Neurovascular Flap Research Articles

Midline raphe scroti artery flap for penile shaft reconstruction

Aim: To investigate a novel method for penile shaft reconstruction. Methods: Penile tissue loss is caused by injury, infections, obesity or cancer resection. Reconstructive techniques comprise skin grafts with the risk of scarring and tissue rigidity. To develop an alternative reconstructive procedure, the pertinent vascular anatomy was studied on fresh cadavers instilled with red latex, which permitted the design of the midline raphe scrotal artery flap (MiRA). After anatomical proof-of-feasibility, penile reconstruction was performed in adult patients with classic buried penis or after cancer resection. Results: Anatomical studies revealed a novel finding of two scrotal septa, each with the terminal branch of the internal pudendal artery. Pedicled on both arteries, a neurovascular island flap could be harvested. In the presence of excess scrotal tissue, the entire circumference of the penile shaft could be covered by this flap. Patients with penile skin defects and excess scrotal tissue were eligible for flap harvest. The flap was raised either as an extended island flap pedicled on both septal arteries for complete penile shaft coverage, or as a VY-flap for partial reconstruction; the donor site was closed primarily. Post-operative complications included swelling or partial wound dehiscence. There were no flap losses or perfusion problems. Patients reported full sensitivity to the penile shaft skin and sufficient skin elasticity for erection. Conclusion: The MiRA flap is a technically safe neurovascular flap suitable for the reconstruction of partial or full defects of the penile shaft, such as after type III buried penis surgery, and provides sufficiently elastic and sensitive skin for functional penile reconstruction.

Reconstruction of Finger Pulp Defects With an Innervated Distally-Based Neurovascular Flap

Finger pulp resurfacing is a challenging reconstructive problem. This article introduces sensory reconstruction of finger pulp defects using an innervated distally-based neurovascular flap raised from the dorsum of the thumb. From May 2015 to May 2017, the innervated distally-based neurovascular flap was used in 36 patients. The mean age at surgery was 37 years (range, 18-61 years). All patients were assessed using the total active motion (TAM) scoring system of the American Society for Surgery of the Hand. The sensitivity of the flap was tested using static 2-point discrimination. Full flap survival was achieved in 35 cases. Partial necrosis at the distal margin of the flap was observed in 1 case. At the final follow-up (mean, 20 months; range, 18-23 months), the mean TAM of the thumb was 206° (range, 188°-238°), including 8 excellent and 28 good results. The mean TAM of fingers was 266° (range, 251°-282°), including 4 excellent and 32 good results. The mean value of static 2-point discrimination was 5 mm (range, 4-7 mm) in the flap, including 31 excellent and 5 good results. The innervated distally-based neurovascular flap raised from the dorsum of the thumb is a reliable alternative for sensory reconstruction of finger pulp defects. Therapeutic IV.

The free neurovascular transverse wrist crease flap for repairing soft tissue defects of the fingers: clinical outcomes of multiple centers

BackgroundFlap transplantation is often needed for soft tissue defects of the fingers that cannot be closed directly. Sensory reconstruction of the fingers is important for patients to recover feelings. In this study, we report clinical outcomes of using free neurovascular transverse wrist crease flap for repairing finger defects from multiple centers.MethodsThis case series includes 72 consecutive patients with finger defects between June 2013 and June 2016 from multiple centers. A neurovascular transverse free radial artery superficial palmar branch flap, named transverse wrist crease flap, was designed to reconstruct soft tissue defects of the fingers with microvascular anastomosis. When there were soft tissue defects of the fingers with digital nerve defect, end-to-end neurorrhaphy between the median palmar cutaneous branch and the digital nerves was also performed. The donor incision was sutured directly. All the patients were followed-up for more than 24 months.ResultsThe soft tissue defects of the fingers were all completely covered with this free neurovascular transverse wrist crease flap, and the flaps in 71 patients survived completely without ischemia. Vascular crisis appeared in one case, and the wound healed gradually after changing wound dressing for nearly 1 month. Slight infections of wounds appeared in eight cases. There were no complications in the donor site, like infection and poor wound healing. At the last follow-up, the mean static two-point discrimination was 9.6 ± 2.4 mm on the injured finger and 4.5 ± 0.8 on the contralateral corresponding finger. The motion range of the distal interphalangeal joint and proximal interphalangeal joint on the injured finger were 72.5 ± 23.3% and 78.7 ± 32.5% of the contralateral corresponding finger, respectively. Patient self-evaluations were good in 53 cases and fair in 19 cases.ConclusionsThe results indicate that the free neurovascular transverse wrist crease flap is a good choice for repairing soft tissue defects of the fingers.Level of evidenceTherapeutic IV

