Repair Of Soft Tissue Defects Research Articles

Repair of digital volar complex soft tissue defect with heterodigital antegrade digital artery island flap innervated by digital nerve

To investigate the effectiveness of heterodigital antegrade digital artery island flap innervated by proper digital nerve and the dorsal branch of proper digital nerve for repairing digital volar complex soft tissue defects. Between May 2014 and January 2018, 27 patients with digital volar complex soft tissue defects were treated. There were 17 males and 10 females with an average age of 37 years (range, 18-60 years). The causes included electric saw injury in 8 cases, twisted injury in 12 cases, and heavy pound injury in 7 case. There were 9 thumbs, 5 index fingers, 6 middle fingers, 3 ring fingers, and 4 little fingers. The interval between injury and admission ranged from 1 to 4 hours (mean, 2.5 hours). The defect size ranged from 2.2 cm×1.4 cm to 3.8 cm×2.3 cm. The mean length of unilateral proper digital nerve defect was 2.9 cm (range, 2-4 cm). All defects were repaired with heterodigital antegrade digital artery island flap innervated by the proper digital nerve and the dorsal branch of the proper digital nerve. The proper digital nerve and the dorsal branch of the proper digital nerve in the flap were anastomosed with the proper digital nerve stumps in the wound. The flap size ranged from 2.4 cm×1.6 cm to 4.1 cm×2.6 cm. A segment of dorsal branch of the proper digital nerve was intercalated into the defect of the proper digital nerve in donor site. And the defect of donor site was repaired with the full-thickness skin graft. All flaps and skin grafts survived, and the wounds healed by first intention. All patients were followed up 12-24 months (mean, 17 months). The appearance, color, and texture of the flaps were similar to the surrounding tissue. There was no pain and double sensibility in any flap. At last follow-up, the static two-point discrimination of the flaps ranged from 4 to 8 mm (mean, 5.3 mm). And the two-point discrimination of digital pulps of recipient and donor fingers ranged from 4 to 10 mm with the average of 6.2 mm and 6.0 mm, respectively. According to the functional assessment criteria of the upper limb formulated by the Hand Surgery Society of the Chinese Medical Association, the results were excellent in 18 cases and good in 9 cases. No scar contracture was observed in donor site. The heterodigital antegrade digital artery island flap innervated by the proper digital nerve and the dorsal branch of the proper digital nerve provides a safe and simple technique with minimal donor site cost and satisfactory effectiveness, which could be an ideal option for repairing digital volar defect, especially for the defect complicated with digital nerve defect.

One-stage repair of soft tissue defects in open leg fracture

Objective To evaluate one-stage repair of leg open fracture with soft tissue defect by fixation plus skin flap. Methods From January 2011 to January 2018, 34 patients with leg open fracture plus soft tissue defect were treated at Department of Orthopedics, The Second Affiliated Hospital to Harbin Medical University. They were 31 males and 3 females, aged from 13 to 54 years(average, 35 years). According to the Gustilo classification, the defects were type ⅢA in 31 cases and type ⅢB in 3 cases. The wound size ranged from 6 cm×3 cm to 25 cm×10 cm. All patients were treated with emergency fracture fixation and flap repair by one stage after thorough debridement. Internal bone plating was performed in 32 patients and external fixation at a single arm in 2 patients. All defects were repaired with a free anterolateral thigh flap. Flap survival, vascular crisis and bone infection were followed up postoperatively. Results All the free flaps survived in the 34 cases with no vascular crisis. These patients were followed up for 6 months to 3 years (average, 10 years). The flaps healed well, with good appearance and soft texture. No bone infection occurred at the defective sites. After postoperative rehabilitation, the knee extension ranged from 160° to 180°, knee flexion from 90° to 110°, ankle dorsal extension from 90° to 110°, and ankle plantar flexion from 100° to 120°. Conclusion Soft tissue defects in leg open fracture can be effectively treated by flap repair after thorough debridement at the same time of fracture fixation, because the primary wound healing can avoid infection and lead to fine survival of the flap. Key words: Fractures, open; Soft tissue defects; Surgical flaps; Reconstructive surgical procedures; Legs

Effects of autologous platelet-rich plasma in the repair of soft tissue defects of rabbits with free flap

