Venous Crisis Research Articles

Clinical efficacy of dorsal digital nerve fasciocutaneous pedicle flap with superficial vein anastomosis in repair of the type III and type IV of fingertip defects

Objective To analysis the clinical efficacy of dorsal digital nerves fasciocutaneous pedicle flap (DDNFPF) with superficial vein anastomosis in the treatment of the type III and type IV of fingertip defect, and the relationship between the incidence of vein crisis and superficial vein anastomosis. Methods A total of 85 patients with 92 fingers, treated by DDNFPF from February, 2017 to December, 2018, were retrospectively analyzed. The superficial veins of 30 patients with 32 fingers were anastomosed, and 55 patients with 60 fingers were not. The difference of the superior rate and the incidence of venous crisis between superficial vein anastomosis and non-superficial vein anastomosis was compared by Chi-square test. The difference was considered as statistically significant when P<0.05. The regular postoperative followed-up was performed. Results The average followed-up time was (7.0±2.9) months. The incidence of venous crisis in anastomosis group (1/32) was lower than that in non-anastomosis group (13/60). The difference was statistically significant (χ2=4.217, P 0.05) . The repaired fingertips of the 2 groups were in good appearance, wear-resistant, stable holders and two-point discrimination was 5 to 8 mm. Conclusion DDNFPF for the type III and IV type of fingertip defect is safe and effective. A anastomosis of superficial veins in recipient area can significantly reduce the incidence of venous crisis. Key words: Dorsal digital nerve fasciocutaneous pedicle flap; Fingertip defects; Superficial vein anastomosis; Venous crisis

Application of modified arterial venalization in replantation of distally severed finger at nail root without venous anastomosis

Objective To introduce an improved method of reconstructing venous reflux in replantation of distally severed finger at nail root, and explore its clinical efficacy. Methods From January 2016 to September 2018, 12 patients with 13 distally severed fingers at nail root were replanted. There were no veins to anastomose the two severed ends. The proximal bilateral proper digital artery was anastomosed with the distal digital artery or two branches. The proximal digital artery was cut off and anastomosed with the proximal dorsal digital vein to establish venous reflux. Results In 13 replanted fingers, 1 finger had partial necrosis due to serious tissue contusion, and the other 12 fingers survived completely. No venous crisis occurred after operation. The postoperative follow-up time ranged from 3 to 9 months with an average of 6.0 months. The skin texture of replanted finger was good, the nail grew well, and the sensation recovered to over S3. The patient was satisfied with the appearance and function. Conclusion The modified arterial venalization can effectively solve the venous reflux problem in venous deficiency and improve the survival rate of replantation of distally severed finger at nail root. It is an effective way to reconstruct venous reflux in the absence of severed veins. Key words: Replantation; Treatment outcome; Arterial venalization; Venous reflux

Application of venous super drainage technique in free flaps transfer

Objective To investigate the effect of venous super drainage applying in free flaps. Methods From June, 2017 to December, 2018, 7 cases who had severe soft tissue injuries were treated with free flap. Cause of injury: 1 electric injuries, 2 tumor-related wounds, 1 deep burns, 2 mechanical trauma, and 1 necrotizing fasciitis. All patients were underwent free flap transplantation. There were 5 cases of anterolateral thigh artery perforator flap, 1 case of superficial circumflex iliac artery perforator flap, and 1 case of first dorsal metatarsal artery perforator flap. The application of venous super-drainage technology was carried out according to needs and specific conditions. Two sets of venous passages were prepared in both recipient and donor site to form a double set of venous reflux super-drainage mode. Blood supply, swelling, exudation, secondary exploration and survival rate of the flap were observed after operation, and regularly followed-up. Results All 7 flaps survived. Venous super drainage technique was applied in 7 cases. No arteriovenous crisis occurred after the operation. The flaps had good blood circulation, slight swelling, less exudation, rapid edema regression and no secondary surgical exploration. Followed-up for 2-18 (average 10.5) months, there was no infection recurred. Flaps survived well, and the donor sites healed well without sensory loss. The flexion and extension function of joint was normal. Conclusion The technique of venous super-drainage prepares 2 sets of venous systems for the free flap in the treatment of vascular pedicle in the free flap repair operation, which is conducive to reducing the venous crisis after flap surgery, reducing flap edema, reducing exudation, reducing secondary surgical exploration and improving the survival rate of the flap. Key words: Venous super drainage; Free flaps; Vascular crisis; Repair

Vascularized flap transfer to fingers with volar digital veins as recipient vessels.