Microsurgical repair of soft tissue necrosis after beak-type calcaneal fracture in 8 cases

Objective To investigate the clinical efficacy of microsurgical repair of soft tissue necrosis after beak-type calcaneal fracture. Methods From January, 2012 to March, 2017, surgically flaps were used to repair wounds in 8 patients with soft tissue necrosis after calcaneal beak fracture. Five patients underwent sural neurovascular flap in the first stage of repair, 2 patients were treated with peroneal perforator propeller flap, and 1 patient was treated with posterior tibial artery perforator propeller flap. The donor sites of 3 flaps were directly closed, and donor areas of the remaining 5 were covered with medium-thickness skin grafts without being sutured directly. The size of flap was 5.0 cm × 3.0 cm-7.0 cm × 5.0 cm. Through postoperative outpatient and WeChat follow-up. The patient’s flap survival, infection, flap shape, sensation and ankle function were evaluated. Results All flaps and skin grafts survived post-operatively. All patients were followed-up for 6-12 (mean, 8.4) months. All patients had good flap survival and no complications such as soft tissue and calcaneal infection. The flaps were good in texture, shape and function of ankle. At the last follow-up, according to the British Medical Research Institute (BMRI), the sensory function was divided into 6 levels. The flap sensory function recovered to S2 in 3 cases, and the remaining 5 cases was S1. According to the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-hindfoot Scale (AHS), the results were excellent in 5 cases, and good in 3 cases. All patients had good clinical results and satisfaction at the last followed-up. Conclusion The treatment of soft tissue necrosis after calcaneus beak fractures can be completed in one stage by using flaps, which avoided the occurrence of calcaneal osteomyelitis. It is easy to perform early rehabilitation exercise and the ankle function is well restored. Key words: Calcaneus; Beak fracture; Propeller flap; Sural neurovascular flap; Microsurgical technique

Island singapore flap vaginoplasty of two adult cases of Mayer– Rokitansky–Küster–Hauser Syndrome Type I

Mayer–Rokitansky–Kuster–Hauser Syndrome Type I is an emotionally distressful rare condition that limits normal sexual functioning and relationships. First described in 1989 by Wee and Joseph, the neurovascular island pudendal thigh flap (Singapore flap) has been variously utilized and modified for use in vaginal reconstruction. We report two adult cases of vaginal agenesis who underwent vaginal reconstruction using the Singapore flap. Both patients reported improved sexual lifestyle. Keywords: Island Singapore flap, Vaginoplasty, Mayer–Rokitansky–Kuster–Hauser syndrome Type I

Results of the application of neurovascular homodigital flaps on cutaneous defects of digital fingertips

Introduction: traumatic injuries of the hand are in the top list of working Industrial accidents. The treatment of these injuries has as goal to restore the function of fingertips, improving the patients' quality of life. Objective: Evaluate results of the application of neurovascular homodigital flaps on cutaneous defects of digital fingertips of the hand large fingers. Method: an observational and descriptive investigation was conducted in a case chain of 33 Patients at Hermanos Ameijeiras Hospital from October 2013 to January 2015. Were Neurovascular homodigital flaps applied with direct circulation (17 patients) or indirect circulation (16 patients). Results: male sex was more affected; frequency was higher Between 36 and 41 years old and over 41 years old. Four complications were confirmed representing 12%. 72.7% obtained good and excellent results with the application of these surgical techniques receiving an appropriate protector of sensibility and satisfactory cutaneous covering. Application of these procedures was 93.9% satisfied. Conclusion: The application of neurovascular flaps homodigital was established on cutaneous defects of digital fingertip of the hand large fingers.

Aesthetic Refinement in the Creation of the Clitoris, Its Preputial Hood, and Labia Minora in Male-to-Female Transsexual Patients.

