Objective To explore the feasibility of peroneal perforating chimeric tissue flap in repairing the composite defects of calf and heel based on lower limb angiography, and the clinical effect. Methods The digital subtraction angiography images of lower limbs of 50 patients met the selection criteria between May 2011 and October 2014 were used as the research object to observe the course of peroneal artery and its perforating vessels. Based on the observation results, between April 2015 and October 2020, the peroneal perforating chimeric tissue flap was designed to repair 7 cases of composite defects of the calf and heel. There were 5 males and 2 females with an average age of 38 years (range, 25-55 years). The causes of injury included traffic accident in 4 cases, falling from height in 2 cases, and machine strangulation in 1 case. There were 5 cases of calf skin defect and tibial defect. The size of skin defect ranged from 5 cm×3 cm to 11 cm×7 cm, and the length of bone defect was 5-8 cm. There were 2 cases of heel skin defect and calcaneal defect. The sizes of skin defects were 5.0 cm×4.0 cm and 7.5 cm×6.5 cm, and the bone defects were 3.0 cm×2.6 cm and 4.0 cm× 3.0 cm. For the calf defect, the size of skin flap ranged from 6 cm×4 cm to 12 cm×8 cm, and the length of the fibula was the same as that of the tibial defect. For the heel defect, the sizes of the skin flaps were 8.5 cm×5.5 cm and 13.0 cm×5.0 cm, and the lengths of the fibulae were 10 cm and 12 cm. Free transplantation was performed in 5 cases and pedicle transplantation in 2 cases. The wound at donor site was repaired with skin grafting or sutured directly. Results The peroneal artery ran close to the fibula 7.25-8.40 cm below the fibula head and send out 5-7 perforating vessels, with an average of 6.5 vessels. Perforating vessels mainly appeared in four places, which were (9.75±0.91), (13.21±0.74), (18.15±1.22), and (21.40±0.75) cm below the fibular head, with the occurrence rates of 94%, 90%, 96%, and 88%, respectively. Clinical application of 7 cases of peroneal perforating chimeric tissue flap all survived, all wounds healed by first intention. The skin graft at donor site survived and the incision healed by first intention. All patients were followed up 6-36 months, with an average of 12 months. Peroneal perforator chimeric tissue flap had good shape and soft texture. X-ray films showed that the bone graft healed well, and the healing time was 6-11 months (mean, 7 months). No obvious bone resorption was observed during follow-up. Five patients had no pain when walking, and 1 had mild pain with claudication. Postoperative heel ulcers formed in 1 case and healed after wearing custom plantar pressure dispersing shoes. At 6 months after operation, 2 patients were rated as grade Ⅳ and 5 patients as grade Ⅴ according to Holden walking function score. ConclusionThe peroneal perforating vessel distribution is constant and the peroneal perforating chimeric tissue flap is safe and reliable for repairing the composite defects of calf and heel.
Objective To investigate the effectiveness of dorsal perforator flap of cross-finger proper digital artery in the treatment of finger soft tissue defect caused by high-pressure injection injury. MethodsBetween July 2011 and June 2020, 14 cases of finger soft tissue defect caused by high-pressure injection injury were repaired with dorsal perforator flap of cross-finger proper digital artery. All patients were male, with a mean age of 36 years (range, 22-56 years). The defects were located on the index finger in 8 cases, middle finger in 4 cases, and ring finger in 2 cases. The causes of injury include 8 cases of emulsion paint injection, 4 cases of oil paint injection, and 2 cases of cement injection. The time from injury to debridement was 2-8 hours, with a mean time of 4.5 hours. The soft tissue defects sized from 4.0 cm×1.2 cm to 6.0 cm×2.0 cm. The flaps sized from 4.5 cm×1.5 cm to 6.5 cm×2.5 cm. The donor site of the flap was repaired with skin graft. The pedicle was cut off at 3 weeks after operation, and followed by functional exercise. ResultsAll flaps and skin grafts at donor sites survived, and the wounds healed by first intention. Twelve patients were followed-up 16-38 months (mean, 22.6 months). The texture and appearance of all flaps were satisfactory. The color and texture of the flaps were similar to those of the surrounding tissues. The two-point discrimination of the flap was 10-12 mm, with a mean of 11.5 mm. There were different degrees of cold intolerance at the end of the affected fingers. At last follow-up, the finger function was evaluated according to the Upper Extremity Functional Evaluation Standard set up by Hand Surgery Branch of Chinese Medical Association, 3 cases were excellent, 8 cases were good, and 1 case was poor. Conclusion The dorsal perforator flap of cross-finger proper digital artery can effectively repair finger soft tissue defect caused by high-pressure injection injury. The operation was simple, and the appearance and function of the finger recover well.
