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.
ObjectiveTo summarize the difficulties and key points of free deep inferior epigastric artery perforator flap (DIEP) transplantation in breast shaping of two-staged breast reconstruction with vertical scar.MethodsThe clinical data of 32 postoperative breast cancer patients after mastectomy who underwent free DIEP transplantation for breast reconstruction between October 2015 and October 2019, whose original surgical incisions were all vertical and longitudinal, were retrospectively analysed. All the patients were female, aged from 31 to 42 years, with an average of 34.6 years. The disease duration of breast cancer ranged from 9 to 48 months (mean, 22.8 months). Free DIEP pedicled with contralateral vessels were used in all cases, and the recipient vessels were intrathoracic vessels. Among them, 17 flaps were placed longitudinally, 15 flaps were placed obliquely; Z-shaped flaps were used in 18 cases to adjust the chest wall skin contracture, and contralateral breast reduction and mastopexy were accomplished at the same time in 23 cases.ResultsAll DIEP survived completely, and all donor and recipient sites healed by first intention. Internal thoracic lymph node metastasis was found in 1 case and treated with radiotherapy. All 32 cases were followed up 9-48 months, with an average of 19.4 months. The appearance and texture of all flaps were satisfactory, and only linear scar was left in donor site. Eleven patients underwent further autologous fat transplantation and nipple reconstruction. All patients had no effect on abdominal wall activity, and no local recurrence and metastasis was found.ConclusionIt is difficult to use free DIEP for two-staged breast reconstruction in patients received mastectomy with vertical longitudinal scar left. Combined with different breast shaping techniques, the outcomes can significantly improve.
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 investigate the effect of pharmacologic delay with pioglitazone, a peroxisome proliferator-activated receptor γ (PPAR-γ) agonist, on extended perforator flap survival in a rat model. MethodsSeventy male Sprague Dawley rats, weighing 250-300 g, were randomly divided into control group (n=35) and experimental group (n=35). A three-territory flap was made, including two choke zones. Pioglitazone was dissolved in 1.5 mL saline. Oral doses of pioglitazone[10 mg/(kg·d)] was given by gavaged for 5 days in the experimental group, while the same volume of saline was given in the control group at same time point. After 7 days, the flap survival area was measured and angiographic diagnosis was made. The tissue samples were harvested from choke zone Ⅱ for histological study and vascular endothelial growth factor (VEGF) expression detection by immunohistochemical staining. The content of nitric oxide (NO) in choke zones I and Ⅱ was measured at immediate, 1, 3, 5, and 7 days after operation. ResultsThe flap general change of 2 groups was similar. Varying degrees of necrosis occurred with the extension of time in 2 groups. At 7 days after operation, the flap survival rate was 87.73%±3.25% in the experimental group and 76.07%±2.92% in the control group, showing a significant difference (t=-10.338, P=0.000). The number of true anastomosis in choke zones I and Ⅱ was 5.40±1.14 and 3.00±0.71 in the experimental group, and was 3.20±0.84 and 0.80±0.84 in the control group respectively, showing significant differences between the 2 groups (t=-3.479, P=0.008;t=-4.491, P=0.002). The microvessel density and the expression of VEGF in choke zone Ⅱ of experimental group were (33.16±7.73)/mm2 and 4 368.80±458.23, respectively, which were significantly higher than those of control group[(23.29±5.91)/mm2 and 2 241.24±554.43] (t=5.073, P=0.000;t=-14.789, P=0.000). The content of NO in the experimental group were significantly higher than those in the control group at other time points (P<0.05) except for at immediate after operation. ConclusionPharmacologic delay with pioglitazone can improve extended perforator flap viability through increasing ischemia-induced angiogenesis and choke vessels vasodilation in rat models.
