Reconstruction Of Complex Soft Tissue Defects Research Articles

The free chimeric medial sural artery perforator flap for individualised and three-dimensional reconstruction of complex soft-tissue defects in extremities.

Trauma or lesion resection often causes complex wounds with deep soft tissue defects in extremities. Simply covering with a skin flap will leave a deep dead space resulting in infection, non-healing wounds, and poor long-term outcomes. Thus, effectively reconstructing complex wounds with dead space leaves a clinical challenge. This manuscript presents our experience using chimeric medial sural artery perforator (cMSAP) flap, to reconstruct complex soft tissue defects of the extremities, thereby exploring broader analysis and indications for future reference. Between March 2016 and May 11, 2022, patients (8 males and 3 females) with a mean age of 41 years (range from 26 to 55 years) underwent reconstructive surgery with the cMSAP flap. The cMSAP flap consists of an MSAP skin paddle and a medial sural muscle paddle. The size of the MSAP skin paddle ranged between 9 × 5cm and 20 × 6cm, and the size of the medial sural muscle paddle ranged between 2 × 2cm and 14 × 4cm. Primary closure of the donor site was achieved in all cases. Of the 11 patients, the cMSAP flap survived in 10 cases. The vascular compromise occurred in one special case and was treated with surgical procedures. The mean follow-up duration was 16.5months (range of 5-25 months). Most patients present satisfactory cosmetic and functional results. The free cMSAP flap is a good option for reconstructing complex soft tissue defects with deep dead space in extremities. The skin flap can cover the skin defect, and the muscle flap can fill the dead space against infection. In addition, three types of cMSAP flaps can be used in a broader range of complex wounds. This procedure can achieve an individualised and three-dimensional reconstruction of the defects and minimise the donor site morbidities.

Customized reconstruction of complex soft-tissue defect in the hand and forearm with individual design of chain-linked bilateral anterolateral thigh perforator flaps

Complex soft-tissue defects of upper extremities still have a high rate of amputation, as the reconstruction of complex soft-tissue defects is always difficult even with the largest conventional free flap. The anterolateral thigh perforator (ALTP) flap is one of the most popular procedures used for the coverage of complex soft-tissue defects of extremities. However, problems associated with donor-site morbidity and inability to repair complex soft-tissue defects in a one-stage procedure persist. The purpose of this study was to present a novel design of using chain-linked bilateral ALTP flap and its various designs for customized reconstruction of complex soft-tissue defects in the hands and forearms. From June 2009 to June 2017, we retrospectively analyzed 15 patients with complex soft-tissue defects in the hands and forearms. All patients in this series underwent extremity reconstruction using the chain-linked bilateral ALTP flaps. Three different types of chain-linked bilateral ALTP flaps were created in this study based on wound characteristics and the maximum available skin paddle size at all donor sites. The chain-linked bilateral ALTP flaps were successfully harvested for the reconstruction of complex soft-tissue defects in the hands and forearms. Among them, ten cases were repaired with chain-linked bipaddle ALTP flaps, two cases were treated with chain-linked tripaddle ALTP flaps, and the remaining three cases were used with chain-linked multi-lobed ALTP chimeric flaps. The sizes of the skin paddles ranged from 11cm × 7 cm to 42cm × 8cm. The areas of the total flaps ranged from 245cm2 to 650cm2 (mean 419.6cm2). Only one case required re-exploration because of the venous congestion. The donor sites were closed directly. The mean follow-up time was 16.4 months. Most cases showed satisfactory contour. The chain-linked bilateral ALTP flap is a reliable option for one-stage reconstruction of complex soft-tissue defects in the hands and forearms with limited donor-site morbidity. It also provides various flap designs, which allow for more individualized treatment approaches.

A Design for the Dual Skin Paddle Circumflex Scapular Artery Perforator Flap for the Reconstruction of Complex Soft-Tissue Defects in Children

