Reconstruction Of Soft Tissue Defects Research Articles

Extracellular matrix graft for reconstruction over exposed structures: a pilot case series.

Soft tissue defects, especially those involving exposed vital structures, present a reconstructive challenge because poor vascularity of such defects typically makes immediate skin grafting unviable. Where flap procedures are inappropriate or not possible, dermal matrices represent an alternative reconstructive option for defects with denuded vital structures. With dermal matrices becoming increasingly available and technologically advanced, we evaluated an ovine-derived extracellular matrix graft in the reconstruction of complex soft tissue defects involving exposed vital structures. Six cases of soft tissue defects exhibiting denuded vital structures underwent reconstruction using an ovine forestomach matrix graft as a dermal matrix. Grafts were fixed directly into defects for immediate coverage and subsequently temporised defects via granulation tissue formation for later skin graft or secondary closure. Defect granulation and epithelialisation were monitored until closure and the final aesthetic and functional outcomes were evaluated. Complete healing was achieved in all cases, with defect granulation becoming observable within one to two weeks and complete granulation occurring within one to six weeks. Granulation tissue resulting from the graft was suitable for skin grafting, with 100% take of skin grafts after one week and complete re-epithelialisation in two to three weeks in the four cases that received a skin graft. Good cosmetic, functional and patient satisfaction outcomes were achieved in all cases. The present series demonstrates our initial use of an extracellular matrix-based dermal matrix in reconstructing defects with exposed vital structures. While such dermal matrices do not supersede or replace flap procedures, they represent an alternative option on the reconstructive ladder in cases where flap procedures are not appropriate or possible.

Distally-based Peroneus Brevis Turnover Muscle Flap in the Reconstruction of Soft Tissue Defects.

Background:Reconstruction of the distal 3rd of the lower leg requires either local or free flap coverage if tendons or bones are exposed. The distally based, pedicled peroneus brevis (PB) flap has been shown to be a valid option in the management of distal 3rd lower limb injuries. Herein, we present 21 cases treated with distally-based PB muscle flaps between May 2017 and September 2019. The defect location varied, and included defects over the lateral and medial malleolar areas, distal tibia (middle and distal 3rd junction, and the distal 3rd), and Achilles tendon area.Methods:The PB was dissected from the lateral fibula and intermuscular septa in a cephalic to caudal direction, to a point no lower than 7 cm proximal to the lateral malleolus tip. This preserved most distal vascular perforators to the muscle, and afforded sufficient mobilization to allow successful turn-over of the muscle, with transposition into the defect within 30 minutes of tourniquet time. A meshed skin graft completed the intervention.Results:The metalwork was removed in all chronic cases (10/21), as bone union had occurred. All flaps survived completely. One patient partially lost the skin graft; the wound was healed by secondary intention. No major complications occurred and no significant patient discomfort was noted. All wounds healed completely by 9 weeks of follow-up.Conclusion:The PB turnover muscle flap is a versatile flap, ideally suited to manage up to moderately sized defects of the distal 3rd of the lower leg, with negligible postoperative morbidity.

The Effect of Medial Sural Artery Perforator Flap on Reconstruction of Soft Tissue Defects: A Meta-Analysis With Multiple Free Soft Flaps.

With the gradual popularity of relatively novel medial sural artery perforator flap (MSAPF), robust studies are needed to compare the surgical outcomes of MSAPF versus multiple free soft flaps (MFSFs) to verify the advantages and disadvantages of MSAPF. The authors searched PubMed, Web of Science, EMBASE, Cochrane Library, Chinese BioMedical Literature Database (CBM), and China National Knowledge Infrastructure (CNKI) until September, 2020, to identify studies that compared surgical outcomes of MSAPF and MFSFs. Two authors followed the PRISMA guidelines, individually extracted the data and performed the quality assessments. Survival rate of flaps, satisfaction degree of patients in recipient and donor site, skin grafting, and morbidity of recipient and donor site were evaluated. A total of 441 cases from 7 studies were included in our analysis. No significant differences were found regarding survival rate of flaps, recipient morbidity, and recipient satisfaction degree between the 2 groups. However, MSAPF group was significantly superior to MFSFs group in terms of skin grafting, morbidity, and satisfaction degree of donor site. Our meta-analysis showed that the MSPAF and MFSFs groups were similar in terms of survival rate of flaps, recipient morbidity, and recipient satisfaction degree. Medial sural artery perforator flap group was superior to MFSFs group in terms of morbidity and satisfaction degree of donor site. The results may prove that MSAPF is gaining popularity for a reason and is a good choice for repairing soft tissue defects.