Objective To investigate the effectiveness of the deep inferior epigastric perforator (DIEP) flap for extreme defects around the knee. Methods Between June 2017 and December 2018, 15 patients with the extreme defects around the knee were admitted. There were 9 males and 6 females with a median age of 36 years (range, 23-51 years). The etiology was the traffic accident in 7 cases, tumor in 5 cases, and burn in 3 cases. The injured location was left knee in 8 cases and right knee in 7 cases. The size of soft tissue defects ranged from 15 cm×10 cm to 30 cm×20 cm, and all defects complicated with exposure of blood vessels, nerves, tendons, and other tissues. Transverse DIEP flaps with 1-2 vascular pedicles were prepared according to the size of the defect, including 6 cases of single-pedicle flaps and 9 cases of double-pedicle conjoined flaps. According to the depth of the defect, 10 cases of skin flaps were thinned under microscope. The size of the DIEP flaps ranged from 16 cm×10 cm to 32 cm×20 cm; the average thickness was 1.5 cm (range, 0.8-1.8 cm); the average pedicle length was 7.5 cm (range, 5.0-9.0 cm). The donor site was directly sutured. Results One single-pedicle flap developed distal necrosis after operation, and healed after skin grafting; the other skin flaps survived, and the wounds at the donor and recipient sites healed by first intention. All patients were followed up 16-28 months (mean, 24 months). The shape and texture of the flap were satisfactory, and there was no abnormal hair growth or obvious pigmentation. There was only linear scar at the donor site and no complication such as abdominal hernia. The appearance and function of the knee were satisfactory. No recurred tumor was observed, and the scar contracture was released. At last follow-up, 13 cases were excellent and 2 cases were good, according to the Knee Society Score (KSS) criteria. Conclusion The DIEP flap is an ideal alternative for repairing the extreme defects around knee, with a concealed donor site, easy dissection, flexible design, as well as less complication.
ObjectiveTo explore the effectiveness of propeller facial artery perforator flap to repair the defect after resection of skin malignant tumor at upper lip.MethodsBetween July 2012 and January 2017, 17 cases with skin malignant tumor at upper lip underwent tumor resection and the remained defect was repaired with propeller facial artery perforator flap. Among the 17 patients, 3 were male and 14 were female, with an average age of 57 years (range, 35-82 years). There were 5 cases of squamous cell carcinoma and 12 cases of basal cell carcinoma. The disease duration ranged from 4 months to 11 years with an average of 20 months. The tumor size ranged from 1.4 cm×0.3 cm to 3.1 cm×1.4 cm. The extended resection of the tumor tissue was performed according to the characters of tumor. According to the location, size, and shape of the defect and the position of facial artery perforator explored with Doppler ultrasonography, the propeller facial artery perforator flap was designed to repair the defect and partial donor site. The flap size ranged from 5 cm×2 cm to 7 cm×3 cm. The length of the perforator pedicle was 0.5–1.0 cm with an average of 0.8 cm. The defect at donor site was directly closed.ResultsCyanosis occurred in 3 cases of the distal flap after operation, then healing after symptomatic treatment. The remaining flaps survived successfully and the wound healed by first intention. Primary healing was obtained in the donor site. All the patients were followed up 6-36 months with an average of 18 months. The shape of the patient’s upper lip was good and the scar on the donor site was unconspicuous. There was no lip deformity, ala nasi deflection, facial tension, entilation dysfunction, or recurrence of tumor during follow-up. At last follow-up, the results of self-evaluation were very satisfactory in 13 cases and satisfactory in 4 cases.ConclusionBased on multiple advantages of good blood supply, large rotation range, aesthetic outcome, and slight injury of the donor site, propeller facial artery perforator flap is not only an optimal choice for repairing upper lip defect after resection of skin malignant tumors, but also can achieve good functional and cosmetic effectiveness.
