Abstract The narrow pedicled intercostal cutaneous perforater (np-ICP) thin flaps were successfully used for reconstruction of hand deformity from scar contraction. This flap was designed with a narrow pedicle (3～5cm in width) which included ICPs of 4th～9th intercostal spaces, and with awide distal part (the maximum is 15cm×15cm) which covered the lower chest and upper abdomen. The thickness of flap was cut until the subdermal vascular networkwas observed. The pedicle was divided between the 7th～14th days after operation. Sixteen flaps in 15 cases were transferred for covering of the skin defects at the dorsum of the hand. The perforators which were included in the narrow pediclewere mostly from the 7th intercostal spaces in 9 flaps. Fifteen of the 16 flapswere survived almost completely, except in one case there was necrosis of the distal portion of the flap. It seemed that this flap was more useful than the conventional methods, not only functionally but also aesthetically. Moreover, the operative techinque was more simple and safer than the island or free intercostalflap due to without the necessity to dissect the main trunk of the intercostalneurovascular bundle. Gentle pressure on the thinning portion of the flap for a short time after operation was important.
Objective To investigate the operative technique and clinical effect of perforator-based flap for repair of glutealsacral skin defects. Methods A new perforator-based flap derived from the gluteal, parasacral and the lumbar arteries was used to repair skin defects ofglutealsacral region caused by trauma or pressure sore. The flap areas ranged from 6 cm×5 cm to 19 cm×11 cm, the diametre of perforating vessel ranged from 1.3 to 2.1 mm,the length of free perforating vessel pedicle ranged from 2.5 to 4.5 cm.Results All the flaps survived andthe wound gained primary healing. All the patients were followed up for 6 to 24months. The colour and texture of the flaps were excellent, the configuration was satifactory and there was no ulcer recurrence. Conclusion This new type of flap is characterized by delicate design, easy dissection, reliable blood supply, nosacrifice of the underlying muscle and no requirement skin graft for donor site closure. It is an optimalmethod in repairing soft tissue defects of the gluteal-sacral region.
Objective To investigate the effectiveness of the wrap-around great toe flap combined with medial plantar artery perforator flap (MPAP) for repairing the completely degloved fingers. Methods Between February 2018 and December 2019, 12 patients with the completely degloved fingers caused by machine strangulation were admitted. There were 9 males and 3 females with a median age of 32 years (range, 18-42 years). The injured finger was index finger in 7 cases, middle finger in 3 cases, and ring finger in 2 cases. The skin was avulsed from the metacarpophalangeal joint level, with the intact tendon and joint. The interval between injury and admission was 1-8 hours (mean, 5 hours). All fingers were taken debridement during the emergency operation. The size of the skin defect ranged from 8.0 cm×5.0 cm to 12.0 cm×7.5 cm. After flap thinning, the wrap-around great toe flap (8.0 m×2.0 cm-12.0 cm×3.5 cm) and MPAP (8.0 cm×4.0 cm-12.0 cm×5.5 cm) were used to repair the degloved finger. The donor sites were repaired with the full-thickness skin graft or the flap. Results All flaps and skin grafts survived completely without significant complications and the wounds at recipient and donor sites healed by first intention. All patients were followed up 12-16 months (mean, 14 months). The texture, appearance, and color of the affected fingers were close to those of normal fingers, and the nails grew normally. At last follow-up, the mean two-point discrimination of the flap was 9 mm (range, 8-10 mm), and the sensation of the injured finger recovered to S3-S4. And 10 cases were rated as excellent and 2 cases as good according to the Michigan Hand Outcomes Questionnaire (MHQ). There was no complication such as pain from walking or skin ulceration at the donor site. The American Orthopaedic Foot and Ankle Society (AOFAS) score was excellent in 9 cases and good in 3 cases. Conclusion Treating for the completely degloved fingers, the wrap-around great toe flap combined with MPAP can obtain good effectiveness in the respect of the sensation, function, and appearance.