Objective: To explore the effects of autologous platelet-rich plasma (PRP) in the repair of soft tissue defects of rabbits with free flap. Methods: Thirty 6-month-old New Zealand white rabbits, male and female unlimited, were used to harvest blood from the heart. PRP was prepared by Aghaloo method, then free flap model with size of 5 cm×3 cm was reproduced on each ear of the rabbit. According to the random number table, one ear of each rabbit was recruited to PRP group, and the other ear was recruited to normal saline group. The base of flap on rabbit ear in PRP group was evenly spread with 1.0 mL autologous PRP, and equivalent volume of normal saline was applied to that in normal saline group. Then, the flap was replanted in situ. On post surgery day (PSD) 2, 3, 5, 7, and 14, 6 rabbits in each group were taken. The survival of flap was observed and recorded. The morphology of the basal tissue of flap was observed by hematoxylin-eosin staining. The expressions of CD31 and α smooth muscle actin (α-SMA) in the basal tissue of flap were detected by immunofluorescence method. Another 6-month-old male New Zealand white rabbit without making flap under the same experimental conditions was used for harvesting whole blood and preparing PRP. Then blood platelet count in whole blood and PRP was determined, and the content of vascular endothelial growth factor (VEGF) and transforming growth factor β (TGF-β) was detected by double-antibody sandwich enzyme-linked immunosorbent assay. Data were processed with analysis of variance of factorial design, paired sample t test, and Bonferroni correction. Results: (1) On PSD 2, the flaps of wounds of rabbits in PRP group were reddish and adhered well to the basal tissue; the flaps of wounds of rabbits in normal saline group were dark red and poorly attached to the basal tissue. On PSD 3, the flaps of wounds of rabbits in PRP group were ruddy and closely adhered to the basal tissue; the flaps of wounds of rabbits in normal saline group were scattered in the plaque-like dark red and generally attached to the base. On PSD 5, the flaps of wounds of rabbits in PRP group were reddish and closely adhered to the basal tissue, and the flaps were alive; while flaps of wounds of rabbits in normal saline group were rosy and closely adhered to the basal tissue. On PSD 7, the surface of flaps of wounds of rabbits in PRP group was covered with a medium amount of rabbit hair. The color of flap was similar to that of the surrounding skin. The flaps of wounds of rabbits in normal saline group were generally attached to the base, and the surface was only covered with a small amount of fluff. On PSD 14, the incisions were healed well in PRP group, while small wounds in normal saline group were not healed. (2) On PSD 2, inflammatory cell infiltration was observed in flaps of wounds of rabbits in both groups. On PSD 3, the flaps of wounds of rabbits in PRP group showed neovascularization, with less interstitial hemorrhage; while there were less neovascularization in the flaps of wounds of rabbits in normal saline group. On PSD 5, a medium number of inflammatory cell infiltration and a small amount of new microvessels were observed in flaps of wounds of rabbits in normal saline group. Many fibroblasts, a small amount of inflammatory cells, and scattered new microvessels were observed in flaps of wounds of rabbits in PRP group. On PSD 7, the number of new microvessels in normal saline group was significantly lower than that in PRP group. On PSD 14, the new microvessels in the flaps of wounds of rabbits in PRP group gradually matured, and a large number of fibroblasts distributed around them. Some of the newly formed microvessels in the flaps of wounds of rabbits in normal saline group were mature, and the healing was slower than that of PRP group. (3) On PSD 2, 3, 5, 7, and 14, the expressions of CD31 and α-SMA in the basal tissue of flaps of wounds of rabbits in PRP group were significantly higher than those in normal saline group (t=10.133, 5.444, 9.450, 6.986, 8.394, 14.896, 10.328, 9.295, 13.902, 10.814, P<0.01). (4) The platelet count in activated PRP of rabbits was (2 863±962)×10(9)/L, which was significantly higher than (393±49)×10(9)/L in whole blood (t=7.690, P<0.05). (5) The content of VEGF and TGF-β in activated PRP of rabbits was (564.3±3.2) and (1 143±251) pg/mL, which was significantly higher than (99.7±0.4) and (274±95) pg/mL in whole blood, respectively (t=287.390, 9.648, P<0.05 or P<0.01). Conclusions: PRP of rabbits contains high concentrations of VEGF and TGF-β. Therefore, PRP can effectively promote microvascular regeneration in free flap tissue and accelerate the survival of free flap.

Application of free lateral tarsometatarsal composite tissue flap in repair of finger composite soft tissue defects

目的 探讨游离足跗外侧复合组织瓣修复手指复合软组织缺损的临床疗效。 方法 自2014年6月至2017年6月，我们对12例手指掌侧复合软组织缺损患者，采用趾长伸肌腱桥接指深屈肌腱、足背外侧皮神经内侧支桥接神经以及跗外侧穿支皮瓣覆盖软组织缺损创面。皮瓣切取面积为1.5 cm×2.0 cm~2.5 cm×4.0 cm。 结果 术后皮瓣及手指远端全部存活，随访时间为6~18个月，平均10个月，皮瓣皮下脂肪少不臃肿，色泽与指体皮肤相似，感觉恢复良好，两点分辨觉为6~11 mm，手指屈伸功能满意。根据手指总主动活动度（TAM）评分法评定手功能：优8例，良3例，可1例。术后皮瓣供区恢复满意。 结论 足跗外侧皮瓣质地薄，血管神经解剖恒定，血管管径与近端指动脉口径相差无几，是手指掌侧复合软组织缺损修复较好的选择。