Traditionally free vascularized flap transfers to the fingers connect to the proper digital artery and dorsal veins. We report our experience using the volar digital veins as recipient veins for free vascularized flap transfers in 14 fingers of 12 patients. One or two veins (three flaps with two veins, 11 flaps with one vein) of the flap were anastomosed to volar digital veins in the recipient site. The arteries of these flaps were connected to the proper digital arteries. All the transferred flaps survived. No vessel crisis occurred. Our patients demonstrated that volar veins can be the recipient veins for free flap transfers in the fingers without increased risk of venous crisis and flap loss. Level of evidence: IV.

Application of venous superdrainage technique based anterolateral thigh flap based on oblique branch for the soft tissue defect of proximal shank

Objective To investigate the application of venous superdrainage technique based anterolateral thigh flap based on oblique branch for the soft tissue defect of proximal shank. Methods Between October, 2012 and March, 2017, 11 cases of the soft tissue defect in proximal shank were treated. There were 8 males and 3 females with a mean age of 43 (range, 26-59) years. Causes of injury: 7 cases of traffic injury, 3 cases of bruise, 1 case of machine wound; The defect sizes ranged from 10 cm×5 cm to 13 cm×10 cm, with fracture or plate exposure. According to the size of the defect, the distally based anterolateral thigh flap was designed to repair the defect. The flap sizes ranged from 14 cm×6 cm to 16 cm×8 cm. The oblique branch and their accompanying vein with great saphenous vein was anastomosed to construct the venous superdrainage, and the donor site suture directly. Three cases followed-up by WeChat, and 8 cases by return visit. Results Distally based anterolateral thigh flaps were derived from oblique branches, and no arteriovenous crisis occurred postoperatively. Eleven flaps healed well after operation. There were no distal end blood supply disorder. Followed-up for 6-12 months, the flaps survived well. The texture was closed to the surrounding skin, and no ulcer exposed. There were no serious complications in donor site. And the thighs were linear scars. Conclusion The distally based anterolateral thigh flap based on oblique branch have a long vascular pedicle. The venous superdrainage technique can effectively avoid venous crisis, and improve the survival quality of the flap and the survival rate. Key words: Anterolateral thigh flap; Perforator flap; Oblique branch, lateral circumflex femoral artery; Shank; Superdrainage technique

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.

Oromandibular reconstruction using microvascularized bone flap: report of 1038 cases from a single institution

This retrospective study was performed to review 1038 patients who underwent mandibular reconstruction with free vascularized bone flaps at a single institution between 2006 and 2017. Of these patients, 827 (79.67%) had fibula flaps, 197 (18.98%) had deep circumflex iliac artery perforator (DCIA) flaps, and 11 (1.06%) had scapula bone flaps. The most common pathological diagnosis was ameloblastoma (n=366, 35.26%), followed by squamous cell carcinoma (n=278, 26.78%) and osteoradionecrosis (n=152, 14.64%). Fifty-seven patients (5.49%) had major complications requiring surgical intervention and one patient died of a pulmonary embolism. Venous crisis was the most frequent major complication (n=20, 1.93%), followed by haematoma (n=17, 1.64%) and flap necrosis (n=14, 1.35%). One-stage mandibular reconstruction was preferred whenever possible, as this generally decreases the financial and hospitalization burden. The four-segment method of jaw reconstruction appeared to achieve good aesthetic appearance results in Asian patients and this was not associated with a higher risk of segment ischemia compared with the three-segment method.