In male-to-female genital sex reassignment surgery, the clitoris, its prepuce, and the labia minora remain among the most difficult structures to construct. We describe the authors' clitoroplasty and vulvoplasty technique. All patients who underwent male-to-female sex reassignment surgery at a single center, between June 2012 and June 2016, were prospectively included. The standard pedicled island neurovascular flap of the glans penis was harvested in a letter M fashion with attached preputial skin. The central triangle of the M was used for the neoclitoris formation. Labia minora and the clitoral prepuce were created with both legs of the M and the preputial skin attached to it. Tactile and erogenous sensitivity was evaluated. Ninety-seven patients were included (mean age, 32 years; range, 17-54 years). All clitoroplasties and vulvoplasties were completed in the same surgical stage as the vaginoplasty. There were no cases of deep or total flap necrosis. Eight patients developed partial and superficial skin necrosis of the flap; one presented an abscess in labia majora, and another patient had urethral hematoma; both required drainage. None of the complications left any sequelae. At 6 months' follow-up all patients maintained tactile and erogenous sensitivity. The proposed technique represents an aesthetic refinement of the previously described pedicled glans penis flap by allowing the creation of a sensate neoclitoris, its preputial hood, and labia minora with excellent outcomes in the same surgical stage as the sex reassignment.

Plate osteosynthesis for one-stage definite treatment of Gustilo type III open fractures of long bone

Objective To report our efficacy of one-stage definite treatment of Gustilo type Ⅲ open fractures of long bone by plate osteosynthesis. Methods A retrospective case series study was conducted of the 69 cases who had undergone plate osteosynthesis for one-stage definite treatment of Gustilo type Ⅲ open fractures of long bone from January 2006 to June 2016 at Microsurgery and War Trauma Center of Chengdu Military Command, 59 Hospital of Chinese PLA. They were 47 males and 22 females with an average age of 34.2 years (from 2 to 62 years). There were 27 shaft fractures of tibia or fibula (13 cases of type ⅢA, 12 cases of type ⅢB and 2 cases of type ⅢC), 4 fractures of distal tibia (2 cases of type ⅢA and 2 cases of typeⅢB), 14 shaft fractures of ulna or radius (9 cases of type ⅢA, 3 cases of type ⅢB and 2 cases of type ⅢC), 12 factures of humeral shaft (7 cases of type ⅢA, 3 cases of type ⅢB and 3 cases of type ⅢC), 3 fractures of distal humerus (all type ⅢC), 6 fractures of femoral shaft (5 cases of type ⅢA and one type ⅢC), and 3 fractures of distal femur (2 cases of type ⅢA and one type ⅢC). The intervals between injury and operation ranged from 4 to 17 hours, averaging 9.6 hours. After thorough debridement, osteosynthesis was performed with locking compression plate, limited contact dynamic compression plate or/and reconstruction locking plate, or 1/3 tubular plate. Direct closure with decreased tension or without tension was used for type ⅢA injury; deep open defects were repaired with perforator flaps, neurovascular axis flaps, traditional axis flaps and muscular flaps, or local flaps; limb reconstructions included neurovascular repair in 12 cases, tendon and ligament repair in 5 cases, and muscle reconstruction in 3 cases. Superficial defects were covered by skin grafts simultaneously or secondarily. Results The duration of hospitalization averaged 19 days (from 5 to 37 days). Partial necrosis occurred in one case of sural neurovascular axis flap. Superficial infection with multiple antibiotic-resistant bacteria occurred in 2 cases. Follow-up for the 69 patients ranged from 12 to 27 months (average, 19.2 months). No deep bone infection occurred. Implant breaking occurred in 4 cases and implant loosening in one. The implant failures were corrected by change into intramedullary nails or plate refixation (respectively in 2 cases) in addition to bone graft. Bone union was achieved after 5 to 15 months (average, 7.7 month) with satisfactory aesthetic and functional outcomes. Conclusion For patients with Gustilo type Ⅲ open fracture of long bone, especially those with metaphyseal, intraarticular or upper limb fracture and pediatric ones, plate osteosynthesis can be a satisfactory one-stage definite treatment besides intramedullar nailing and external fixation, providing that through debridement and satisfactory soft-tissue coverage can be achieved. Key words: Fractures, open; Bone plate; Surgical flaps; One-stage procedures