A multivariable miRNA signature delineates the systemic hemodynamic impact of arteriovenous shunt placement in a pilot study

Arteriovenous (AV) fistulas for hemodialysis can lead to cardiac volume loading and increased serum brain natriuretic peptide (BNP) levels. Whether short-term AV loop placement in patients undergoing microsurgery has an impact on cardiac biomarkers and circulating microRNAs (miRNAs), potentially indicating an increased hemodynamic risk, remains elusive. Fifteen patients underwent AV loop placement with delayed free flap anastomosis for microsurgical reconstructions of lower extremity soft-tissue defects. N-terminal pro-BNP (NT-proBNP), copeptin (CT-proAVP), and miRNA expression profiles were determined in the peripheral blood before and after AV loop placement. MiRNA expression in the blood was correlated with miRNA expression from AV loop vascular tissue. Serum NT-proBNP and copeptin levels exceeded the upper reference limit after AV loop placement, with an especially strong NT-proBNP increase in patients with preexistent cardiac diseases. A miRNA signature of 4 up-regulated (miR-3198, miR-3127-5p, miR-1305, miR-1288-3p) and 2 down-regulated miRNAs (miR30a-5p, miR-145-5p) which are related to cardiovascular physiology, showed a significant systemic deregulation in blood and venous tissue after AV loop placement. AV loop placement causes serum elevations of NT-proBNP, copeptin as well as specific circulating miRNAs, indicating a potentially increased hemodynamic risk for patients with cardiovascular comorbidities, if free flap anastomosis is delayed.

The distally based dorsal metacarpal artery flap (DMCA)

Regional flap for the reconstruction of combined skin and soft-tissue defects of the fingers or the distal parts of the palm. Full-thickness soft-tissue defects of the fingers dorsally up to the distal interphalangeal joint, of the fingers palmarly up to the middle phalanx, or of the distal parts of the palm. Damage of the dorsal metacarpal artery or of the distal anastomosis by trauma or previous operation. Ongoing infections. Preoperative Doppler examination. Planning of aflap using the proximal or distal anastomosis of the metacarpal artery with the palmar system as its pivot point. Raising of an adipofascial flap including as many veins as possible. Alternatively, the metacarpal artery can be raised alone as afascial flap. Tension-free insertion of the flap into the defect. To avoid venous congestion, we do not recommend subcutaneous tunneling of the flap. The skin bridge should be incised instead. Loose cotton dressing, periodic monitoring, bed rest for 5days. After 3days active and passive physiotherapy can start. Suture removal after 14days. Reliable and relatively secure flap with aflap loss rate up to 20% in literature. The donor site can be closed primarily up to aflap width of 2 cm. The fourth metacarpal artery is missing in up to 30% of the cases.

Free extended posterior tibial artery perforator flap with the neurovascular plexus of a saphenous nerve branch for large soft tissue and sensory reconstruction: Anatomic study and clinical application.