Objective To investigate the effectiveness of free peroneal artery chimeric perforator flap in repairing the defect after advanced local lesions resection in parotid gland carcinoma (PGC). Methods Between June 2010 and June 2020, 32 patients with advanced local lesions of PGC were treated with extended radical resection. After that, 17 patients were repaired with the free peroneal artery chimeric perforator flaps (trial group) and another 15 patients were repaired with the pedicled pectoralis major myocutaneous flaps (control group). There was no significant difference in gender, age, disease type, histopathological classification, clinical stage, and pathological stage between groups (P>0.05). The size of skin flap in trial group ranged from 7 cm×6 cm to 12 cm×8 cm and the size of soleus muscle flap ranged from 5 cm×3 cm to 6 cm×4 cm. The donor sites were repaired with skin grafting. The size of the pedicled pectoralis major myocutaneous flaps in control group ranged from 9 cm×6 cm to 14 cm×7 cm. The donor sites were sutured directly. The operation time, survival rate of flap, and postoperative survival of patients were recorded and compared between groups. At 1 year after operation, the University of Washington quality of life (UW-QOL) questionnaire was used to evaluate the quality of life of patients in the two groups, including appearance, shoulder movement, sociability, masticatory function, speech function, and mood. Results The operations completed successfully. The operation time was (6.19±0.72) hours in trial group and (6.41±0.71) hours in control group, showing no significant difference between groups (t=–0.863, P=0.395). The survival rate of flap in trial group was 94.1% (16/17); and 1 patient suffered from vascular crisis after operation and was replaced with the pedicled pectoralis major myocutaneous flap. The survival rate of flap in control group was 100%. All grafts survived and the incisions healed by first intention in the two groups. All patients were followed up. The follow-up time was 6-60 months (median, 60 months) in trial group and 7-60 months (median, 60 months) in control group. Cumulative survival rates of patients at 1, 3, and 5 years after operation were 94.1%, 64.7%, and 58.8% in trial group, respectively; 86.7%, 66.7%, and 53.3% in control group, respectively. There was no significant difference in the cumulative survival rate between groups (χ2=0.090, P=0.762). According to the UW-QOL questionnaire at 1 year after operation, the scores of appearance, shoulder movement, sociability, and mood in trial group were significantly higher than those in control group (P<0.05); and there was no significant difference in masticatory function and speech function scores between groups (P>0.05). Conclusion The peroneal artery perforator has an invariable anatomical relationship. Each perforator emits the muscular branch that nourishes the soleus muscle. Therefore, personalized free peroneal artery chimeric perforator flap can be designed according to the tissue defect, and used to repair the defect after advanced local lesions resection in PGC.
Objective To introduce the technique and clinical application of free lobed anteromedial thigh perforator flap. MethodsBetween October 2017 and December 2021, 65 patients with buccal and oral cancer penetrating defects were planned to treat with free lobed anterolateral thigh flap transplantation, of which 15 cases were found that the sole anterolateral thigh perforator was actually a branch of the anteromedial thigh perforator, and then the free lobed anteromedial thigh perforator flap was harvested for repair. There were 12 males and 3 females with an average age of 34.6 years (range, 29-55 years). According to Union for International Cancer Control (UICC) TNM staging, there were 7 cases of T4N0M0, 4 cases of T4N1M0, 2 cases of T3N1M0, and 2 cases of T3N2M0. The disease duration was 1-10 months (mean, 6.3 months), and the area of secondary soft tissue defect left after radical resection of buccal and oral cancer was from 5 cm×4 cm to 10 cm×6 cm. The anterolateral thigh skin flap ranged from 5 cm×4 cm to 13 cm×6 cm, and the anteromedial thigh skin flap ranged from 5 cm×3 cm to 10 cm×6 cm. The free trilobed anteromedial thigh flap was prepared according to the actual branches of the main trunk of the anteromedial thigh perforator in 4 cases, and the vastus medialis muscle flap was used to fill the cavity defect of the floor of mouth in 7 cases. Among the 15 patients, the vessel pedicles of the anteromedial thigh perforators were derived from the main femoral artery and vein in 8 cases, from the main descending branch of the lateral femoral circumflex artery in 4 cases, and from the main lateral femoral circumflex artery in 3 cases. Results Hematoma occurred in 2 cases after operation, which was successfully saved after emergency exploration. No vascular crisis occurred, and partial necrosis of anterolateral femoral