Anatomic basis and clinical application of perforator flap thinning of posterior tibial artery

Objective To explore the anatomic basis of the thinning of the free posterior tibial artery perforator flaps and the clinical effect of repairing wound on hand or foot due to trauma. Methods From November, 2016 to December, 2017, 10 cases of lower extremity cadaver specimens perfused with red ralex were dissected, which were perfused through the amputated femoral artery. Five of them were left and the rest were right. All cases were males. The number, diameter, branches and distribution of the perforator was observed. From September, 2012 to September, 2017, there were 13 cases of clinical application, which were 5 cases of hand wound and 8 cases of foot wound. The size of the wound was 3.0 cm × 2.0 cm to 6.0 cm × 4.0 cm, and the flap area was 3.5 cm × 2.2 cm to 6.5 cm × 4.5 cm. The repairing procedure was suitable for the wound associated with tendon, bone, joint capsule exposure. Results The number of posterior tibial artery perforating branches that more than 0.50 mm in diameter was 4 to 6, and the mean diameter was (0.87±0.26) mm. The perforating branch penetrated into the fat layer and was divided into 3 layers of vascular network: deep fat vascular network, superficial fat vascular network and subdermal vascular network. The perforating branch was located according to the positional relationship from deep to shallow, and vessel diameter become smaller step by step. The perforating branch trunk gave off branches to the deep vascular network, and the superficial vascular network had the same origin or shared with the deep blood vessels. The subdermal vascular network issued from the superficial vascular network or directly from the perforating branch trunk. There was no or few communicating branch between the deep vascular network and superficial ones, besides the vessel pedicle. So trimming deep fat layer will not affect the blood supply of superficial vascular network and neither will affect the flap blood supply. Most of the deep fat tissue was trimmed in 13 cases. The superficial and subdermal fat vascular network was preserved, and the same to the trunk and branches of the pedicle. All the flaps survived. Of which, 1 appeared arterial crisis on the 2nd day after operation, and relieved by the local injection of papaverine. There was 1 case of venous crisis on the 3rd day, and improved by stitches, local release of congestion. Followed-up time was ranged from 2 to 12 months. All flaps were soft with good blood supply and good appearance, and did not need a second thinning surgery. Flaps restored the protective feeling 6 months later. Conclusion The microdissection of perforator flap of posterior tibial artery provides a theoretical basis for the perforator flap thinning, and the thinning of perforator flap is a good method to repair the appearance and function of the wound after foot and hand injuries. Key words: Posterior tibial artery perforator flap; Applied anatomy; Wound; Repair; Microsurgical operation

Application of free ilioinguinal flap for repair of hand skin and soft tissue defects

Objective To investigate the clinical effect of individualized free ilioinguinal flap in repairing hand skin and soft tissue defects. Methods From January 2013 to December 2017, 97 cases of hand skin and soft tissue defects were treated with free ilioinguinal flap. There were 63 cases of superficial circumflex iliac artery flap (26 cases of superficial circumflex iliac artery flap with iliac bone), 15 cases of superficial abdominal artery flap and 19 cases of combined flap of superficial circumflex iliac artery and superficial abdominal artery (7 cases of lobulated flap). The area of skin defects ranged from 4 cm×6 cm to 11 cm×23 cm. During the operation, end to end anastomosis of flap artery and the end branch of radial artery in 5 cases, end to side anastomosis of radial artery in 58 cases, end to side anastomosis of ulnar artery in 20 cases, end to side anastomosis of common digital artery in 14 cases. All the superficial circumflex iliac veins and superficial abdominal veins were repaired (a concomitant vein were repaired at the same time in 31 cases). The donor site was sutured directly after flexion of hip and knee without skin grafting. Three weeks, 1.5 months, 3 months, 6 months, 1 year and 2 years after the operation, the healing of donor area and the appearance and sensory recovery of recipient area skin flaps were observed. Results Postoperatively 94 cases survived successfully. Arterial crisis occurred in 1 case and venous crisis in 2 cases. 2 cases received surgical exploration and 1 case received conservative treatment. After that, 1 case survived smoothly and 2 cases suffered skin necrosis. Subcutaneous soft tissue survived after secondary escharectomy and survived after skin grafting. In one case of abdominal donor site, the incision dehiscence occurred in the first week of walking upright after operation, and healed after secondary suture. The remaining donor sites achieved primary healing. The follow-up period ranged from 0.5 to 1.5 years. The flaps were soft and slightly swollen, and the sensation returned to S2 or S3. There were only linear scars in the abdominal donor site. Conclusion According to the skin and soft tissue defects in the recipient area of the hand, the individualized free ilioinguinal flap transplantation can meet the different needs of the recipient area. The donor site is concealed, the cutting area is large, and it can be directly sutured. It belongs to the axial skin flaps. The blood vessels are constant, the cutting is convenient, the main blood vessels are not destroyed, and the operation time is short. Therefore, it is one of the ideal methods to repair the skin and soft tissue defects of limbs. Key words: Hand injuries; Surgical flaps; Skin and soft tissue defects; Free; Individualized