The posterior tibial artery perforator (PTAP) flap is a useful tool for reconstruction of soft tissue defects in the leg. However, the size and reliability of the flap largely depends on the quality of the perforator by which the flap is supplied, and the sensory recovery of the flap is limited. In this study, the anatomy of the saphenous nerve branches and their accompanying vessels was investigated, and a free extended PTAP flap with the neurovascular plexus of a saphenous nerve branch was designed for large soft tissue and sensory reconstruction in a series of clinical cases. Sixteen adult cadaveric legs perfused with red latex in the femoral artery were dissected. The number and location of the saphenous nerve branches and the features of their accompanying vessels were dissected and studied. From January 2016 to December 2017, six patients with soft tissue defects ranged from 8 × 2.5 cm to 21 × 4 cm were repaired by the free extended PTAP flap. The patients' average age was 48 years. The causes of the defects included machine injuries in three patients and traffic injuries in the other three. The defects located at the hand in three cases, foot in two cases, and ankle in one case. The flap was designed based on the perforators of the posterior tibial artery and included a branch of saphenous nerve. The perforator pedicle and the nerve branch were connected to the vessels and nerve in the recipient site, respectively. The saphenous nerve gave off 5.8 ± 1.1 branches, with a relatively constant one issuing 8.1 ± 0.7 cm distal to the medial femoral condyle. Every nerve branch had an accompanying vessel, which connected with the PTAPs and supplied the skin. The size of the flap ranged from 10 × 3.5 cm to 23 × 5 cm. All of the flaps survived completely without complications. Follow-up varied from 6 to 12 months. All the patients obtained cold/hot sensation and pain sensation. The results of Semmes-Weinstein monofilament test ranged from 4.31(2 g) to 5.46 (26 g), and the 2-point discrimination test varied from 20 to 35 mm. The free extended PTAP flap, containing the saphenous nerve branch and its accompanying vessels, may be an alternative for large soft tissue reconstruction with improved sensation recovery.

Delayed reconstruction of soft tissue defects in mangled lower extremities: A report of three cases

Background: The best timing for the soft tissue reconstruction procedure in the mangled lower extremity is still controversial. Despite the advantages of acute treatment, delayed soft tissue reconstruction are often inevitable for various reasons. This case report aims to present three cases of delayed reconstruction to treat lower extremities soft-tissue defects in mangled lower extremity following high-energy trauma.Case Series: This study included three cases that underwent delayed reconstruction for the mangled lower extremity. The definitive reconstructions were done in 15, 30, and 60 days after injury and all cases underwent serial debridement before the definitive procedure. The reconstruction methods used were skin graft and free flap. There was no graft/flap loss observed in this study.Conclusion: We believe that soft tissue reconstruction of mangled lower extremities following high-energy trauma may also be safely done in a delayed setting if the wound debridement is adequately done, and the basic reconstructive principles are fulfilled.

Free neurosensory flap based on the accompanying vessels of lateral sural cutaneous nerve: anatomic study and preliminary clinical applications

Background The posterior aspect of the leg is an ideal donor site for flap surgery. In this study, the anatomy was investigated of the lateral sural cutaneous nerve (LSCN) and its accompanying artery, superficial lateral sural artery (SLSA), and a lateral sural neurocutaneous flap was designed. Methods Five fresh adult cadaver legs perfused with red latex were dissected to observe the course and relationship between LSCN and SLSA. The outer diameter of SLSA at its origin was measured. Then a lateral sural neurocutaneous flap was designed and used to repair soft tissue defects in six patients. Results The anatomic results showed that the SLSA gave rise to branches that followed the LSCN and ramified into terminals at the ramification of the nerve. It originated directly from the popliteal artery 4.2 ± 0.2 mm above the fibular head, where its outer diameter was 0.96 ± 0.23 mm. Several perforators penetrated from the crural fascia and anastomosed to the SLSA, creating a fine anastomotic network. The clinical results showed that the size of the flap ranged from 12 × 6 cm to 25 × 8 cm. All six flaps survived completely without complications. Follow-up ranged from 6 to 18 months with 11 months on average. The overall contour and sensory recovery of the flap were satisfied. Conclusion A free innervated flap may be elevated safely based on the LSCN and its accompanying vessels. It provides an alternative in reconstruction of soft tissue defects where sensory recovery is important.