Formation of a sensate forearm stump through neurovascular tissue transplantation

The use of neurovascular flaps can help to maximize limb length and gain sensory re-innervation in amputees. We describe the case of a 19-year-old patient who underwent an innovative reconstructive approach aimed at preserving viable limb length with sensory regeneration by using innervated tissue transfer after traumatic upper extremity amputation below the elbow. The forearm length was maximized by means of two neurovascular free flaps that formed a robust, functional, and versatile stump. The mechanism of this reconstruction originated from the practice of placing a double-innervated anterolateral thigh flap over a myocutaneous flap for covering protruding forearm bone shafts. This form of vascularized tissue transplantation helps to minimize the risk of necrosis of radial and ulnar bone shafts. In this patient, an upper arm prosthesis would have been necessary if lower arm bone shafts had been shortened for primary wound closure. Therefore, the newly formed stump enabled the patient to wear a forearm prosthetic instead of a less functional upper arm device. In addition, neurovascular tissue transfer facilitates sensory re-innervation, improvement of the healing process and serving a protective function over the covered area. Through co-adaptation of free nerve endings, neuroma formation can also be prevented. To ensure long-term success, it is vital that the patient be in good mental and physical health, as well as demonstrate the capacity for long-term rehabilitation therapy prior to performing such reconstructions. Level of Evidence: Level V, therapeutic study.

Effectiveness of limbs shortening and re-lengthening in treatment of tibial infectious bone defect and chronic osteomyelitis

To evaluate the limbs shortening and re-lengthening in the treatment of tibial infectious bone defect and chronic osteomyelitis. Between January 2011 and April 2016, 19 cases of tibial infectious bone defect and chronic osteomyelitis were treated with the limbs shortening and re-lengthening technique. There were 13 males and 6 females, aged from 22 to 62 years (mean, 44 years). The causes of injury included traffic accident injury in 16 cases, crush injury in 1 case, and falling from height in 2 cases. One patient was infected after plate internal fixation of closed tibial fracture and 18 patients after external fixation of open tibial fractures (Gustilo type IIIB). The mean previous operation times was 3 times (range, 2-5 times). The time from injury to bone transport operation was 3-11 months (mean, 6.5 months). The bone defect length was 2.0-5.5 cm (mean, 4.3 cm) after debridement. After tibial shortening, limb peripheral blood supply should be checked after release of the tourniquet. Seven wounds were closed directly, 5 were repaired with adjacent skin flap, 5 were repaired with sural neurovascular flap, 1 was repaired with medial head of gastrocnemius muscle flap, and 1 underwent skin grafting. Single arm external fixator or ring type external fixator were used, and completely sawed off between 2 sets of external fixation screws at proximal and distal metaphysis of the tibia. Limb lengthening was performed after 1 week with the speed of 1 mm/d. All patients were followed up 10-36 months with an average of 14 months. Two cases delayed healing of the wound after operation, and the other wounds healed primarily. Natural healing of the opposite end of the bone were found in 18 cases, and 1 case had nonunion in the opposite end of the bone because of incomplete removal of lesion bone. There were 5 cases of slow growth of the callus, and healed smoothly by "accordion" technology and injecting red bone marrow in 4 cases, and by bone grafting and internal fixation in 1 case. The time of bone lengthening was 1-3 months, the prolongation index was 1.6-2.7 cm/month (2.20 cm/month). The bone healing time was 7-13 months (mean, 11.1 months). According to tibial stem diagnostic criteria Johner-Wruhs score, 9 cases were excellent, 8 cases were good, 2 cases were fair, with an excellent and good rate of 89.5%. Limbs shortening and re-lengthening is an effective method for the treatment of tibial infectious bone defect and chronic osteomyelitis, with the advantages of improving the immediate alignment of the osteotomy ends, significantly shortening the bone healing time of opposite ends of bone.