Stage I repair of skin and soft tissue defects using lateral femoral perforator free flap in pilon fracture surgery

Background: To investigate the clinical effects of stage I repair of skin and soft tissue defects using lateral femoral perforator free flap in pilon fracture surgery. Methods: Fifteen cases of pilon fractures were selected from our hospital between April 2013 and January 2017. There were 8 cases of 43-C1, 4 cases of 43-C2 and 3 cases of 43-C3 fractures, as defined by the Miller AO classification. In all cases, severe contusion of skin and soft tissue around the fracture, skin darkening and necrosis, and tissue edema during surgery, led to difficult closure of incision. The skin and soft tissue defects were repaired at stage I by ipsilateral lateral femoral perforator free flap. Results: Venous crisis occurred in one case, while the other 14 cases survived. During the 6–18 months of follow-up, the function of ankles was satisfactory and the wearing of shoes was not affected by the abnormal foot. The flap color and texture were normal and the protective sensation of the flap recovered. Only a linear scar remained at the donor site and no muscle adhesion occurred. Conclusions: Stage I repair of skin and soft tissue defects using lateral femoral perforator free flap in pilon fracture surgery apparently decreased postoperative infection and protected the blood supply around the fracture. Hence, it was an effective repair method.

Repair of the soft tissue defects combined dead space in lower extremities with the descending branch of lateral circumflex femoral artery chimeric perforator flap

Objective To investigate the feasibility and clinical effects of chimeric perforator flap based on the descending branch of lateral circumflex femoral artery(d-LCFA) for reconstructing the three-dimensional tissue defect in lower extremities. Methods From May, 2008 to June, 2017, 79 cases of soft tissue defects with dead space were repaired by using a d-LCFA chimeric perforator flap, in which 33 cases of car accident trauma, 12 cases of chronic tibial osteomyelitis, 10 cases of plowing machine injury, 9 cases of chronic calcaneal osteomyelitis, 6 cases of falling injury, 5 cases of crushing injury, 3 cases of spoke injury, and 1 case of suppurative knee arthritis. These patients were accompany with different degrees of infection and dead space after radical debridement. The dead cavity was filled by muscular flap, and perforator flap covered the superficial wound. Recording the flap’s appearance, color, texture, osteomyelitis recurrence and the patient’s knee extension at 1, 3, 6, 9 and 12 months followed-up. Results Seventy-five flaps survived without complications, and the donor sites were closed directly. All patients had no postoperative hematoma or secondary infection. Vascular crisis occurred in 2 days after the operation in 4 flaps, 1 flap had an arterial crisis on the second-postoperative-day, and the flap was necrotic after surgical exploration. The deep circumflex iliac artery chimeric perforator flap was used for repairing. Three flaps with venous crisis during 48 h after operation, in which 2 flaps survived eventually after surgical exploration, and another flap was necrosis and repaired by skin graft. The followed-up periods ranged from 3 months to 30 months(mean, 9.7 months). All flaps had satisfied with appearance and texture. There were no osteomyelitis recurrence and any ranges of motion limitations in the hip and knee joints of the operated leg. Conclusion The chimeric perforator flap with d-LCFA merely anastomosed 1 group vascular pedicle can make the dead space be filled and cover the superficial wound simultaneously. It is an ideal option for reconstructing the skin defect with dead space in lower extremity, which can improve the quality of restoration of recipient site and reduce the damage of donor site. Key words: Lateral circumflex femoral artery, descending branch; Chimeric flap; Perforator flap; Dead space; Lower limb; Microsurgical technique