Individualized design of double skin paddle anterolateral thigh perforator flaps to repair complex soft tissue defects of the extremities: An anatomical study and retrospective cohort study

This study describes our experience using individually designed double skin paddle anterolateral thigh perforator (ALTP) flaps to reconstruct complex soft tissue defects. An anatomical study of double skin paddle ALTP flaps was conducted in six fresh cadavers (12 thighs). We also performed a retrospective cohort study of 36 patients who underwent reconstruction using double skin paddle ALTP flaps from January 2009 to June 2019. The soft tissue defects were large or non-adjacent defects that could not be repaired by a single flap. Three types of double skin paddle ALTP flaps were designed. In type I, separate perforators supplied each flap: one perforator from the transverse branch of the lateral circumflex femoral artery (LCFA) and one from the descending branch of the LCFA (d-LCFA). In type II, both perforators were from the d-LCFA. In type III, a single perforator from the d-LCFA had two branches that each supplied one flap. In the cadaver study, type I was observed in 11 thighs, type II in 10, and type III in six. All patients were successfully treated using double skin paddle ALTP flaps. Four patients received type I flaps, 23 received type II, and nine received type III. Vascular compromise occurred in one patient, and the flap was saved by emergency revascularization. Most patients had satisfactory contours and functional recovery during follow-up. Individually designed double skin paddle ALTP flaps is a reliable option for reconstructing complex soft tissue defects. Moreover, we created an algorithm for microvascular reconstruction of complex soft tissue defects.

Distally based peroneal artery perforator-plus fasciocutaneous flap in the reconstruction of soft tissue defects over the distal forefoot: a retrospectively analyzed clinical trial

BackgroundDistally based peroneal artery perforator-plus fasciocutaneous (DPAPF) flaps are widely used for reconstructing soft-tissue defects of the lower extremity. However, reports on the reconstruction of the defects over the distal forefoot using the DPAPF flaps are scarce. Herein, we describe our experience on the reconstruction of these defects using DPAPF flaps in a considerable sample size.MethodsBetween February 2005 and August 2019, a total of 56 DPAPF flaps in 56 patients were used to reconstruct soft-tissue defects in the forefoot. In order to reduce the length of fascial pedicle and the total length of the DPAPF flaps, the ankles were fixed in dorsiflexion using a Kirschner wire before designing the flaps. The flaps were elevated by the anterograde–retrograde approach. Patient factors and flap factors were compared between the “survival” and “partial necrosis” groups.ResultsOverall, 47 flaps had survived completely in one stage. Partial necrosis developed in nine flaps, with only one remnant defect covered using a local flap. By fixing the ankles in dorsiflexion, the length of the fascial pedicle was reduced approximately 2.35 ± 0.58 cm, the total length of the flap was simultaneously shortened by the same amount as the length of the fascial pedicle. The width of the fascia pedicle varied from 3.0 cm to 6.0 cm. The fascial pedicle width > 4 cm was found in 21 flaps. The partial necrosis rate of the DPAPF flaps with the top edge located in the 8th zone was significantly lower than that in the 9th zone (p < 0.05).ConclusionsThe DPAPF flaps can be effectively used to reconstruct the defects over the distal forefoot because of convenient harvest and reliability. By fixing the ankle in dorsiflexion with Kirschner wire and widening the fascial pedicle appropriately, the top edge and LWR of the flaps will be decreased, and thus the procedures are helpful for the flaps survival.

Assessment of surgical outcomes and oncological safety for submental artery perforator flap reconstruction after ablation of oral cancer

The submental artery perforator flap (SAPF) has been a new option for the intraoral reconstruction of oral squamous cell carcinoma (OSCC) patients in recent years, but its surgical outcomes have not been well assessed. We compared the surgical outcomes and oncological safety of SAPF reconstruction for medium-sized soft-tissue defects after the ablation of primary oral cancer with traditional submental island flaps (SIF) and anterolateral thigh perforator flaps (ALTPF). Fifty-one SAPFs, 30 SIF, and 74 ALTPF were reviewed for the intraoral medium-sized reconstructions after the ablation of oral cancer from our institutional clinical oncological databases. We performed comparative assessments on the variables of surgical outcome and oncological safety among the 3 cohorts. A Kaplan-Meier estimate of survival for each flap was calculated. Operating time was significantly reduced in the SIF and SAPF groups than ALTPF (p = 0.021 and 0.014, respectively). Flap thickness of SAPF was the significantly thinnest (mean 0.5 cm) among three groups. The common complications of donor site for both SAPF and SIF group were incision dehiscence and orocutaneous fistula. There was no significant difference in disease-free survival (DFS) among the 3 groups. However, several OSCC patients with the SIF reconstruction were found to have recurrences with a metastatic lymph node under the flap after the first operation. SAPF could be a versatile choice of the intraoral reconstruction for the medium-sized soft-tissue defects after the ablation of oral cancer.