Objective To improve the harvesting techniques of anterolateral thigh perforator flap, and to reduce the operation time. Methods Between January 2008 and June 2015, 400 patients undergoing repair with anterolateral thigh perforator flap were included to analyze the technical factors, including 370 cases (92.5%) obtaining primary healing and 30 cases (7.5%) receiving re-exploration. Combined with the literature, a modified flap dissection was made: reverse tracing and sequential dissection of the descending branch of the lateral circumflex femoral artery. Between June 2015 and June 2016, the modified free anterolateral thigh perforator flap was used in 100 cases. Of 100 cases, 76 were male and 24 were female, aged from 11 to 71 years (mean, 35.6 years). The wound size ranged from 8 cm×5 cm to 23 cm×9 cm. The time between injury and surgery ranged from 5 to 31 days (mean, 14.3 days). Results The operation time of modified flap dissection was reduced to (30.1±19.3) minutes from (85.0±30.2) minutes (unmodified flap dissection). Postoperatively, 94 flaps survived uneventfully, and incision healed by first intention. Six flaps received re-exploration surgery because of vascular compromise; the flap survived after removal of thrombosis in 4 cases of vein thrombosis; the flap necrosed in 2 cases of vein and artery thrombosis, and skin grafting was performed. Ninety-four patients whose flaps survived were followed up 3-12 months (mean, 6.3 months); the flaps had good color and appearance, and second stage operation was performed to make the flap thinner in 21 cases. Conclusion Improved harvesting technique of free anterolageral thigh perforator flap could decrease surgery time and difficulty in dissection.
ObjectiveTo investigate the application value of contrast-enhanced ultrasound (CEUS) technique to assist the repair of oral and maxillofacial defects by superficial inferior epigastric artery perforator flap.MethodsSixteen oral cancer patients, 10 males and 6 females, who were to undergo superficial inferior epigastric artery perforator flap repair between June 2018 and February 2020, were selected, with an average age of 55.8 years (range, 24-77 years). There were 13 cases of squamous cell carcinoma, 2 cases of adenoid cystic carcinoma, and 1 case of mucinous epidermis-like carcinoma. The color Doppler ultrasound (CDUS) and CEUS were used to screen the superficial inferior epigastric artery, assisted in the design of the flap, and compared it with the actual intraoperative exploration. The sensitivity, specificity, positive predictive value, and negative predictive value of CEUS and CDUS examinations were analyzed. Fourteen of 16 patients were repaired with superficial inferior epigastric artery perforator flap, and 2 patients were repaired with superficial iliac artery flap because the source artery was not found. After surgery, regular follow-up was performed to check for disease recurrence and metastasis and to evaluate the appearance of the patien’s donor area, the recovery of transoral feeding function, and the presence of complications.ResultsComparison of preoperative CDUS and CEUS findings and intraoperative exploration showed that CEUS had 100% sensitivity, specificity, positive predictive value, and negative predictive value for vascular exploration of the superficial inferior epigastric artery perforator flap, compared with 57%, 100%, 100%, and 25% for CDUS. The preoperative CDUS identified 25 penetrating vessels in 14 cases repaired with superficial inferior epigastric artery flaps. All vessel signals were enhanced by CEUS enhancement, and an additional 11 penetrating vessels were identified confirmed intraoperatively. The preoperative CEUS measurements of the initial diameter of superficial arteries in the abdominal wall were significantly higher than both CDUS and intraoperative measurements (P<0.05); the difference in peak systolic velocity between CEUS and CDUS measurements was significant (t=3.708, P=0.003). One case of superficial epigastric artery perforator flap developed venous embolism crisis at 48 hours after operation, the wound healing delayed. The other incisions in donor sites healed by first intention. All the patients were followed up 3-12 months, with an average of 8 months. No recurrence or metastasis appeared during the follow-up. There was no serious complications such as abdominal wall hernia, the location of abdominal scarring was hidden, and transoral feeding was resumed.ConclusionThe superficial inferior epigastric artery perforator flap with small injury in supply area and hidden scar location is a better choice for repairing oral and maxillofacial defects. The use of CEUS technique to assist the preoperative design of the superficial inferior epigastric artery perforator flap has good feasibility and high accuracy.
Objective To summarize and discuss the key factors affecting the hemodynamics in the distal end of the multi-territory perforator flap, so as to provide a theoretical basis for the follow-up research and clinical application in this field. Methods The related recent literature about multi-territory perforator flaps was extensively reviewed, and the concepts and researches of perforasome, choke vessel zone, arterial super-charge, and venous super-drainage were summarized. Results The multi-territory perforator flap is composed of multiple perforasomes, and there are different types of vascular anastomosis in the choke vessel zones, which have important impacts on the hemodynamics of the flap. In order to ensure the survival of the multi-territory perforator flap, arterial super-charge and venous super-drainage are mainly used in clinical practice. However, no consensus has been reached on the choice of the two techniques. The different distribution of blood vessels in the flap, the number of perforasomes, and the type of vascular anastomosis may be the main reasons for the different results. Conclusion The location, diameter, and axial characteristics of perforators, the number of perforasomes, and the type of vascular anastomosis are the key factors affecting the hemodynamics of the multi-territory perforator flaps, which should be paid attention to in preoperative design and surgical procedure.