Clinical analysis of surgical re-exploration of free flaps

Objective To investigate the causes, managements and related risk factors of re-exploration after free flap transplantation. Methods A retrospective study on free flap transplantation for repair of the skin and soft tissue defects of the extremities from January 2015 to December 2016 was conducted. The cases of re-exploration after skin flap transplantation were screened and analyzed. Results In 122 patients with 126 free flaps for repair of skin and soft tissue defects of extremities, 10 cases underwent re-exploration, accounting for 7.9%. There were 8 males and 2 females, with an average age of 31.4 years. There were 5 cases of skin flaps in the upper and lower limbs, respectively. The re-exploration was performed due to venous crisis in 8 flaps including 4 flaps with venous occlusion, 3 flaps with venous compromise by hematoma and 1 flap with mismatching of the artery and vein. The other reasons for re-exploration included arterial crisis in 1 flap and subcutaneous hemorrhage in 1 flap. The re-exploration occurred at 6 to 57 hours postoperatively, with an average of 22.7 hours. The skin flaps survived after re-anastomosis and hemostasis in 8 cases and died in 2 cases. The success rate of rescue was 80%. Conclusion The main reason for the re-exploration of free flap is venous problems. Timely re-explorations and appropriate intraoperative managements are critical for the survival of skin flaps. Key words: Surgical flaps; Transplantation; Venous crisis; Re-exploration

A new operative technique for dissecting perforator vessel in perforator flap: a better way to minimize donor-site morbidity

Background: The purpose of this paper was to introduce our experience on a new operative technique for dissecting perforator vascular in the perforator flap and explore its clinical outcome. Methods: Between June 2013 and December 2016, 119 patients underwent soft tissue defects reconstruction with anterolateral thigh perforator flaps (ALTPs) were included in this study. Ninety-eight patients were male, and twenty-one patients were female. The average age of those patients was 40.58 years. Results: The ALTPs were successfully elevated to reconstruct soft tissue defect for 119 patients. The size of skin paddle was 120.59±59.31 cm 2 . A total of 148 perforators were included in the ALTP (84 percent was musculocutaneous perforator, 16 percent was septocutaneous perforator). The mean flap elevation time was 60.85±20.25 minutes. The success rate of flap elevation was 98%, only three perforators were injured and one perforator occurred vasospasm during the operation. Five cases, including three venous crisis and two artery crisis, presented with vascular crisis after flap transfer. The rate of vascular crisis was 4.2%. All of flaps were completely survived except one flap had partial flap necrosis. The mean follow-up time was 13.32±8.9 months. No muscular weakness was displayed in this group. Conclusions: Orderly retrograde dissection of the perforator vessels in the perforator flap can provide with less donor site morbidity, shorter operative time and safer than the traditional methods. It is a reliable operation for elevating the perforator flap.

Unilateral digital arterial ligation combined with low molecular weight heparins in severed finger without venous anastomosis.