skin island occurred in 1 case, which was healed with debridement. The remaining flaps survived successfully, and the wounds and donor site incisions healed by first intention. All the patients were followed up 12-36 months (mean, 14.6 months). The appearance of the flap was satisfactory, and no obvious swelling was found; the mouth opening and language function were satisfactory; only linear scar was left in the donor area, and the thigh function was not significantly affected. Local recurrence occurred in 3 cases, and the defect after tumor resection was repaired with pedicled pectoralis major myocutaneous flap. Four patients with neck lymph node metastasis, including ipsilateral side in 3 patients and contralateral side in the other 1 patient, all underwent neck lymph node dissection again. The 3-year survival rate was 86.7% (13/15). Conclusion The anteromedial thigh perforator vessels distributed in the anterolateral region of the thigh can be used to prepare the anterolateral thigh split lobed flap to repair the buccal and oral cancer penetrating defects.
ObjectiveTo summarize the combination methods and optimization strategies of the harvest procedure of anterolateral thigh chimeric perforator myocutaneous flap. MethodsA clinical data of 359 cases of oral cancer admitted between June 2015 and December 2021 was retrospectively analyzed. There were 338 males and 21 females with an average age of 35.7 years (range, 28-59 years). There were 161 cases of tongue cancer, 132 cases of gingival cancer, and 66 cases of buccal and oral cancer. According to the Union International Center of Cancer (UICC) TNM staging, there were 137 cases of T4N0M0, 166 cases of T4N1M0, 43 cases of T3N1M0, 13 cases of T3N2M0. The disease duration was 1-12 months (mean, 6.3 months). The soft tissue defects in size of 5.0 cm×4.0 cm to 10.0 cm×7.5 cm remained after radical resection were repaired with the free anterolateral thigh chimeric perforator myocutaneous flaps. The process of harvesting the myocutaneous flap was mainly divided into 4 steps. Step 1: exposing and separating the perforator vessels, which mainly came from the oblique branch and the lateral branch of the descending branch. Step 2: isolating the main trunk of the perforator vessel pedicle and determining the origin of the vascular pedicle of muscle flap, which was came from oblique branch, lateral branch of the descending branch, or medial branch of the descending branch. Step 3: determining the source of muscle flap, including lateral thigh muscle and rectus femoris muscle. Step 4: determining the harvest form of muscle flap, which included muscle branch type, main trunk distal type, and main trunk lateral type. Results The 359 free anterolateral thigh chimeric perforator myocutaneous flaps were harvested. In all cases, the anterolateral femoral perforator vessels existed. The perforator vascular pedicle of the flap came from the oblique branch in 127 cases and the lateral branch of the descending branch in 232 cases. The vascular pedicle of muscle flap originated from the oblique branch in 94 cases, the lateral branch of the descending branch in 187 cases, and the medial branch of the descending branch in 78 cases. The muscle flaps harvested from the lateral thigh muscle in 308 cases and the rectus femoris muscle in 51 cases. The harvest forms of muscle flaps included 154 cases of muscle branch type, 78 cases of main trunk distal type, and 127 cases of main trunk lateral type. The size of skin flaps ranged from 6.0 cm×4.0 cm to 16.0 cm×8.0 cm, and the size of muscle flaps range from 5.0 cm×4.0 cm to 9.0 cm×6.0 cm. In 316 cases, the perforating artery anastomosed with the superior thyroid artery, and the accompanying vein anastomosed with the superior thyroid vein. In 43 cases, the perforating artery anastomosed with the facial artery, and the accompanying vein anastomosed with the facial vein. After operation, the hematoma occurred in 6 cases and vascular crisis in 4 cases. Among them, 7 cases were successfully saved after emergency exploration, 1 case had partial necrosis of skin flap, which was healed after conservative dressing change, and 2 cases had complete necrosis of skin flap, which was repaired by pectoralis major myocutaneous flap. All patients were followed up 10-56 months (mean, 22.5 months). The appearance of the flap was satisfactory, and the swallowing and language functions were restored satisfactorily. Only linear scar left in the donor site with no significant effect on thigh function. During follow-up, 23 patients had local tumor recurrence and 16 patients had cervical lymph node metastasis. The 3-year survival rate was 38.2% (137/359). Conclusion The flexible and clear classification of the key points in the harvest process of anterolateral thigh chimeric perforator myocutaneous flap can optimize the protocol to the greatest extent, increase the safety of the operation, and reduce the difficulty of the operation.