Clinical effects of free superficial femoral artery femoral triangle perforator flap in the repair of skin and soft tissue defects in extremities

Objective: To investigate the clinical effects of free superficial femoral artery femoral triangle perforator flap in the repair of skin and soft tissue defects in extremities. Methods: From January 2016 to November 2017, 14 patients (9 males and 5 females, aged 19 to 54 years) with skin and soft tissue defects in extremities accompanied with tendon and bone exposure were admitted to our unit. The size of skin and soft tissue defects after debridement ranged from 7 cm×3 cm to 10 cm×7 cm. The defects were repaired with free superficial femoral artery femoral triangle perforator flaps, with size ranging from 13.0 cm×2.0 cm to 20.0 cm×4.5 cm. The medial femoral cutaneous nerve was applied to the flap. The perforator flap was grafted onto the medial femoral cutaneous nerve in 6 patients. The donor sites were sutured directly. The survival of flaps and the follow-up of patients were observed. Results: All flaps of 14 patients survived successfully. The recipient sites and donor sites were healed completely in 13 patients, and 1 patient with partial skin necrosis at the edge of flap was healed after treatment. All patients were followed up for 6 months to 1 year after the operation. The flaps were in good shape, with nearly normal color and soft texture and no cicatrix contracture deformity. The flaps recovered protective sense in 6 patients who had medial femoral cutaneous nerve grafting, and the sensory recovery of the flap was slightly worse in the remaining 8 patients. There was no significant complications on the appearance and walking of the donor thigh in 14 patients, only a linear scar was left on the inner thigh, and no numbness was felt in the donor sites of patients. Conclusions: The free superficial femoral artery femoral triangle perforator flap is an ideal therapy for repairing skin and soft tissue defects in extremities.

Clinical effects of dorsal perforator fascia pedicle flap of the deep palmar arch in the repair of skin and soft tissue defects of finger web area

Objective: To explore the clinical effects of dorsal perforator fascia pedicle flap of the deep palmar arch in the repair of skin and soft tissue defects of finger web area. Methods: Eleven patients (7 males and 4 females, aged from 18 to 73 years) with soft tissue defects of finger web area in distal dorsal side were admitted to Xinhua Hospital (Chongming) of Shanghai Jiao Tong University School of Medicine from October 2010 to September 2018. The sizes of skin and soft tissue defects ranged from 2.5 cm×1.5 cm to 6.0 cm×2.5 cm. According to the origin, course, branches, and distribution of the dorsal perforator of deep palmar arch, and the anatomical characteristics with vascular network of dorsal carpal and dorsal metacarpal, dorsal perforator fascia pedicle flaps of the deep palmar arch from the back of the injured hands were designed and transferred to repair the wounds of finger web area in distal dorsal side. The sizes of the flaps of patients ranged from 3.5 cm×2.0 cm to 6.5 cm×3.0 cm. The donor sites were sutured directly or covered with free forearm full-thickness skin graft. The clinical effects and swelling degree of flaps in early and late stages were evaluated during the follow-up of 3 to 36 months post surgery. Results: All the flaps survived in 11 patients, the incisions in donor and recipient sites were healed. During the follow-up of 3 to 36 months post surgery, the survival of flaps was good, and the appearance, color, and elasticity were close to normal skin, with two-point discrimination distance of 7 to 10 mm and sensory function recovery of grade S(3). The wounds in donor site had small scar without infection. The efficacy was evaluated as satisfactory in 8 patients, general in 3 patients, and dissatisfactory in no patient. Flap swelling rating in early stage was 1st degree in 7 patients, 2nd degree in 2 patients, and 3rd degree in 2 patients. Flap swelling rating in late stage was 1st degree in 8 patients, 2nd degree in 2 patients, and 3rd degree in 1 patient. The extension and flexion of the metacarpal and interphalangeal joints were basically normal and the patients were satisfied with the outcomes. Conclusions: Based on the dorsal perforator of deep palmar arch, dorsal perforator fascia pedicle flap of the deep palmar arch is reliable to transfer to repair skin and soft tissue defects of finger web area in distal dorsal side, which is worthy of promotion in clinic.