Combination of vascularized fibular head epiphysis and superficial peroneal neurovascular reverse flap repair defects of bone and skin in lateral malleolus in children

Objective To explore the clinical effect of combination of vascularized fibular head epiphysis and peroneal neurovascular reverse flap repair defects of bone and skin in lateral malleolus in children. Methods Eight children with defects of bone and skin in lateral malleolus were recruited from May, 2009 to September, 2014. The age of children was ranging from 4 to 12 years old. Four children were injured by wheel twist, 2 children were injured by traffic accident, 1 was injured by machinery, and 1 was crashed with heavy object. The size of soft-tissue defect was ranging from 3 cm × 5 cm to 7 cm × 9 cm. The flap and bone healing along with ankle joint function scoring were evaluated. Patients were reviewed every 4 to 6 weeks during one year after their surgery, and they were reviewed every 6 months one year later. Results Secondary repair were conducted in all children. The curative effect got well after follow up for 6 months to 2 years(mean, 12 months). The flap and fibular head epiphysis were well developed. The ossification of fibular head epiphysis did not found. According to American Orthopaedic Foot and Ankle Society (AOFAS) ankle function evaluation criteria, the results were excellent in 5 cases, good in 2 cases and poor in 1 at 10 months after operation. The shape and function of ankle joint were good, with one exception. The average motion degree of ankle joint was (68±5.12) °. Conclusion Combination of vascularized fibular head epiphysis and peroneal neurovascular reverse flap repair defects of bone and skin in lateral malleolus in children is effective. Key words: Lateral malleolus injury; Fibular head; Superficial peroneal neurovascular reverse flap; Children

Clinical application of changeable cross-leg style sural neurovascular flap in repairing contralateral fairly large soft tissue defect on dorsum of forefoot

To explore the effectiveness of changeable cross-leg style sural neurovascular flap in repairing contralateral fairly large soft tissue defects on dorsum of forefoot. Between June 2006 and June 2015, 12 patients with fairly large soft tissue defect on dorsum of forefoot were treated. There were 8 males and 4 females, with an average age of 35.6 years (range, 18-57 years). Defects were caused by traffic accident injury in 4 cases, machine crush injury in 3 cases, and heavy object crush injury in 3 cases, with a median disease duration of 11 days (range, 5 hours to 28 days) in the 10 cases; the defect cause was atrophic scar in 2 cases, with disease duration of 2 years and 3 years respectively. The wound size of soft tissue ranged from 6.2 cm×4.1 cm to 11.5 cm×7.4 cm; combined injuries included tendon exposure in all cases and bone exposure in 6 cases. The changeable cross-leg style sural neurovascular flaps were used to repair defects. The width and length of flap pedicle were increased. The cross-leg position was maintained with the elastic net bandage. The size of flaps was 16 cm×7 cm to 21 cm×11 cm, with a pedicle of 8-16 cm in length and 5-6 cm in width. After operation, 10 flaps survived, and wound healed by first intention. Extravasated blood occurred at the flap edge in 2 cases and was cured after symptomatic treatment. No pressure sore occurred. All patients were followed up 3-24 months (mean, 7 months). The appearance and function of the affected legs were good, and the flaps had soft texture and normal color. Changeable cross-leg style sural neurovascular flap can achieve good effectiveness in repairing fairly large soft tissue defect on dorsum of forefoot. Some drawbacks of single cross-leg style can be avoided.

Choosing of the posterior lateral leg pedide skin flaps supplyed by different blood repair of foot and ankle soft tissue defect