Objective To explore the application value of infrared thermography in the design and harvesting of ultrathin anterolateral thigh perforator flaps. Methods Between June 2024 and December 2024, 9 cases of ultrathin anterolateral thigh perforator flaps were designed and harvested with the assistance of infrared thermography. There were 7 males and 2 females, aged 21-61 years (mean, 39.8 years). The body mass index ranged from 19.49 to 26.45 kg/m² (mean, 23.85 kg/m²). Causes of injury included 5 cases of traffic accident injuries and 4 cases of machine crush injuries. There were 3 cases of leg wounds, 2 cases of foot wounds, and 4 cases of hand wounds. After debridement, the size of wound ranged from 7 cm×4 cm to 13 cm×11 cm. The time from admission to flap repair surgery was 5-12 days (mean, 7 days). Preoperatively, perforator localization was performed using a traditional Doppler flow detector and infrared thermography, respectively. The results were compared with the actual intraoperative locations; a discrepancy ≤10 mm was considered as consistent localization (positive), and the positive predictive value was calculated. All 9 cases were repaired with ultrathin anterolateral thigh perforator flaps designed and harvested based on thermographic images. The size of flap ranged from 8 cm×5 cm to 14 cm×8 cm, with a thickness of 3-6 mm (mean, 5.2 mm). One donor site was repaired with a full-thickness skin graft, and the others were sutured directly. Postoperatively, anti-inflammatory, anticoagulant, and anti-vascular spasm treatments were administered, and follow-up was conducted. ResultsThe Doppler flow detector identified 22 perforating vessels within the set range, among which 16 were confirmed as superficial fascia layer perforators intraoperatively, with a positive predictive value of 72.7%. The infrared thermograph detected 23 superficial fascia layer perforating vessels, and 21 were verified intraoperatively, with a positive predictive value of 91.3%. There was no significant difference between the two methods [OR (95%CI)=3.93 (0.70, 22.15), P=0.100]. The perforator localization time of the infrared thermograph was (5.1±1.3) minutes, which was significantly shorter than that of the Doppler flow detector [(10.1±2.6) minutes; MD (95%CI)=–5.00 (–7.08, –2.91), P<0.001]. Postoperatively, 1 case of distal flap necrosis healed after dressing change; all other flaps survived successfully. The skin grafts at donor site survived, and all incisions healed by first intention. All patients were followed up 3-6 months (mean, 4.7 months). No pain or other discomfort occurred at the donor or recipient sites. All patients with foot wounds could walk with shoes, and no secondary flap revision was required. Flaps in 3 hand wound cases, 2 foot wound cases, and 3 leg wound cases recovered light touch and pressure sensation, but not pain or temperature sensation; the remaining 2 cases had no sensory recovery.ConclusionPreoperative localization using infrared thermography for repairing ultrathin anterolateral thigh perforator flaps can help evaluate the blood supply status of perforators, reduce complications, and improve surgical safety and flap survival rate.