Repair of skin and soft tissue defects of vulva, vagina, and buttock with internal pudendal artery perforator " angel wing" island flaps in six cases

From November 2015 to July 2017, six patients with skin and soft tissue defects of vulva, vagina, and buttock after resection of vulvar tumors were hospitalized in our unit. All patients were female, aged 45-70 years. Among them, four patients had bilateral defects, and two patients had unilateral defect. The defect area on each side ranged from 6 cm×4 cm to 12 cm×6 cm. Internal pudendal artery perforator " angel wing" island flaps were used to repair and reconstruct the defects. The area of flaps ranged from 7 cm×5 cm to 14 cm×7 cm. The donor sites were sutured directly. All 10 flaps of 6 patients survived. Two patients had local incision infection 3 days after operation. One of the two patients was healed 2 weeks after dressing change, and the other one underwent debridement and suture 1 week after dressing change and was healed 1 week after surgery. Follow-up for 6-12 months after surgery showed no recurrence of tumors, no eversion of vagina, better shape of vulva in bilateral reconstruction cases, and slightly worse symmetry in unilateral reconstruction cases. The skin of the reconstructed area was soft, with sensations of pain, temperature, and touch recovered in varying degrees. The distance of a two-point discrimination was 20-30 mm. Linear scars were left in the flap donor sites, with no impact on squatting or striding. In vaginal examination, 1.5 to 2.0 fingers could be inserted in bilateral reconstruction cases, while 2.0 to 3.0 fingers could be inserted in unilateral reconstruction cases. The anus functioned well during defecation.

Reconstructive surgery for foot and ankle defects in pediatric patients: Comparison between anterolateral thigh perforator flaps and deep inferior epigastric perforator flaps

BackgroundsDue to the delicate tissue, small blood vessels and incomplete development of interarticular ligaments, skin and soft-tissue defects of the foot and ankle in pediatric patients remain a challenge for orthopedic and plastic surgeons. Anterolateral thigh perforator (ALTP) flap and deep inferior epigastric perforator (DIEP) flap are the most commonly used flaps for the repair of lower-extremity soft-tissue defects. The literature contains a shortage of evidence involving the differences between ALTP and DIEP flaps in the reconstruction of young patients with complex foot and ankle defects. This study was designed to determine which type of flap is better for foot and ankle repair in pediatric patients. MethodsFrom January 2004 to January 2018, 79 children younger than 14 years treated with DIEP flap (41 cases) or ALTP flap (38 cases) for composite defects of the feet and ankles were retrospectively investigated. The two groups were homogeneous in terms of age, the location of the defect, etiology, and flap area. Complications, scarring, cosmetic appearance, flap sensory recovery, and functional outcome were analyzed, and statistical analysis was performed. ResultsThe ALTP group had shorter operation time (155.0 ± 12.0 min vs 212.2 ± 23.9 min), flap harvested time (39.6 ± 5.1 min vs 57.2 ± 10.4 min), and operative blood loss (143.4 ± 23.7 ml vs 170.7 ± 44.7 ml) than the DIEP group (P < 0.05). In short-term follow-up, ALTP group showed a lower flap necrosis rate (5.3% vs 24.4%) and vascular insufficiency rate (2.6% vs 19.5%) than DIEP group (P < 0.05). In long-term follow-up, ALTP group showed a lower late complication rate and better cosmetic, functional, scar outcomes than DIEP group (P < 0.05). ConclusionsThe study showed that an ALTP flap may brings better results than a DIEP flap in terms of short- and long-term complications, scarring, and morpho-functional outcomes for pediatric patients undergoing reconstruction of foot and ankle defects.

The application of micro-dissected polyfoliate anterolateral thigh perforator flap in repair of complex wound in extremities

Objective To investigate the design, incisional method and clinical experiences of using the microdissected polyfoliate anterolateral thigh perforator flap to repair of complex soft tissue defect in extremities. Methods From June, 2017 to September, 2018, 12 cases of different kinds of complex soft tissue defect in extremities were repaired by micro-dissected free polyfoliate anterolateral thigh perforator flap. Each flap was divided into two cutaneous perforators to give two separate flap with a common vascular supply. The flaps were cut from the superficial layer of the deep cervical fesciae and without fascia lata. The donor sites were treated by subcutaneous cosmetic suture. Patients were followed-up by outpatient service, telephone and WeChat video to observe and record the flap’s appearance, sensory recovery, extremities function and the scars of the donor site to evaluate its clinical efficacy. Results All flaps survived without vascular crisis happened except one-leaf necrosis occurred, which healed with local flap transferring. The donor sites remained linear scars. The mean flap thickness of this group after micro-dissection was (4.5±0.5) mm. All the patients were followed-up for 5-15 months. The 2 point discrimination ranged between 0.5-2.0 cm. Sensory restoration ranking was S3-S3+. The range of montion of wrist joint was 65°-90°, and that of ankle joint was 40°-60°. Conclusion The micro-dissected polyfoliate anterolateral thigh perforator flap is an ideal method for complex and irregular multiple sites soft tissue defect in extremities as it can keep good economic benefit and minimal damage to the donor site. Key words: Polyfoliate, perforator flap; Anterior lateral thigh flap; Flap thinning technique; Extremities; Microsurgical technique