Objective According to the characteristics of skin defects in ankle and foot select the posterior lateral leg pedide skin flaps supplyed by different blood to repair, providing advice and reference. Methods Between January, 2001 and December, 2015, 163 cases of soft tissue defects at the foot and ankle were treated in our department. ①The sural neurovascular flap was used in 93 cases in ankle and foot defect. ②The sural nerve nutritional vessel flap pediele with the perforating branch of the peroneal artery in 36 cases in ankle and foot defect. ③The sural nerve nutritional vessel flap pediele with the perforating branch of the peroneal artery including sensory reconstruction in 16 cases in heel rejion defect. ④Peroneal artery perforator flap in 10 cases in anterior ankle, lateral malleolus and posterior malleolus defect.⑤The use of the sural fasciocutaneous flap alonged with peroneal artery and perforators in 8 cases in dorsal foot defect. The donor site with skin graft. Results Of the 93 sural neurovascular flaps, 8 had partial loss, which were cured after dressing. All the sural nerve nutritional vessel flaps pediele with the perforating branch of the peroneal artery survived. Sensory grading standard by UK Medical Research Council was used to evaluate the recovery of sensory function on the last follow-up. The sensory function recovery of heel region flaps with reconstruction of the sensory was between S0 and S1. All peroneal artery perforator flaps survived. One of the sural fasciocutaneous flap alonged with peroneal artery and perforators occurred distal epidermis, which were cured after dressing. All patients were followed up 6-50 months (mean 20 months). All patients had recoveryed walking function, and infection wound had no recurrence after surgery. Conclusion According to the location, size, severity and the injury of peripheral vascular, select the most simple, safe, minimal damage flap for the soft tissue defects at the foot and ankle. The right choice and the exact design can improve flap survival rate, and recieve good clinical results. Key words: Foot and ankle; Soft tissue defect; Surgical flap; Repair; Sense reconstruction

The anterograde sural neurovascular flap based on the popliteal artery perforator for covering tissue defects in middle and distal upper leg

Objective To evaluate the clinical effect of popliteal artery perforator-based sural neurovascular flap for repairing soft tissue defects in middle and distal upper leg. Methods Between December, 2011 to September, 2015, 18 cases with skin soft tissue defects on the middle and distal upper leg were treated with popliteal artery perforator-based sural neurovascular flap, in which 12 cases were males, and 6 cases were females. The age was from 24 to 55 years, with the average age of 35.9 years. The size of tissue defects ranged from 3.0 cm × 3.0 cm to 7.0 cm × 9.0 cm. Results All flaps survived completely in 18 cases, 1 case of marginal infection heated after dressing, and the rest cases in Ⅰhealing. The outline and function of survived flap were satisfactory during 3-16 months follow-up, with two-point discrimination of 4.0-10.0 mm. Conclusion The anterograde sural neurovascular flap based on the popliteal artery perforator provides a practical option for covering tissue defects in middle and distal upper leg. This flap is characteristiced by reliable blood supply without sacrificing main vesses, good contour and texture, in addition, the operation is easy of handling. Key words: Upper leg; Popliteal artery perforator; Sural neurovascular flap; Soft tissue defects; Microsurgical operation

Boot-shaped Neurovascular Island Flap for Reconstruction of Radial Polydactyly

Hypothesis: Reconstruction of radial polydactyly with a boot-shaped neurovascular island flap can result in good outcomes. Materials and Methods: A number of techniques are used for reconstruction of radial polydactyly, with the aim of reconstruction to obtain a stable, mobile thumb of adequate size and shape. Techniques include preserving the ulnar (or radial) thumb, reconstructing a contour defect with a boot-shaped neurovascular island flap and the Bilhaut-Cloquet procedure. A persistent problem is the asymmetry between the reconstructed and normal contralateral thumb. Between 2013 and 2015, 9 thumbs in 8 patients had reconstruction with a boot-shaped neurovascular island flap. The study group included 1 Wassel type I, 6 Wassel type IV, and 2 Wassel type VII. A boot-shaped neurovascular island flap was dissected out from the thumb to be removed. Specific modifications include the use of Bruner incisions dorsally and volarly to reduce scarring at the interphalangeal joint and also complete mobilization of the island flap on its pedicle to allow easier inset. A flexor pollicis longus and extensor tendon rebalancing technique was used to correct deviation of the reconstructed thumb’s interphalangeal (IP) joint in the Wassel type IV thumb duplication. Results: All boot-shaped neurovascular island flaps survived with good contour and shape, and obtained symmetry eponychial fold compared with the contralateral thumb. Reconstruction of radial polydactyly with a boot-shaped island neurovascular flap allows for good symmetry in shape and size following reconstruction, especially where 2 digits are equal or almost equal in size. Summary Points: A boot-shaped neurovascular island flap can be used for reconstruction of radial polydactyly with good outcomes.

Thumb Reconstruction Using Foucher's Flap.