Reconstruction of soft tissue defect of the achilles tendon with islanded VY advancement flap

Background: Stable skin cover over exposed tendo achilles is essential for proper healing of tendo achilles to regain its normal function. Exposed tendo achilles can be a result of open injuries, repair of closed tendo achilles rupture, complications occurring after repair. Various methods have been described in literature for coverage of repaired tendo achilles for example distally based skin flaps, advancement flap, free tissue transfers and islanded flaps. This article describes the usefulness of islanded VY advancement flap for stable skin cover over tendo achilles. Methods: A 34-year-old male had a injury over left TA region following trauma causing a raw area near its insertion. Preop and intra op doppler was done to locate and verify the position of the perforator.Results: The flap survived and on follow up the tendo achilles had good function with stable, supple, healthy skin overlying the tendon. Tendoachilles strength was assessed by asking the patient to stand on toes. Conclusions: Islanded VY Advancement flap cover over tendo achilles provides a stable, reliable, single stage procedure with good aesthetic appearance.

Versatile design of compound vastus lateralis muscle and anterolateral thigh musculocutaneous perforator free flaps for customized reconstruction of complex skin and soft tissue defects in the extremities.

Compound anterolateral thigh flaps are popular for three-dimensional reconstruction of complex soft tissue defects. We present our 10-year experience using compound vastus lateralis (VL) muscle and anterolateral thigh musculocutaneous perforator (ALTP) flaps, and introduce three versatile customizations of this flap for individualized reconstruction of complex three-dimensional soft tissue defects. From May 2008 to June 2017, compound VL muscle and ALTP flaps were performed in 67 consecutive patients aged 14-75 years (62 men and 5 women). The defects were in either the lower (n = 53) or upper extremity (n = 14), and ranged in size from 8 × 4 cm2 to 25 × 6 cm2. Dead space volume ranged from 4 × 2 × 1 cm3 to 20 × 3 × 2 cm3, and all flaps were harvested from patients' thighs as one of three types. In type A, a single perforator supplied both the skin and muscle components, with the vascular bundle penetrating the muscle component. In type B, a single perforator supplied both skin and muscle components with separate branches to the skin and muscle. In type C, separate vessels supplied the skin and muscle. In the 67 patients, 65 flaps survived, and the donor site was closed directly. Vascular compromise occurred in four patients on the first postoperative day. Two flaps were salvaged after emergency re-exploration. Flap loss occurred in two patients, and these defects were repaired using other flaps. The follow-up period ranged from 8 to 60 months (mean, 11.9 months). All flaps had satisfactory appearance and texture, and no patients experienced limited hip and knee joint mobility from the donor site operation. Compound VL muscle and ALTP flaps are a reliable option to reconstruct complex defects of the extremities. Identifying three flap types allowed for more precise customization to cover complex defects with limited donor site morbidity.

Reconstruction of Full-thickness Soft Tissue Defects with Integra: Risk Factors and Treatment Algorithm.