Clinical application of fascial pedicle digital artery cutaneous branch chain flap of the same finger for repair of soft tissue defects of fingertip

Objective To analyze the surgical method and clinical efficacy of fascial pedicle digital artery cutaneous branch chain flap of the same finger in repairing soft tissue defects of fingertip. Methods From April 2016 to October 2018, 16 fingers of 16 patients with fingertip defects were treated. The defect area was 1.2 cm×1.8 cm to 2.3 cm×2.8 cm. All of them were repaired with fascial pedicle digital artery cutaneous branch chain flap. Results All the flaps survived after operation. And 1 of them developed swelling and blisters, and survived after lifting the affected limb and removing part of the suture. 15 cases obtained follow-up after operation and 1 case was lost. The follow-up time ranged from 6 to 24 months with an average of 14.5 months. The appearance, texture, elasticity and sensation of the flaps recovered well, with an average of 6.9 mm for two-point discrimination. TAM function was evaluated as excellent in 11 cases, good in 3 cases and fair in 1 case. Conclusion The repair of fingertip soft tissue defect with fascial pedicle digital artery cutaneous branch chain flap of the same finger does not require deliberate search for cutaneous branch vessels, which greatly shortens the operation time, simplifies the operation, has a high survival rate, good appearance, texture and elasticity of the flaps, and has a satisfactory curative effect. Key words: Finger injuries; Surgical flaps; Soft tissue defects; Fascial pedicle

Application of free thenar flaps with the cutaneous branch in repair of skin and soft tissue defects of palmar fingers

目的 探讨游离大鱼际皮支皮瓣在手指掌侧软组织缺损中的应用及临床疗效。 方法 自2015年3月至2018年2月，我们共收治14例手指掌侧软组织缺损伴有指骨肌腱外露的患者，设计切取同侧大鱼际皮支皮瓣，大小为1.4 cm×2.5 cm~2.0 cm×4.2 cm，术中将大鱼际区动脉皮支与创面区指动脉皮支吻合，皮瓣皮下浅静脉与指掌侧静脉吻合，皮瓣内的神经皮支与一侧指神经缝合重建皮瓣感觉。大鱼际供区创面直接拉拢缝合。 结果 术后所有创面均Ⅰ期愈合，14例患者14指均获得随访，时间为6~22个月，平均13个月，皮瓣外形、质地良好。末次随访时11例感觉恢复至S3，皮瓣两点分辨觉为8~11 mm；2例S2；1例S1。术后患指运动功能恢复正常。供区线性瘢痕愈合良好，无并发症，无疼痛，手部握力正常。 结论 游离大鱼际皮支皮瓣血管皮支较多，手术切取容易，疗效较为满意，可作为一种修复手指掌侧软组织缺损较好的手术方法。

Additive manufacturing of photo-crosslinked gelatin scaffolds for adipose tissue engineering

There exists a clear clinical need for adipose tissue reconstruction strategies to repair soft tissue defects which outperform the currently available approaches. In this respect, additive manufacturing has shown to be a promising alternative for the development of larger constructs able to support adipose tissue engineering. In the present work, a thiol-ene photo-click crosslinkable gelatin hydrogel was developed which allowed extrusion-based additive manufacturing into porous scaffolds. To this end, norbornene-functionalized gelatin (Gel-NB) was combined with thiolated gelatin (Gel-SH). The application of a macromolecular gelatin-based thiolated crosslinker holds several advantages over conventional crosslinkers including cell-interactivity, less chance at phase separation between scaffold material and crosslinker and the formation of a more homogeneous network. Throughout the paper, these photo-click scaffolds were benchmarked to the conventional methacrylamide-modified gelatin (Gel-MA). The results indicated that stable scaffolds could be realized which were further characterized physico-chemically by performing swelling, mechanical and in vitro biodegradability assays. Furthermore, the seeded adipose tissue-derived stem cells (ASCs) remained viable (>90%) up to 14 days and were able to proliferate. In addition, the cells could be differentiated into the adipogenic lineage on the photo-click crosslinked scaffolds, thereby performing better than the cells supported by the frequently reported Gel-MA scaffolds. As a result, the developed photo-click crosslinked scaffolds can be considered a promising candidate towards adipose tissue engineering and a valuable alternative for the omnipresent Gel-MA. Statement of SignificanceThe field of adipose tissue engineering has emerged as a promising strategy to repair soft tissue defects. Herein, Gel-NB/Gel-SH gelatin-based hydrogel scaffolds were produced using extrusion-based additive manufacturing. Using a cell-interactive, thiolated gelatin crosslinker, a homogeneous network was formed and the risk of phase separation between norbornene-modified gelatin and macromolecular crosslinkers was reduced. UV-induced crosslinking of these materials is based on step growth polymerization which requires less free radicals to enable polymerization. Our results demonstrated the potential of the developed scaffolds, due to their favourable physico-chemical characteristics as well as their adipogenic differentiation potential when benchmarked to Gel-MA scaffolds. Hence, the hydrogels could be of great interest towards future development of adipose tissue constructs and tissue engineering in general.