The main drawbacks of the use of the circumflex scapular artery perforator (CSAP) flap for complex soft-tissue defect repair are the limitation of skin paddle size, which can be harvested to allow precise wound coverage and primary closure of the donor site. We developed a variant of the dual skin paddle CSAP flap to extend its applications and minimize donor-site morbidity when reconstructing complex soft-tissue defects in children. A detailed anatomical investigation of circumflex scapular artery (CSA) branches was conducted using a standardized injection of lead oxide in 25 fresh cadavers. Dual skin paddle CSAP flaps were harvested for the reconstruction of complex defects in the extremities in 16 children. Three types of dual skin paddle CSAP flap were used in this study: transverse chain-shaped, oblique chain-shaped, and trefoil-shaped flaps. Three CSA branching patterns with superior branch diameters were observed: 34% of CSAs were of the transverse branch dominant type, 54% were of the descending branch dominant type, and 12% were of the codominant type. Sixteen dual skin paddle CSAP flaps were elevated successfully; they were of the transverse chain-shaped type in 2 cases, the oblique chain-shaped type in 9 cases, and the trefoil-shaped type in 5 cases. All flaps survived postoperatively. Primary closure of the donor site was achieved in all cases. The CSA system is an appropriate source for harvesting dual skin paddle CASP flap. Use of this flap for the reconstruction of complex soft-tissue defects in the extremities in children is an alternative approach that reduces morbidity and improves the cosmetic outcome at the donor site.

Reconstruction of complex soft-tissue defects around the knee using the proximally based sural Island fasciocutaneous flap.

: Complex soft tissue defects around the knee are not common. They pose significant reconstructive challenges; hence, several methods have been tried. In this study, the use of proximally based sural island fasciocutaneous flap is evaluated. : The aim of this study is to report our experience with the use of proximally based sural island fasciocutaneous flap in the reconstruction of complex soft tissue defects around the knee. This was a prospective study. All patients that presented to the unit with complex soft tissue defects around the knee between December 2012 and November 2014 were included in this study. Data on age, sex, etiology, anatomical location of the defect, and flap size were noted and analyzed using descriptive statistics. Follow-up was for a minimum of 6 months. : There were 15 cases: 11 males and 4 females. Their ages ranged from 6 years to 47 years with an average age of 29 years. Ten of the defects resulted from road traffic accidents, while five were missile injuries. The anterior and lateral surfaces of the knee were more often involved, while the posterior surface was least involved. The flap sizes ranged from 8 cm × 6 cm to 16 cm × 12 cm, and the pedicle length ranged from 6 cm to 12 cm. All 15 flaps had full survival. A total of 13 patients had their donor sites skin grafted primarily with 96%-100% graft take. The other two patients had their donor sites closed directly. The proximally based sural island fasciocutaneous flap is a simple and reliable method of reconstruction for soft tissue defects around the knee.

The Supraclavicular Flap in Head and Neck Reconstruction

The supraclavicular artery island flap has recently become increasingly used for the reconstruction of complex soft-tissue defects after head and neck oncologic ablative procedures. In an aging population with multiple comorbidities, with surgery often being performed in the salvage setting, many patients who are not good candidates for free tissue transfer are in still need of advanced reconstructive options. The goal of this article is to review the evolution of this flap and to highlight the recent technical modifications and outcomes data regarding the use of the supraclavicular flap in head and neck reconstruction. The supraclavicular artery island flap provides a versatile fasciocutaneous flap with minimal donor site morbidity that affords the reconstructive surgeon a thinness, pliability, color, and texture unmatched by other regional pedicled flaps. It is cost-effective and has been shown to have similar functional outcomes to free tissue transfer for a variety of ablative defects, including those of the lateral skull base and parotid, larynx, oral cavity, and oropharynx. The supraclavicular artery island flap has a number of proven advantages in the reconstruction of complex soft-tissue defects after head and neck oncologic ablative procedures. In an era in which salvage surgery is increasingly being performed in an aging patient population with rising comorbidities, the supraclavicular artery island flap provides a reliable, efficient alternative to free tissue transfer reconstruction that can ultimately result in decreased healthcare costs and lower patient morbidity.

Reconstruction of complex soft-tissue defects in the extremities with chimeric anterolateral thigh perforator flap

IntroductionThe reconstruction of extensive three-dimensional defects in the extremities is a difficult challenge. Many attempts have been made to reconstruct such defects using the chimeric flap concept, enabling flaps with larger surface areas to be used while maintaining economical tissue use. The anterolateral thigh (ALT) chimeric flap is one of the most useful tools for the reconstruction of complex three-dimensional defects in the extremities. MethodsFrom January 2010 to March 2012, Twenty-two patients underwent extremity reconstruction using chimeric ALT perforator flaps, which consists of a skin component on its isolated perforator and a portion of the fascia and muscle flaps on the same pedicle from the descending branch of the lateral circumflex femoral artery (LCFA). The defects were in either a lower (n = 10) or an upper extremity (n = 12). The area of the soft tissue defects ranged from 43 × 35 cm to 19 × 9 cm (mean, 25 × 18 cm), containing extensive, irregular, ring-like soft tissue defects or degloving injuries. ResultsThe mean dimension of skin flap was 19.8 × 11.2 cm. The mean dimension of fascia flap was 8.9 × 7.1 cm. The mean dimension of muscle flap was 11.1 × 7.5 cm. No total flap loss occurred. One patient presented with venous thrombosis, and re-anastomosis and vein grafting were performed. Two cases exhibiting partial skin graft loss at the site at which the fascia flap was inset were treated via secondary skin grafts. During a follow-up period of 18 months–30 months, patients were satisfied with the functional and aesthetic outcome. No serious donor-site complications occurred. DiscussionChimeric anterolateral thigh perforator flap can be one of the best choice for reconstruction of complex soft-tissue defects in the extremities. ConclusionsThe various tissue components and maximal freedom offered by chimeric tissue flaps associated with the same descending branch of the LCFA provide versatile coverage of large, complex, and irregular soft-tissue defects in the extremities.