Background:Despite the fact that dermal substitutes are widely used in reconstructive surgery, there have been no studies focused on predictors of complications or delayed matrix take. We propose an algorithm for management of soft tissue reconstruction with Integra dermal matrix, based on our 5-year-long clinical experience.Methods:An estimated 111 patients who underwent Integra reconstruction of full-thickness soft tissue defects of different anatomical sites and etiology were enrolled, and dichotomized in two groups according to complications. Participants were further studied according to the wound healing strategy: healing by secondary intention, skin graft (STSG), and flap surgery. A regression analysis was conducted in the whole sample to identify possible predictors of complications.Results:No significant differences according to complications were observed. The between-group statistical analysis showed significant differences in age, comorbidities, defect area, diagnosis, and defect site. The regression analysis revealed that the timing of split-thickness skin graft (STSG) was not influenced by age, comorbidities, body mass index (BMI), defect area, site, wound etiology, and risk factors in the subjects who underwent a two-step reconstruction. Healing by secondary intention is recommended for small post-oncological defects of the head, especially in elderly and multimorbid patients. Variables that may interfere with dermal substitutes’ incorporation are independent of the timing of STSG placement; therefore, no predictors of complications or delayed matrix take were identified.Conclusions:Our findings showed that Integra can be used in a wide range of patients regardless of their general features, thus acting as a useful alternative to conventional reconstructive techniques in selected cases.

Reconstruction of Elbow Joint and Soft Tissue Defect with Anterolateral Thigh Flap and Total Elbow Replacement: A Case Report

Soft tissue and bone defect due to the machinery penetrating injury of elbow joint are a rare and challenging problem for reconstructive surgeons. After reconstructing soft tissue with anterolateral thigh (ALT) flap and external fixator, the authors planned restoration of elbow function using total elbow replacement (TER). Finally, the patient regained the soft tissue reconstruction and the motion of the elbow using TER, and satisfied with the clinical results. Therefore, the authors present the successful case of ALT flap and TER to treat the machinery penetrating the injury of the elbow.

Potential Benefits from the Use of the Supraclavicular Artery Island Flap for Immediate Soft-Tissue Reconstruction During the COVID-19 Pandemic.

IntroductionThe coronavirus disease 19 (COVID-19) pandemic has placed significant strains on healthcare resources including staff, theatre, high dependency and intensive care availability. Surgery remains the optimal treatment for the majority of oral malignancies, and primary reconstruction is often necessary to avoid significant morbidity as a result of ablative procedures.DescriptionThe supraclavicular artery island flap (SCAIF) is increasingly finding a place as an alternative to free flap reconstruction of soft-tissue defects and has several specific advantages when compared to use of a soft-tissue free flap during the COVID-19 pandemic. It can be used for a range of head and neck defects.ResultsWe describe our experience with the SCAIF during the pandemic in five patients with a variety of tumour types and locations. All five patients had a successful outcome with none requiring further reconstruction and all had a functional swallow postoperatively, including a patient who underwent a total pharyngeal reconstruction with a SCAIF.DiscussionThe use of a SCAIF during the current COVID-19 pandemic has significant advantages and is a reliable alternative to a soft tissue free flap.

Quality of life in patients with oral hard or soft tissue defects after reconstructive microsurgery

With current advances in medicine, many surgical methods have emerged for the reconstruction of soft and hard tissue defects of the head and neck. Current literature provides only a limited amount of evidence in studies addressing differences in quality of life for specific therapeutic measures in microvascular reconstruction. The validated University of Washington quality of life questionnaire version 4 (UW-QoL v4), a distress thermometer, and two questions addressing donor-site morbidity were sent to 134 patients at a tertiary care centre. All participants had undergone a type of microvascular reconstructive surgery of the head and neck. They were distributed into three groups according to the defect and type of treatment: defects reconstructed by soft-tissue microvascular tissue transfer, defects involving the hard tissue and treated by alloplastic reconstruction, and hard tissue defects receiving microvascular osseous reconstruction. A total of 82 patients completed the questionnaire in full and returned it. Patients from all the groups showed improved distress thermometer values postoperatively. Those who underwent osseous microvascular reconstruction had better functional items than those who had alloplastic reconstruction plates. Donor-site morbidity was rated low in all groups. Microvascular osseous reconstructive surgery might help to improve functional outcomes in patients with osseous defects more than alloplastic reconstruction.