Posterior Tibial Artery Perforator Flaps Carrying Partial Gastrocnemius Muscle for Repair of Soft Tissue Defects With Dead Space in the Ankle and Foot.

Soft tissue defects with dead space in the ankle and foot remain a challenge for surgeons. The aim of the study was to evaluate the surgical technique and clinical significance of posterior tibial artery perforator flaps carrying partial gastrocnemius muscle for patients with soft tissue defects with dead space in the ankle area. Between August 2015 and August 2017, 14 patients (2 women and 12 men) between 20 and 58 years old (median age, 42 years) were hospitalized in The First Affiliated Hospital of Soochow University. All injuries involved damage to the ankle area and formation of soft tissue defects with dead space. In all patients, posterior tibial artery perforator flaps carrying partial gastrocnemius muscle were transplanted to cover soft tissue defects with dead spaces. Hospitalization duration ranged from 10 to 20 days (mean, 16 days). All flaps survived and healed well. At follow-up after 6 to 24 months, all cases had recovered successfully in terms of aesthetic and functional aspects. Posterior tibial artery perforator flaps carrying partial gastrocnemius muscle can be an optimal reconstruction method for repairing soft tissue defects with dead space in the ankle and foot.

Repair of soft tissue defect of foot and ankle with the supercharged peroneal artery perforator propeller flap

Objective To explore the clinical technical points of the treatment of soft tissue defect of the foot and ankle with the supercharged peroneal artery perforator propeller flap, and to provide theoretical support by anatomical observation. Methods From January, 2010 to February, 2018, a total of 10 patients with soft tissue defect of foot and ankle were treated with supercharged peroneal artery perforator propeller flap. Cause of injury: trauma in 7 cases, wound ulcer in 1 case, and poor healing of the calcaneus incision in 2 cases. Defect site: 5 cases of heel, 2 cases of medial and lateral malleolus, and 3 cases of dorsum and sole. The size of flap ranged from 6.0 cm×3.0 cm to 16.0 cm×5.0 cm. All patients were followed-up at 1, 3, 6 months after operation, and the function recovery was judged by AOFAS Ankle Hindfood Scale at 3 months post-opertively. From November, 2016 to May, 2017, the anatomical basis and operative points of the supercharged peroneal artery perforator flap were summarized. Results All the 10 cases of supercharged peroneal artery perforator propeller flap survived. Two of them had local epidermal necrosis at the proximal end of the flap. After 1 to 2 weeks of dressing, they finally healed. The other 8 cases healed well. Anatomical studies showed that different planes of the supercharged peroneal artery perforator propeller flap can only reduce the compression of the double pedicles and reduce the distal necrosis rate of the flap by rotating in different rotation directions. Conclusion The supercharged peroneal artery perforator propeller flap can enhance the blood supply and venous return in the big paddle artery of the flap, preventing distal necrosis. Key words: Peroneal artery perforator flap; Propeller flap; Supercharged; Foot and ankle

Application of deep femoral artery third perforating artery flap for reconstruction of soft tissue defect in lower limles

Objective To investigate the feasibility and clinical effects of deep femoral artery third perforating artery perforator flap for reconstruction of soft tissue defect in lower limbs. Methods From September, 2008 to October, 2016, 8 cases of soft tissue defect in lower limbs which were repaired by deep femoral artery third perforating artery perforator flap, including 4 cases of traffic accident trauma, 2 cases of chronic ulcer, 1 case of a fall injury, 1 case of the scar after fracture operation. The area of wounds was 8.0 cm×7.0 cm-19.0 cm×8.0 cm. Seven patients were accompanied by different degrees of infections. The deep femoral artery third perforating artery perforator flap was designed to repair, including 5 cases of pedicled flaps and 3 cases of free flaps. The flap’s appearance, color, texture, infection recurrence and the recovery of lower limb function were recorded at 1, 3, 6, 9 and 12 months followed-up. Results One flap suffered partial necrosis due to cross-zone backflow disorder, the ipsilateral medial sural artery pedicled perforator flap was used to repair. The rest of the flaps survived successfully. Skin graft was used to close the donor site in 1 case, and other donor sites were closed directly. All patients had no postoperative hematoma or secondary infection. The followed-up periods ranged from 2 to 28 months (mean, 8.1 months). All flaps had satisfied appearance and texture. There were no complications such as paresthesia and numbness in the donor sites. And no motion limitations in hip and knee joint of the operated leg. Conclusion Deep femoral artery third perforating artery perforator flap can be used for both free flaps and pedicled flaps, which is a feasible method to repair soft tissue defect in lower limbs. Key words: Perforator flap; Deep femoral artery; Third perforating artery; Lower limb; Soft tissue defect