Curative effect of unilateral digital arterial ligation combined with low molecular weight heparins in the treatment of severed finger without venous anastomosis and its influence on venous crisis was studied. A total of 80 patients with distal severed finger treated in Wuxi No. 9 People's Hospital from May 2014 to July 2016 were selected into the study. According to the random number table, they were divided into the control group (n=40) and the research group (n=40). The patients in control group were treated with unilateral digital arterial ligation, while the patients in research group were treated with unilateral digital arterial ligation combined with low molecular weight heparin. The wound healing time after operation, hospitalization time, hemorheology detection results, survival rate and necrosis rate of replanted finger, incidence rate of venous crisis and recovery effect of replanted finger were compared between the two groups. After operation, the wound healing time and hospitalization time of patients in research group were lower than those in control group, and the differences were statistically significant (p<0.05). At 72 h after operation, the platelet adhesion rate, whole blood viscosity, whole blood low-shear viscosity, hematocrit and fibrinogen level in patients in research group were lower than those in control group, and the differences were statistically significant (p<0.05). At 7th day after operation, the survival rate of replanted finger in the research group was higher than that in control group, but the necrosis rate of replanted finger and incidence rate of venous crisis were lower than those in control group, and the differences were statistically significant (p<0.05). At 6 months after operation, the nail length, sensation, two-point discrimination and mobility of distal interphalangeal joint of patients in the research group were superior to those in control group, and the differences were statistically significant (p<0.05). Unilateral digital arterial ligation combined with low molecular weight heparin has a significant effect in the treatment of severed finger without venous anastomosis, which can effectively reduce or prevent the occurrence of venous crisis, improve the survival rate of replanted finger and promote the function recovery of replanted finger, so it is worthy of clinical promotion.

Repair of large area skin defect of forearm with overlength thoracic umbilical conjoined perforator flap with double blood supply

Objective To explore the surgical method and clinical effect of repairing the large area skin defect of forearm with the perforator flap pedicle with the inferior epigastric artery perforator and the lateral cutaneous branch of the posterior intercostal artery. Methods From January, 2006 to January, 2016, 14 cases of forearm large area of skin defects were treated with the overlength flap at one stage. The proximal flap to the inferior epigastric artery umbilical perforation and the flap distal to the posterior interphalangeal artery perforation were used for the blood supply of superficial flap. The length of the flap was 25-43 cm (average, 36 cm) . The width of the flap was 5-14 cm (average, 9 cm) . All patients were followed-up regularly. The content of the follow-up included three aspects: appearance, hand function and the recovery of the donor site. Results Twelve cases of postoperative flaps successfully survived. Arterial crisis was seen in 1 flap 28 hours after surgery. The re-surgical exploration was adopted after conservation treatment for 1 h without remission and the proximal anastomotic flap embolization was confirmed. The flap survived. Venous crisis was seen in 1 case. The flap survived with the help of removing the suture, smoothing drainage and bleeding for 5 d. The wounds and the donor site of the thoracic and abdominal region healed at the first stage. The follow-up time was 8-72 months, with an average of 31 months. The flaps had no obvious bloated, the skin texture was close to forearm skin and the flaps were restored protected sensation. There was no ulceration, infection and other complications. The healing of skin graft was satisfactory in 2 cases in abdominal donor site. No skin graft contracture occurred. The remaining 12 cases had linear scar in the abdomen of the donor site. The edge of the scar was soft and no obvious contracture occurred. Conclusion Super long thoracic umbilical conjoined perforator flap can repair the lager area skin defect of forearm with double blood supply. The length of flap is significantly longer with enough-blood-supply of distal part of the flap. The clinical efffect is satisfactory. Key words: Conjoined flap, perforator flap; Inferior epigastric artery; Posterior intercostal artery; Forearm; Defects

Clinical study of propacetamol and dezocine for the prevention and treatment of vascular crisis in preemptive analgesia after digit replantation