The Application and Mechanism of Action of External Volume Expansion in Soft Tissue Regeneration.

The reconstruction of large-volume soft tissue defects is a major problem in plastic surgery. Many plastic surgeons have focused on external volume expansion (EVE) because of its capacity to promote regeneration of soft tissues, including breast, subcutaneous fat, and skin. EVE is a minimally invasive and less costly tissue engineering approach that has shown great clinical potential. However, many challenges still need to be addressed before such technology can become a common clinical practice. Basic in vivo and in vitro studies have been performed to determine the possible mechanisms by which EVE promotes tissue regeneration and to design optimized animal models. EVE application was found to facilitate cell proliferation and migration, enhance adipogenesis, improve angiogenesis, and provide available space for soft tissue growth. Understanding the mechanical and chemical signals associated with EVE during tissue regeneration may enable the clinical adaptation of this technology. This article reviews the clinical application of EVE techniques, describes preclinical animal models, and evaluates the possible mechanisms by which EVE induces tissue regeneration. Impact statement The reconstruction of large-volume soft tissue defects is a major problem in plastic surgery. External volume expansion (EVE) is a minimally invasive and less costly tissue engineering approach that has shown promise in clinical applications. This article reviews the clinical application of EVE techniques, describes preclinical animal models, and evaluates the possible mechanisms by which EVE induces tissue regeneration.

VERSATILITY OF PARAUMBILICAL PERFORATOR FLAP FOR UPPER LIMB RECONSTRUCTION

Background Microvascular flap and groin flap are the most commonly used flaps for upper limb reconstruction. Microvascular flap can not be done in certain situations and groin flap is not convenient for coverage of forearm defect and elbow defect. Paraumbilical perforator (pup) flaps can provide a large amount of tissue for coverage of forearm , elbow defects and mitigates the side effects of groin flap. Material and method A retrospective study was conducted for reconstruction of soft tissue defects from finger tip to elbow between January 2016 to December 2019 with PUP flaps .Demographic data, size of the defect, etiology ,flap design and flap complication were analysed . Result The age of the patients ranged from 12 years to 56 year with mean age of 29.85 years and SD = 11.073. Male to female ratio was 1.5 : 1 (M=12 , F= 8). Size of the defect varied between 20 cm2 to 288cm2 with mean of 88.1 cm 2 and SD = 29.69 .No of cases with flap dimension &lt; 100 cm 2 (n= 13), and &gt; 100 cm2 (n= 7) . Aetiology of injury included vehicular accidents in 10 patients, machine injury in 2 patients, electrical burns in 6 patients post snake bite ulcer 2 patients. The location of the defect included hands, forearm and the elbow, and fingers.Flap was directed Superolaterally in 18 patients , inferolaterally in one case , and combined medially and laterally in one case. There was no case of complete flap failure. Conclusion Paraumbilical perforator flap can be a safe and reliable option for soft tissue reconstruction in varied areas of upper limb.

Propeller Flaps for Hand and Digit Reconstruction.

The reconstruction of soft tissue defects of the hand, as seen often after trauma or tumor excision, is a challenge due to the great differentiation of tissues depending on the hand area involved. The classical intrinsic "workhorse flaps" of the hand are associated with a significant donor-site morbidity. Capturing perforator vessels in discrete donor areas can reduce the amount of soft tissue that has to be dissected and included in what now would be a perforator flap, while also insuring robust vascularization of those transferred tissues. Moreover, the presence of perforator vessels both on the dorsal and volar sides of the hand allows harvest of perforator flaps that will respect the like-with-like principle by maintaining the main characteristics of volar and dorsal skin as desired. However, the dissection of these flaps, especially those based on volar palmar and digital perforators, still requires microsurgical skills to preserve the fine vascularization of these flaps. These small flaps are also amenable for application of the propeller flap concept. This is an especially valuable means for preserving the length of an amputated finger where bone is exposed by using more proximal uninjured tissues. Although in general only a short dissection is required to raise a propeller flap in this region, most often the donor site will have to be closed by a skin graft.