Clinical effect of free anterolateral thigh flap in repairing large annular soft tissue defect of lower leg after burn

Objective: To explore the clinical effect of free anterolateral thigh flap in repairing large annular soft tissue defect of lower leg after burn. Methods: From January 2014 to December 2018, 9 patients with large annular soft tissue defects of lower legs after burns were hospitalized in Zhengzhou First People's Hospital, including 1 case with wounds on both legs. After debridement, area of wounds was 16 cm×11 cm-38 cm×21 cm, and the burn wounds were repaired with free anterolateral thigh flaps in the area of 18 cm×12 cm-32 cm×24 cm. End-to-end anastomosis of posterior tibial vessels or anterior tibial vessels with lateral circumflex femoral vessels was performed in manual way or by microvascular stapler. For the affected legs without condition for anastomosis, the sound medial lower leg flaps with areas of 10 cm×8 cm-15 cm×10 cm were excised and made into skin tubes, the posterior tibial vessels of the flaps were anastomosed with the vessels of free anterolateral femoral flaps, and the wounds of the injured lower legs were repaired by bridge-type cross-over free transplantation of anterolateral thigh flaps. The pedicles were broken 4 to 5 weeks later. The donor site was transplanted with autologous intermediate split-thickness skin graft from thigh. The outcome of the treatment, the number of perforators included in the flaps, and the anastomotic vessel in the recipient area of patients were recorded. The anastomosis time between manual way and microvascular staplers was recorded and compared. The patency of blood vessels, methods of free transplantation, and follow-up condition were recorded. Data were processed with Wilcoxon rank sum test for two independent samples. Results: All the 10 free flaps and skin grafts of 9 patients survived, and all the wounds were closed by primary operation. Seven flaps contained two perforators each, and three flaps contained three perforators each. The anastomotic vessels were posterior tibial vessels in 6 recipient areas and anterior tibial vessels in 4 recipient areas. Microvascular stapler was used to anastomose 12 veins, while 8 veins and 10 arteries were anstomosed manually. The time consumed by the former method was 4.00 (3.55, 4.38) min, significantly shorter than 12.80 (12.13, 13.40) min of the latter (W=78.00, P<0.01). The patency rates of veins and arteries were 100%. There was no vascular crisis due to vascular anastomosis. Three patients underwent bridge-type cross-over free transplantation, while the others underwent conventional free transplantation. Follow-up for 3 to 30 months showed that the donor site of the thigh had good motor function, without numbness or pain, but hypertrophy of scar could be seen. Four patients had slightly overstaffed flaps transplanted in the recipient area of the lower legs, while the other patients were satisfied with their appearance, and the walking function of the affected limbs gradually recovered. Conclusions: Free anterolateral thigh flap transplantation is a safe and reliable clinical limb salvage method for the repair of large annular soft tissue defect of lower leg after burn. Intraoperative application of microvascular stapler for venous anastomosis can shorten the time of vascular anastomosis and has great clinical application value.

Repair of skin and soft tissue defects in extremities with the superior lateral genicular artery perforator flap

To investigate the feasibility and effectiveness of the superior lateral genicular artery perforator flap for repairing of soft tissue defects in extremities. Between September 2010 and October 2017, 11 cases of skin and soft tissue in extremities were repaired with the superior lateral genicular artery perforator flap. There were 10 males and 1 female, with an average age of 37.6 years (range, 6-72 years). The causes of injury were traffic accident in 6 cases, machine injury in 1 case, falling down injury in 1 case, falling from height in 1 case, crushing injury in 1 case, and electric injury in 1 case. The defects located at the forearm in 1 case, knee in 5 cases, popliteal fossa in 2 cases, shank in 1 case, and foot and ankle in 2 cases. The area of the wound ranged from 8.0 cm×4.5 cm to 27.0 cm×8.0 cm. The interval from injury to admission was 6 days on average (range, 3-12 days). The area of perforator flap ranged from 9.0 cm×5.5 cm to 28.0 cm×9.0 cm. There were 8 cases of pedicle flap and 3 cases of free flap. All the donor sites were closed directly. Eight flaps survived without any complications and the donor sites healed by first intention. Two flaps had arterial crisis and 1 flap had venous crisis after operation, and the wounds healed after symptomatic treatment. There was no hematoma and secondary infections in all patients after operation. Ten patients were followed up 2-48 months (mean, 13.1 months). All flaps had satisfied appearance and texture. There was no motion limitations in the hip and knee joints of the operated legs. The superior lateral genicular artery perforator flap not only can be used to repair the soft tissue defect around the knee joint as pedicle flap, but also can be used to repair the forearm and foot skin and soft tissue defects as free flap, which is a feasible way to repair soft tissue defects in extremities.