BACKGROUND:Extensive pulp defects of the thumb, with the exposure of tendon or bone, are challenging reconstructive problems. Surgical treatment includes the use of local, regional, and free flaps.AIM:This paper is focused in Foucher’s neuro vascular flap. First DMCA or Foucher’s pedicle flap is a successful thumb reconstruction method, especially in patients not disturbed by its cosmetic appearance.MATERIAL AND METHODS:The first dorsal metacarpal artery (FDMCA) arises from the radial artery in the first intermetacarpal space, just distal to the tendon of the extensor pollicis longus. Pulp area of the thumb is the area where Foucher’s flap is more utilizable. This technique has other applications such as first web reconstruction, thumb lengthening, and following resection of tumors on the dorsum of the hand.RESULTS:We have in study 7 cases with work related trauma in two years period of time, between 2012 and 2014. We had only one partial flap survival and all the other flaps survived entirely. We have also taken in consideration subjective satisfaction with a range score from 4 to 10, cold intolerance, flap area and donor site sensibility with a range score from low to medium to normal.CONCLUSION:Careful pedicle discovery, secured elevation, pedicle strangulation prevention are very important for flap survival.

Macrosurgery for fingertip amputations

Due to the high concentration of sensitive receptors, the fingertip is widely used in plenty of activities and, therefore, frequently exposed to trauma and amputation. Simple revision amputation was used in the past for the treatment of these injuries. However, replantation, revascularization, or reconstruction allows preservation of the nail, length of the digit, and, mainly, sensibility of the pulp. Undoubtedly, the best way to restore function to an amputated digit is to restore the amputated part by microsurgical vascular anastomosis. However, the replantation of very distal segments is technically challenging due to the size and fragility of the vessels. Furthermore, the amputated part is not always available. Reattachment of the amputated part without vascular anastomosis is described as composite graft [1]. Other authors described different ways for improving the success rate. Brent [2] described the reattachment in amputations that occurred between the lunula and the DIP joint by performing deepithelization of the amputated part and embedding it in a subcutaneous pocket in the contralateral chest. Arata et al. [3] modified this procedure using the ipsilateral palm as the pocket site. We consider subzone 1 Ishikawa level as suitable for reconstruction without replantation. In this case, a local flap can adequately restore function and appearance. The neurovascular homodigital advancement flap [4] is the most useful flap for coverage of the amputated part. For larger areas that cannot be covered with a homodigital advancement flap, we use innervated cross finger flaps [5]. The Moberg flap is a good option to reconstruct medium-size defects of the pulp of the thumb [6]. For covering larger areas, we use the first metacarpal island flap [7]. Raising a racket flap as proposed by Holevich [8] adds safety regarding venous congestion, once a subcutaneous tunnel is avoided, and can improve cold intolerance, since it transfers more nerve branches to the thumb allowing for a better temperature control [9]. The nail complex tissues, as hyponychium, paronychium, and sterile matrix cannot be reconstructed with local tissue. If the amputated part is available, these parts can be used as grafts applied to the flap used to reconstruct the pulp[10]. The eponychial flap [11] can be used to increase the exposed part of the nail bed. This is achieved by removing a rectangle of dorsal skin and performing a proximal translocation of the eponychium.

Repair of high energy injury-induced soft tissue wound of the heel

Objective To investigate the methods and effects of different flaps for repair of high energy injury-induced soft tissue wound of the heel. Methods From January 2002 to June 2012, the patients including 12 males and 9 females aged 18-57 years (mean, 32 years) underwent heel soft tissue defect reconstruction. Causes of injury were traffic injury in 11 case and mechanical injury in 10 cases. Dimension of soft tissue defect ranged from 5 cm×3 cm to 8 cm×6 cm. Soft-tissue defect was repaired with sural neurovascular flaps at the posterolateral heel in 9 cases (Group A), with posterior tibial artery flaps at the posterolateral heel in 5 cases (Group B), and with medial plantar flaps at the loading area of heel in 7 cases (Group C). Sensory recovery and two point discrimination motion of the ankle joint were observed and compared among groups 12 month after operation. Heel pain was observed during weight bearing and joint activity was evaluated using the visual analogue scale (VAS). Results All the flaps survived, except for one with epidermal necrosis over the distal part, which healed after partial changing medication. Duration of follow-up was 12-24 months. There were no differences in the appearance, texture and contour between the flaps and recipient sites. Flaps showed no ulcer in the weight-bearing area and recovered their protective sense. Patients could walk normally after surgery. At postoperative 1 year, sensory recovery rate of the flaps in Groups A, B and C was 0, 20% and 100% respectively (P 0.05). While heel pain existed in weight-bearing exercise.Difference in VAS was significant among the three groups (P 0.05). Conclusion Medial plantar flaps are suitable for tissue defect of 5-8 cm in length but sural neurovascular flaps and posterior tibial artery flaps should be considered for over 8 cm defect in order to elevate survival rate of the flaps and reconstruct limb function. Key words: Foot injuries; Soft tissue injuries; Surgical flaps