Novel Use of Acellular Dermal Matrices (Alloderm) in Maxillofacial Trauma, Tumor & Reconstructive Surgery

Utilization of acellular dermal matrices for the reconstruction of complex soft-tissue defects has expanded across multiple surgical specialties over the last 20 years, particularly in plastic surgery/breast-reconstruction

Reconstruction of complex soft-tissue defects around the knee joint with distally based split vastus lateralis musculocutaneous flap: A new technique

The aim of this study was to report our experience of using distally based spilt vastus lateralis musculocutaneous flaps for soft-tissue defects around the knee joint - a new technique. Cadaver dissection studies were conducted in three cadavers to demonstrate perforators entering the lower third of the vastus lateralis muscle arising from the superior lateral genicular artery. Its application in eight clinical cases for the reconstruction of soft-tissue defects around the knee joint is reported. Seven out of eight flaps survived well without any flap loss. One flap with a skin island measuring 12×20cm suffered a loss of 2cm distally. This was later treated with skin grafting. Six out of eight donor sites were closed primarily. Six patients achieved full functional range of motion by 3 months. One patient had a 10° limitation of knee extension. One patient had foot drop due to primary injury and walks with a limping gait. This flap is a new reconstructive option for knee defects. It can reach distally up to the tibial tuberosity and does not require an intraoperative change of position. The donor site can be closed primarily and is hidden inside the clothing. The function of the knee is not affected as the majority of the muscle is kept in continuity.

Free deep inferior epigastric artery perforator flap for reconstruction of soft‐tissue defects in extremities of children

The deep inferior epigastric artery perforator (DIEP) flap has been a valuable tool in breast reconstruction, but seldom in extremity reconstruction. The aim of this report is to present our experience on the use of the DIEP flap for reconstruction of soft-tissue defects in the extremities of pediatric patients. From January 2007 to February 2011, 22 consecutive free DIEP flap transfers were performed for reconstruction of complex soft-tissue defects in the extremities of children with a mean age of 5.7 years old (ranging 2-10 years old). The flap design included transverse, oblique, and irregular DIEP flaps, containing one to three perforators in the flap. The flap size ranged from 7 × 4 cm to 18 × 17 cm. Primary donor-site closure was accomplished in all of patients. The postoperative course was uneventfully in most of cases. The venous congestion was observed in two cases. One case of venous congestion was caused by flap inset with tension. The other case with venous thrombosis ended with partial loss of the flap after salvage procedure. There was one total flap loss due to the arterial thrombosis. The flap survival rate was 95.5%. The mean follow-up was 12 months (ranging 6-36 months). All reconstructed extremities had satisfactory aesthetic and functional outcomes except two cases undergoing the secondary debulking procedures. The donor sites healed well in all cases without complications. Our experience showed that the free DIEP flap could be an alternative for reconstruction of soft-tissue defects in the extremities of children.

Treatment of Complex Soft-Tissue Defects at the Metacarpophalangeal Joint of the Thumb Using the Bilobed Second Dorsal Metacarpal Artery–Based Island Flap

The purpose of this study is to report on reconstruction of complex soft-tissue defects around the metacarpophalangeal joint of the thumb using a bilobed second dorsal metacarpal artery-based island flap taken from the dorsum of the proximal phalanges of the index and long fingers. From March of 2007 to October of 2009, the bilobed second dorsal metacarpal artery-based island flap was transferred in 13 patients. There were two defects on the metacarpophalangeal joint of the thumb. The mean size of the dorsal defects was 2.4 × 3.2 cm; the mean size of the volar defects was 2.6 × 4.0 cm. The mean size of the flaps taken from the index and long fingers was 2.6 × 3.4 cm and 2.8 × 3.2 cm, respectively. The mean pedicle length was 4.9 cm. All flaps survived completely. At a mean follow-up of 14 months, the mean active motion arc of the thumb metacarpophalangeal joints was 42 degrees. The motion of the donor fingers was similar to that on the opposite side. The mean values of static two-point discrimination of the donor sites of the index and long fingers were 6 and 7 mm, respectively. Transferring the bilobed second dorsal metacarpal artery-based island flap is a useful and reliable technique for reconstructing complex defects around the metacarpophalangeal joint of the thumb. Therapeutic IV.