Objective To explore the clinical effect of propacetamol and dezocine for the prevention and treatment of vascular crisis in the preemptive analgesia after digit replantation. Methods 85 cases of patients treated with digit replantation were selected for the study and divided into the propacetamol group (n=45) and the dezocine group (n=40) according to the different postoperative preemptive analgesic method. The two groups were given with propacetamol or dezocine and fentanyl and ondansetron patient-controlled intravenous analgesia (PCIA) respectively. The analgesic and sedative effects were observed between the two groups, and the occurrence of vascular embolism and vascular crisis and the survival rate of replantation were counted. Results There was no significant difference between the two groups in the visual analogue pain score (VAS) at 3 hours after operation (P<0.05). The VAS scores of the two groups were significantly increased at 6 h and 24 h after operation while the VAS score was significantly decreased at 48 h after operation (P<0.05), and the VAS scores were significantly lower in the propacetamol group than those in the dezocine group at 6 h, 24h and 48 h after operation (P<0.05). The difference of the Ramsay sedation scores distribution at 3 hours after operation was statistically significant between the two groups (P<0.05), and the sedative effect was more satisfactory in the propacetamol group. Within 48 h after operation, PCI effective times/actual sub values of the propacetamol group were significantly higher than the dezocine group (P<0.05). The incidence rates of postoperative vascular thrombosis and arterial or venous crisis were 4.44%, 6.67% and 6.67% respectively in the propacetamol group, which were significantly lower than those in the dezocine group with 20.00%, 22.50% and 27.50% (P<0.05). The survival rate of digit replantation, digit replantation at 6 months after treatment were 97.78%, 85.00% which was higher than that of the dezocine group with 91.11%, 75.00% (P<0.05). Conclusions Compared with dezocine, propacetamol can attain the ideal analgesic and sedative effects and improve the survival rate of replantation, which has a significant role in the prevention and treatment of vascular crisis in the adjuvant treatment of postoperative analgesia in digit replantation. Key words: Acetaminophen/AA; Acetaminophen/AD; Morphinans/AA; Morphinans/AD; Analgesia; Finger injuries/SU; Replantation; Vascular diseases/PC

Modified anterolateral thigh perforator flap pedicled by cross-bridge microvascular anastomosis for repairing soft tissue defects in middle and lower segments of leg

To explore the effectiveness of modified anterolateral thigh perforator flap pedicled by cross-bridge microvascular anastomosis in treatment of soft tissue defects in the middle and lower segments of the leg. Between March 2011 and June 2015, 15 cases with skin and soft tissue defects in the middle and lower segments of the legs were treated. There were 9 males and 6 females, aged 22-48 years (mean, 32.6 years). Of whom, 8 patients caused by traffic accidents, 5 by machine twist, and 2 by crash injury of heavy object. The mean interval from injury to admission was 82.6 hours (range, 2 hours to 1 week). The area of defect ranged from 13 cm×9 cm to 23 cm×16 cm. After primary debridement and vaccum sealing drainage treatment, the defects were repaired with modified anterolateral thigh perforator flap pedicled by cross-bridge microvascular anastomosis. The size of flap ranged from 15 cm×10 cm to 25 cm×15 cm. The donor sites were sutured directly or repaired with the skin grafts. The pedicle division was done at 4 weeks after operation. After operation, venous crisis occurred in 1 case and distal skin necrosis in 2 cases which was healed by dressing change. The other tissue flaps survived successfully and wounds healed by first intention. All skin grafts at donor site survived after operation, and primary healing of wound was obtained. All patients were followed up 6-24 months (mean, 13 months). All flaps were characterized by soft texture, satisfactory appearance, and restoring the protective sensation. Moreover, the two-point discrimination ranged from 15 to 28 mm (mean, 19.5 mm) at 6 months after operation. The function of both lower extremities were normal without obvious contracture of scar at donor site. Modified free anterolateral thigh perforator flap, with little damage in donor site, a reliable blood supply by making a cross-bridge microvascular anastomosis with pretibial or posterior tibial blood vessel on normal leg, is a reliable alternative method for repairing soft tissue defects with the main vessels of serious injury in the middle and lower segments of the leg.

Reverse dorsal digital island flap with cutaneous branches of proper digital nerve for repair of soft tissue defects of the same fingertip