Repair of soft tissue defect of fingers with modified arterialized venous flap

To summarize the effectiveness of modified arterialized venous flaps in repairing soft tissue defect of fingers. Between January 2017 and April 2018, 16 patients with soft defects of fingers were treated. There were 12 males and 4 females, with an average age of 41 years (range, 24-74 years). One case was resulted from resection of cicatricial contracture and 15 cases was caused by mechanical strangulation. The defects located at thumb in 3 cases, index finger in 5 cases, middle finger in 4 cases, ring finger in 2 cases, and little finger in 2 cases; and at the palmar aspect in 4 cases, and dorsal aspect in 12 cases. The size of defect ranged from 3 cm×2 cm to 10 cm×3 cm. All flaps were harvested from the palmar aspect of the ipsilateral forearm. The distal ports of the two veins were ligation. Partial fat was eliminated and the all connecting minute branches between the two veins were ligation under microscope in order to achieve the thorough shunt restriction. Then the flaps were positioned over the recipient site without inversion. The size of flap ranged from 3.5 cm×2.5 cm to 10.5 cm×3.5 cm. All donor sites were directly sutured except that 1 case was recovered with free skin graft. All flaps survived entirely except that 1 case happened vein crisis. Three flaps demonstrated mild-to-moderate venous congestion without any treatment and the swelling of flaps gradually subsided after 1 week. Skin grafting at donor site survived and all incisions healed by first intension. Thirteen patients were followed up 8-16 months (mean, 11 months). The textures and appearances of the flaps were satisfactory. At last follow-up, the mean size of the Semmes-Weinstein (SW) monofilament test of the flaps was 4.01 g (range, 2.83-4.56 g); the mean static two-point discrimination of the flaps was 12 mm (range, 6-20 mm). Modified arterialized venous flaps with thoroughly restriction of arteriovenous shunting can offer decreased congestion of venous flaps and improve survival rate. Better effectiveness can be achieved by using this flap to repair soft tissue defect of finger.

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.

Use of a sequential chimeric perforator flap for one-stage reconstruction of complex soft tissue defects of the extremities.

One-stage reconstruction of complex soft tissue defects of the extremities is a challenging problem. Repair of complex soft tissue defects requires adequate skin tissues to cover the large surface wound and special tissues for obliterating the dead space. The chimeric flap is one of the most popular approaches for reconstruction of complex soft tissue defects. However, the problems of donor-site morbidity and inability to repair very large defects at one-stage remain. The purpose of this study was to present our clinical experience using sequential chimeric perforator flaps for reconstruction of complex extremity defects with primary closure of the donor site. From August 2013 to March 2017, 12 patients with complex soft tissue defects underwent extremity reconstruction using sequential chimeric perforator flaps, which were composed of a chimeric anterolateral thigh perforator (ALTP) flap and an additional free perforator flap. The skin paddles were placed side-by-side to cover the large surface soft tissue defects, and the muscle component was used to obliterate the dead space. Of these patients, one was injured by a crushing accident, while the other 11 patients were injured in traffic accidents. The size of the skin paddles ranged from 26 cm × 8 cm-10 cm × 6 cm to 30 cm × 8.5 cm-29 cm × 9 cm. The muscle paddle size ranged from 2 cm × 3 cm × 4 cm to 22 cm × 4 cm × 2 cm. All-components of the sequential chimeric flaps survived in all-patients. Vascular compromise was observed in one case. One case suffered minor wound-edge necrosis and was treated conservatively. Primary closure of donor-site was successfully achieved in all-patients, and all-donor-site wounds healed uneventfully. The mean follow-up time was 15.25 months. Most of the cases showed a satisfactory contour, and only two patients presented with mildly bulky appearance that treated with a debulking procedure. The sequential chimeric perforator flap is an alternative procedure for reconstruct complex soft tissue defects of the extremities. This approach allows for flexible design, a larger cutaneous area, and low donor site morbidity.