Free‐flap resurfacing of tissue defects in the foot due to large gouty tophi

Large or extensive gouty tophi on the feet can cause functional impairment, drainage sinus, and infected necrosis, finally resulting in complex soft-tissue defects with tendon, joint, bone, nerve, and vessel exposure. Reconstruction of complex soft-tissue defects of the foot is still challenging. The purpose of this report was to review the outcomes of free-flap reconstructive surgery for treating the metatarsal joint defects of the feet caused by chronic tophaceous gout. Ten patients who had large tophus masses (>5 cm) and ulceration on the feet were admitted to our hospital between September 2006 and September 2010. Six patients underwent free-flap reconstruction after debridement to resurface the circumferential wound, protect the underlying structures, and provide a gliding surface for exposed tendons. The patients' age, sex, comorbidities, location and size of the defects, reconstructive procedures, surgical outcomes, complications, follow-ups, and recurrence of tophaceous gout were reviewed and recorded. The mean patient age was 49.8 years (range, 36-72 years). The average skin defect size was 92.2 cm(2) . Five patients were treated using free anterolateral thigh flaps, and 1, using a free medial sural flap. These free flaps were safely raised and showed excellent functional and cosmetic results, with a mean follow-up of 31.7 months (range, 7-50 months). Chronic tophaceous gout can cause severe skin infection and necrosis, even resulting in deformity or sepsis if left untreated. Surgical debridement is inevitable in patients with extensive wounds. We reconstructed the large, ulcerative skin and soft-tissue defects on the dorsum of the foot by performing free-flap reconstruction after adequate debridement and achieved good functional and cosmetic results.

Versatility of the Anterolateral Thigh Flap with Vascularized Fascia Lata for Reconstruction of Complex Soft-Tissue Defects: Clinical Experience and Functional Assessment of the Donor Site

The anterolateral thigh flap is commonly used for reconstruction of various soft-tissue defects. This article presents the authors' approach to one-stage reconstruction of composite soft-tissue defects using an anterolateral thigh flap with a vascularized fascia lata. This retrospective review analyzed 973 patients who had undergone anterolateral thigh flap reconstruction for various soft-tissue defects over the past 10 years. Various types of complicated defects in 36 patients were reconstructed with a composite anterolateral thigh flap combined with vascularized fascia lata. The fascia lata component of the flap was used for abdominal wall and fascial defect reconstruction in 12 patients, for lip-cheek defect reconstruction in 15 patients, for reconstruction of composite defects in extremities in nine patients, and for reconstruction of the perineum in one patient. Functional outcomes of donor sites were investigated by using a dynamometer. All flaps except one survived. The overall flap survival rate was 97 percent. Patients achieved satisfactory results without major postoperative complications. The study revealed that vascularized fascia may mimic a fascial sheath but lacks the muscle-synchronized excursion properties. Apart from a mild deficiency in quadriceps femoris muscles contraction in the donor thighs, no difficulties in daily ambulation were reported by the patients. The anterolateral thigh flap with vascularized fascia lata provides a reliable fascial component for single-stage reconstruction of complex soft-tissue defects.

The venoneuroadipofascial pedicled distally based sural island myofasciocutaneous and muscle flaps: anatomical basis of a new concept

Reconstruction of soft-tissue defects of the lower third of the leg, the heel and the foot remains a challenge. The distally based sural neurocutaneous flap has been used effectively to resurface these defects. However, the paucity of bulk in this flap makes it inadequate for complex post-traumatic or post-ablative soft-tissue reconstruction. We dissected 20 freshly amputated lower limbs after injecting them with a mixture of lead oxide and gelatin. We found muscular branches of the accompanying artery of the sural nerve to the gastrocnemius muscle in all 20 limbs. This led us to conceptualise the distally based venoneuroadipofascial pedicled island sural myofasciocutaneous and muscle flaps. These flaps are useful for the reconstruction of complex soft-tissue defects of the lower third of the leg, the heel and the foot.