ObjectiveTo investigate the clinical anatomy and application of free profunda femoral artery pedicled chimeric myocutaneous perforator flap in the defect reconstruction after radical resection of tongue carcinoma. MethodsBetween April 2011 and January 2016, 44 cases of tongue carcinoma underwent radical resection, and tongue defects were reconstructed by free profunda femoral artery pedicled chimeric myocutaneous perforator flaps at the same stage. There were 40 males and 4 females, with a mean age of 46.3 years (range, 32-71 years). The pathologic type was squamous cell carcinoma, which involved the lingual margin in 24 cases, the ventral tongue in 17 cases, and the mouth floor in 3 cases. According to Union for International Cancer Control (UICC) TNM staging, 16 cases were rated as T4N0M0, 11 cases as T4N1M0, 9 cases as T3N1M0, and 8 cases as T3N2M0. The course of disease ranged from 1 to 22 months (mean, 8.6 months). The size of perforator flap ranged from 8.5 cm×4.0 cm to 12.0 cm×6.5 cm, and the size of muscle flap ranged from 4.0 cm×3.0 cm to 7.5 cm×5.0 cm. The adductor magnus myocutaneous flap with a pedicle of (8.3±0.5) cm was used in 11 cases, and the gracilis muscle myocutaneous flap with a pedicle of (8.1±0.8) cm was used in 33 cases. The donor sites were sutured directly. ResultsAll 44 perforator flaps survived uneventfully, and the donor site healed well. The patients were followed up for 12 to 40 months (mean, 23.8 months). The reconstructed tongue had good appearance and function in swallowing and language. No local recurrence was found. Only linear scar was left at the donor sites. ConclusionThe free profunda femoral artery pedicled chimeric myocutaneous perforator flap can be harvested in various forms, and is an ideal choice to reconstruct defect after radical resection of tongue carcinoma.
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 discuss the feasibil ity of repairing soft tissue defects of lower extremity with a distally based posterior tibial artery perforator cross-bridge flap or a distally based peroneal artery perforator cross-bridge flap. Methods Between August 2007 and February 2010, 15 patients with soft tissue defect of the legs or feet were treated. There were 14 males and 1 female with a mean age of 33.9 years (range, 25-48 years). The injury causes included traffic accident in 8 cases, crush injury by machine in 4 cases, and crush injury by heavy weights in 3 cases. There was a scar (22 cm × 8 cm atsize) left on the ankle after the skin graft in 1 patient (after 35 months of traffic accident). And in the other 14 patients, the defect locations were the ankle in 1 case, the upper part of the lower leg in 1 case, and the lower part of the lower leg in 12 cases; the defect sizes ranged from 8 cm × 6 cm to 26 cm × 15 cm; the mean interval from injury to admission was 14.8 days (range, 4-28 days). Defects were repaired with distally based posterior tibial artery perforator cross-bridge flaps in 9 cases and distally based peroneal artery perforator cross-bridge flaps in 6 cases, and the flap sizes ranged from 10 cm × 8 cm to 28 cm × 17 cm. The donor sites were sutured directly, but a spl it-thickness skin graft was used in the middle part. The pedicles of all flaps were cut at 5-6 weeks postoperatively. Results Distal mild congestion and partial necrosis at the edge of the skin flap occurred in 2 cases and were cured after dressing change, and the other flaps survived. After cutting the pedicles, all flaps survived, and wounds of recipient sites healed by first intention. Incisions of the donor sites healed by first intention, and skin graft survived. Fifteen patients were followed up 7-35 months with an average of 19.5 months. The color and texture of the flaps were similar to these of the reci pient site. According to American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score system, the mean score was 87.3 (range, 81-92). Conclusion A distally based posterior tibial artery perforator cross-bridge flap or a distally based peronealartery perforator cross-bridge flap is an optimal alternative for the reconstruction of the serious tissue defect of ontralateral leg or foot because of no microvascular anastomosis necessary, low vascular crisis risk, and high survival rate.