One-stage reconstruction of open fractures of leg, ankle and foot of Gustilo types III B and III C

Objective To explore one-stage reconstruction of open fractures of leg,ankle and foot of Gustilo types Ⅲ B and ⅢC.Methods From January 2001 to April 2012,160 open fractures of leg,ankle and foot of Gustilo types Ⅲ B and Ⅲ C were treated with one-stage reconstruction.They were 103 men and 57 women,with an average age of 36.3 years.There were 113 cases of tibial shaft fracture (type ⅢB in 91 and type ⅢC in 22),4 cases of tibial distal end fracture (ⅢB in 3 and type ⅢC in one),and 43 cases of ankle and foot fracture (ⅢB in 37 and type ⅢC in 6).Time from injury to surgery ranged from 3 to 37 hours,averaging 12.7 hours.After thorough debridement,crucial soft-tissue wounds were covered with surgical flaps,such as perforator flap,neurovascular flap,traditional axial skin or muscular flap and even local flap.The fractures were reduced and fixated definitively using external frames in 121 cases,plates in 20 cases,screws and/or K-wires in 14 cases,and intramedullary nails in 5 cases.Other limb reconstructions included neurovascular repair,transposition of the tendon and nerve,and joint stabilization of ankle and foot.Results Mean in-hospital time was 28.0 days (ranged from 9 to 76 days).Crucial wounds were repaired primarily.The limbs were savaged successfully in 159 cases while amputation was performed in one case of tibiofibular fracture of Gustilo type Ⅲ C 2 months after primary operation because of consistent and severe pain.Follow-ups ranged from 12 to 83 months (average,21.3 months).No severe or persistent infection occurred and bone union time ranged from 6 to 19 months (average,11.7 months) with satisfactory aesthetic and functional results.Conclusions One-stage reconstruction of open fractures of leg,ankle and foot of Gustilo types Ⅲ B and Ⅲ C with standard techniques of plastics and fracture management can significantly simplify the procedures and reduce complications.In addition,fresh wounds are easier to get repaired.Moreover,flap coverage of only crucial defects but not the whole wounds can minimize donor sacrifice and recipient bulking. Key words: Leg; Foot; Fractures, open; Surgical flaps; Microsurgery

Repairing defects of foot and ankle by sural neurovascular adipofascial flap

Objective To investigate the clinical effect of repairing soft tissue defects of foot and ankle by sural neurovascular adipofascial flap.Methods Application of sural neurovascular adipofascial flap to repaire soft tissue defects of foot and ankle in 19 patients,inclouding 3 csaes with the soft tissue defects of medial malleolus and 16 cases of dorsum pedis from May,2006 to May,2013.The size of soft tissue defects was 3 cm ×3 cm-7 cm ×9 cm.The skin of the donor site was sutured directly.The recipient area was reshaped granulation and underwent free skin graft after the adipofascial flap survived.Results After followed up of 3-18 months,the adipofascial flaps were all survived,the recipient area was almost flat with the surrounding tissue,the donor area only leaving linear scar,the appearance and function of donor area and adopt area were satisfactory.The sensation of lateral dorsal region of foot decreased to S3,and the sensation of recipient site recovered to S2.There were some changes in pigmentation with the skin graft region.Conclusion Sural neurovascular adipofascial flap can be effectively repaired soft tissue defects of foot and ankle,and it can avoid irregularity of donor area and enlargement of adopt area,the appearance and function were satisfactory. Key words: Sural nerve ; Adipofascial flap ; Foot ; Ankle ; Microsurgical operation