ObjectiveTo investigate the feasibility and effectiveness of the superior lateral genicular artery perforator flap for repairing of soft tissue defects in extremities.MethodsBetween 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.ResultsEight 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.ConclusionThe 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.
ObjectiveTo investigate the clinical application of the forearm interosseous dorsal artery perforator sublobe flaps in repairing two wounds in dorsal hand or wrist. MethodsBetween October 2009 and October 2012, 12 patients with two wounds in the dorsal hand or wrist were included in the study. There were 4 cases of skin defects (grade IV) and bone exposure caused by machine injury, 3 cases of skin defects with bone and tendon exposure caused by traffic accident, and 3 cases of skin defect and tendon exposure caused by crash injury of heavy object, with a duration of 3-12 hours (mean, 6 hours) between injury and admission; defects in the wrist and tendon exposure were caused by tumor resection in 2 cases. Four cases had metacarpal fractures. The size of larger skin and soft tissue defects ranged from 4.0 cm×3.5 cm to 5.0 cm×3.0 cm, and the size of smaller defects was from 2.5 cm×2.0 cm to 4.0 cm×3.0 cm. The flap size was from 6 cm×4 cm to 8 cm×3 cm and 3.0 cm×2.5 cm to 5.0 cm×3.0 cm. The donor sites were directly sutured or repaired with free skin graft. ResultsAll the flaps survived, and wound healed in first stage. All the cases were followed up 6-36 months (mean, 20 months). The flaps had good color and texture. Three cases underwent secondary surgery of thinning the flaps. At last follow-up, two-point discrimination of flaps was 10-14 mm, 12 mm on average. According to function standard for evaluation of upper extremity with total active motion of the fingers from the Hand Surgery Society of Chinese Medical Association, the results were excellent in 10 cases, and good in 2 cases. ConclusionForearm interosseous dorsal artery perforators sublobe flaps can be used to repair two wounds in the dorsal hand or wrist simultaneously, and it has the advantages of simple operation, less injury at donor site, and reliable blood supply.
ObjectiveTo explore the effectiveness of free profounda artery perforator flap (PAPF) in the posteromedial femoral region for the treatment of traumatic skin defects of limbs.MethodsBetween March 2015 and April 2017, 11 cases of traumatic limb skin defect with deep tissue exposure were treated with free PAPF in posteromedial femoral region. There were 7 males and 4 females, with an average age of 39 years (range, 26-54 years). There were 4 cases of upper limb skin defect and 7 cases of lower limb skin defect. The causes of injury included 6 cases of traffic accident injury, 3 cases of machine crush injury, and 2 cases of crush injury. The size of wounds ranged from 11 cm×7 cm to 18 cm×11 cm. The time from post-traumatic admission to flap repair were 4-9 days (mean, 7.3 days). The size of free PAPF ranged from 15 cm×9 cm to 22 cm×13 cm. The donor site of 8 cases were closed directly; 3 cases could not be closed directly, and skin grafting was used to cover the wound.ResultsThe time of skin flap harvest was 40-90 minutes (mean, 47 minutes). All flaps and skin grafts survived and the wounds healed by first intention. All the 11 patients were followed up 6-19 months (mean, 12 months). The skin flaps were soft in texture, similar in color to the skin around the injured limbs, without obvious pigmentation and hair overgrowth. Three of them underwent second-stage skin flap thinning. At last follow-up, the limb function of all patients recovered well. Longitudinal scar could be seen in the donor site of the flap, and the location was concealed. All patients did not complain that scar of the donor site affected their sexual life during the follow-up.ConclusionFree PAPF can achieve satisfactory results in repairing skin defects of extremities. The flaps have the advantages including constant perforator branches, simple operation, and concealed donor site.