All patients were followed up for a mean of 16.5 months (range, 12-26 months). At the last follow-up, the mean static two-point discrimination was 7.3 ± 0.9 mm on the affected side and 4.6 ± 0.7 on the contralateral side. The range of motion of the metacarpophalangeal joint and the interphalangeal joint were 66.8 ± 8.4° (contralateral, 85.2 ± 3.8°) and 67.0 ± 6.9° (contralateral, 80.5 ± 5.0°), respectively. Patient self-evaluations were good in five cases and fair in one case. The reverse island flap based on the SPBRA is feasible for soft-tissue defects and establishing blood circulation in the thumb. The donor site can be closed primarily, and the scar is inconspicuous in the wrist crease.

Distal run-off vessel of descending branch of lateral femoral circumflex artery used for reconstruction of extremity defects with free anterolateral thigh flap

Objective To explore the value of the distal run-off vessel of the descending branch of the lateral circumflex femoral artery in reconstruction of extremity defects with free anterolateral thigh flap. Methods From March 2009 to June 2013, 14 patients with extremity defects were repaired with free an-terolateral thigh flap that carried the distal run-off vessel of the descending branch of the lateral circumflex femoral artery. They were 13 men and one woman, with an average age of 34.6 years (from 8 to 57 years). The soft tissue defects involved the ankle and foot in 8 cases, leg in 3 and hand in 3, ranging from 5.5 cm×4.5 cm to 25.0 cm×14.0 cm in area. The distal run-off vessel was used in a flow-through flap for vascular reconstruction and wound coverage in 4 cases, in a flow-through flap for preservation of vascular continuity at the recipient site in 6 cases, in a recombinant chimeric flap for toe-to-2nd finger transplantation and simul-taneous flap resurfacing in one case, in a flap with connected transverse and perforating branches for repair of massive defects at the dorsal foot in one, and as a backup vessel to salvage a dying flap in postoperative ex-ploration of vascular crisis in 2 cases. Results The dissection time of distal run-off vessel was between 3 and 7 minutes (average, 4.6 minutes). The lengths of distal run-off vessels averaged 3.8 cm (from 1.5 to 6.0 cm). None complication occurred at the donor site due to removal of distal run-off vessel. The 14 patients obtained an average follow-up of 6.4 months (from 2 to 18 months). All the 14 flaps survived thoroughly. Follow-ups revealed no infection or necrosis but fine texture and colour. The foot recovered locomotion with good blood supply to the distal foot in 8 cases of ankle and foot defects and in 3 cases of leg defects. Three cases of hand defects gained fine functional recovery. Conclusions In surgery with free anterolateral thigh flap, the distal run-off vessel of the descending branch of the lateral circumflex femoral artery can play an important role because its easy dissection causes no additional injury to the donor site, an appropriate length can be harvested according to dif-ferent operational needs, and it can be used in a flow-through or a recombinant chimeric flap or as a backup vessel. Key words: Surgical flaps; Arteries; Microsurgery; Soft tissue injuries; Extremities

Experiences with the flow-through radial forearm flap as a bridge in lower extremity reconstruction.

Various techniques have been proposed in order to overcome recipient vessel problems in microsurgery. In cases with no suitable recipient vessels close to the defect, the flow-through flap is a valuable and reliable alternative for accessing healthy recipient vessels in a single stage. We describe our experiences with combined flaps and discuss the advantages of the flow-through radial forearm flap as a bridge. Between 2003 and 2009, eight combined flaps were used to reconstruct soft-tissue defects of lower extremities. Seven patients had acute or subacute wound with exposed bone and vascular injury caused by trauma, one had a chronic nonhealing wound. The flow-through radial forearm flap was used as a bridge flap with combined a cover flap in all cases. Radial forearm flaps provided recipient vessel lengthening. In one patient, the distal ALT flap failed and replaced with latissimus dorsi flap. Other postoperative courses were uneventful and all of flaps survived. In one patient although the flaps were healthy, sepsis developed and the extremity was amputated. Recovery and ambulation were achieved in the remaining patients. Combined flaps with the flow-through radial forearm flap are an appropriate technique for overcoming recipient vessel problems. Although the technique involves a more complicated procedure and increases the number of microvascular anastomoses, it is a valuable, safe and comfortable alternative in selected cases.

Microsurgical reconstruction of the maxilla: Algorithm and concepts

The main purpose of this article is to highlight free tissue transfers as the first-choice method for three-dimensional (3D) maxillary reconstruction, particularly in providing enough bone for palate and maxillary arch reconstruction and consequently an implant-retained prosthesis. To achieve this, the myosseous free iliac crest was selected whenever possible as the first choice inside the reconstructive algorithm and free flap armamentarium. A new maxillectomy classification and algorithm reconstruction are proposed. Technical modifications and improvements accomplished over time are discussed, considering palate, dental implants and prosthesis, nasal sidewall, cranial base and dura, as well as recipient vessels. We present functional and aesthetic outcomes of the senior author's past 24-year experience (H. C.) with complex midface reconstructions. The authors report and analyse a 24-year experience with 57 midface defects in 54 patients (30 males and 24 females). A total of 57 maxillary defects - classified as Class I (limited maxillectomy)=12, Class II (subtotal maxillectomy)=15, Class III (total maxillectomy)=19 and Class IV (orbitomaxillectomy)=11 - were analysed regarding sex, age, tumour recurrence, free flap, reconstruction and necrosis. In addition, functional outcomes were evaluated regarding diet, speech, globe position and vision, while aesthetic outcomes were evaluated by patient and surgeon scores. A total of 52 free flaps were performed in 47 patients; three patients were operated upon twice; and two other patients needed two sequentially linked flow-through flaps. The free flap survival was 96% with two total flap losses (4%). The other seven patients were fitted with a soft tissue-retained obturator prosthesis. Microsurgical vascularised osteomyocutaneous free flaps are actually the gold standard for reconstruction of complex defects following maxillectomy. This algorithm is based on the anatomofunctional defect of the maxilla and it facilitates flap selection, which is a must.

Salvage of a free flap using postoperative percutaneous angioplasty in patients with diabetic foot ulcers.

Salvage of a free flap using postoperative percutaneous angioplasty in patients with diabetic foot ulcers.