Objective To explore the clinical outcomes of reverse dorsal digital island flap with cutaneous branches of proper digital nerve for repair of soft tissue defects of the same fingertip. Methods From March 2014 and June 2016, 25 patients (30 fingers) of fingertip soft tissue defects were treated using reverse dorsal digital island flap with cutaneous branches of proper digital nerve. The proper digital cutaneous branches of the flap were sutured with the digital nerve of the wound. The fingertip defect area ranged from 1.4 cm×1.6 cm to 2.0 cm×3.5 cm (average, 2.1 cm×2.5 cm). The flap area was enlarged by 10%. The donor sites were covered with autologous full-thickness skin. Results All the flaps survived. All the donor and recipient wounds achieved primary healing. Venous crisis occurred in one case which healed after the removal of some sutures. Postoperative follow-up period ranged from 6 to 18 months. The shape of the flaps was plump and the texture was soft. Partial superficial sensation of the flaps recovered without donor site pain and interphalangeal joint dysfunction. The two-point discrimination ranged from 5 to 8 mm, with the average being 5.7 mm. According to the functional evaluation standards issued by Hand Surgery Society of the Chinese Medical Association, the results were excellent in 17 cases, good in 8 cases. Conclusion The application of reverse dorsal digital island flap with cutaneous branches of proper digital nerve for repair of soft tissue defects of the same fingertip can achieve good sensory recovery. Key words: Finger injuries; Surgical flaps; Treatment outcome; Sensory reconstruction

Treatment of Toe-to-toe Defect with Arterial Skin Flap

&lt;p&gt;&lt;strong&gt;Objective:&lt;/strong&gt; To study the repairing effect of arterial skin flap on the toe defect. &lt;strong&gt;Methods:&lt;/strong&gt; Six patients with hallux defect were treated in our hospital from February 2014 to February 2016. The skin flap of the thumb was used to repair the defect.&lt;strong&gt; Results:&lt;/strong&gt; After the operation, the skin flap had symptom of venous crisis. One patient survived after the dressing and partial removal of the pedicle of the flap. The other 5 cases survived and the wounds were healed. The skin grafts in the donor site survived and the incision reached grade I healing. The average follow-up period was 10 months. The flap elasticity and texture were good. Patients’ foot felt with burden, with normal walking, without obvious discomfort and without ulceration. &lt;strong&gt;Conclusion:&lt;/strong&gt; The toe-to-toe defect is repaired with the arterial skin flap. The skin flap does not cause damage to the blood vessels, and the clinical result is ideal.&lt;/p&gt;

Repairing donor site of foot after improved toe-to-thumb reconstruction utilizing superficial circumflex iliac ar-tery perforator chimeric flap

Objective To evaluate the clinical outcome of the method of repairing donor site of foot after im-proved toe-to-thumb reconstruction utilizing superficial circumflex iliac artery perforator (SCIAP) chimeric flap. Meth-ods Fourteen cases of thumb defect were recruited from April, 2012 to January, 2016. According to Gu Yudong’s clas-sification, 5 cases met the criterion of type I, 4 cases met the criterion of type II, and 5 cases met the criterion of type III. For type I, the thumb was reconstructed with the great toe wrap-around flap. For type II and III, the thumb was recon-structed by the combined tissue with mutual artery (great toe wrap-around flap, and the bone-tendon tissue of the sec-ond toe). All the donor sites of foot were repaired utilizing SCIAP chimeric flap. Results All the reconstructed thumbs survived. Among 14 free flaps of donor site, 1 case suffered venous crisis and survived after exploration and rescue sur-gery. Dorsal skin necrosis of the second toe was found in 1 case, which was healed by local skin flap transposition. All pa-tients were followed-up ranged from 3 to 30 months (averaged at 16 months). In spite of slightly bloated, the color and texture of all the flaps’was satisfied, and the average healing time of the bone in the donor sites was 2.5 months. All pa-tients did not feel painful and had no adverse effect when walking and running. Three months after the operation, 5 slight-ly bloated flaps in the donor sites under went flap plastic and achieved better appearance. On the part of iliaca, there was only one inconspicuous linear scar without any discomfort. Conclusion Repairing donor site of foot after improved toe-to-thumb reconstruction utilizing SCIAP chimeric flap was an ideal method. Using this method, the reconstructed thumb can achieve good appearance and function, all the toes of donor site were reserved, and the disability of the donor site is minimized. Key words: Superficial circumflex iliac artery; Chimeric flap, perforator flap; Tissue transplantation; Thumb reconstruction; Donor site; Microsurgical technique