Objective To investigate the feasibility and effectiveness of designing wide pedicle of abdominal pedicled flap and repairing large skin defect of upper limb with improved suture method. Methods Between March 2014 and August 2016, 11 cases with hand and forearm skin soft tissue defect were repaired with abdominal pedicled flaps. Among them, 8 cases were male and 3 were female; aged 18-65 years (mean, 38 years). The causes of injury were machinery injury in 7 cases and traffic accident in 4 cases. The wound located at left upper limb in 6 cases and right upper limb in 5 cases. The size of wound ranged from 12 cm×7 cm to 20 cm×10 cm. The interval from injury to operation was 2-5 days (mean, 4 days). Four cases were repaired with lower abdominal flap and 7 with umbilical flap. The size of flap ranged from 10 cm×9 cm to 22 cm×10 cm. And the flap was designed with wide pedicle at width of 8 to 18 cm (mean, 15 cm); then the wound was sutured with improved method. The pedicle was cut after 3 weeks. Results All the flaps survived without congestion, necrosis, and tension blisters. The wound and the incision were both healed at stage Ⅰ. All patients were followed up 4-12 months (mean, 8 months). The skin color, texture, and shape were satisfying, and no ulcer formed. Only line-like scar left at the donor site. Conclusion Abdominal pedicled flap with wide pedicle and improved suture method can reduce the abdominal skin waste, avoid postoperative infection, and be feasible to repair large skin defect of upper limb with advantages of simple operation and reliable fixation.
ObjectiveTo investigate the effectiveness of free-style perforator flap in repairing the soft tissue defect of knee.MethodsBetween December 2011 and October 2017, 13 patients with the soft tissue defects of knees were repaired with the free-style perforator flaps. There were 9 males and 4 females, with an average age of 40 years (range, 14-65 years). The injuries were caused by traffic accident in 7 cases, crushing in 4 cases, and falling from height in 2 cases. The soft tissue defects in 9 cases formed after 2 weeks-2 months (mean, 1 month) of lower extremity fractures fixation. The other 4 cases were urgently admitted to the hospital after injury, and the time from injury to admission was 0.5-18.0 hours (mean, 8 hours). The size of soft tissue defect ranged from 3 cm×2 cm to 12 cm×8 cm after debridement. Nine propeller flaps, 6 rotating flaps, and 2 V-Y advanced flaps were used; and 9 cases were repaired by single flap and 4 cases were repaired by combined flaps. The size of flap ranged from 7.5 cm×2.5 cm to 20.0 cm×6.0 cm. The donor sites were sutured directly.ResultsThe flaps survived smoothly and incisions healed by first intention in 12 cases. The congestion occurred in 1 case, which obtained delayed healing after symptomatic treatment. All incisions at donor sites healed by first intention. All patients were followed up 3-24 months with an average of 6 months. The shape and motions of knee were satisfactory.ConclusionThe free-style perforator flap can maximize the utilization of the donor area around the knee wound, with reliable blood supply, small trauma, and easy operation. It is an ideal flap for the soft tissue defect of knee.
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.
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 investigate the feasibility and effectiveness of thoracodorsal artery perforator (TDAP) flap for repairing serious scar contracture of the opisthenar. Methods Between March 2015 and June 2017, 7 cases of serious scar contracture of opisthenar were repaired with TDAP flaps. There were 5 males and 2 females with an average age of 31 years (range, 11-48 years). The time from injury to operation was 8-67 months, with an average of 42 months. After the relocation of the joint and release of the scar, the size of soft tissue defect ranged from 5 cm×4 cm to 10 cm×8 cm. The size of TDAP flap ranged from 5.5 cm×5.0 cm to 10.5 cm×9.0 cm. Results All flaps survived completely with primary healing at both donor site and recipient site. The flaps of 3 patients were bulky and underwent second-stage skin flap thinning at 3 months after operation. All 7 patients were followed up 6-32 months, with an average of 15 months. The skin flaps were soft and elastic. According to the upper limb function evaluation system recommended by Chinese Society of Hand Surgery, sensory function was classified as \begin{document}$\small{{\rm{S}}_{{{\scriptsize 3}^ + }}}$\end{document} in 2 cases, \begin{document}$\small{{\rm{S}}_{{{\scriptsize 3} }}}$\end{document} in 1 case, \begin{document}$\small{{\rm{S}}_{{{\scriptsize 2} }}}$\end{document} in 3 cases, and \begin{document}$\small{{\rm{S}}_{{{\scriptsize 1} }}}$\end{document} in 1 case. The hand function was excellent in 2 cases, good in 4 cases, and fair in 1 case. There was no significant effect on shoulder movement. Conclusion The TDAP flap is an ideal method for serious scar contracture of opisthenar.
Objective To explore the method of the distal perforator-based gluteus maximus muscle V-Y flap to treat the sacral ulcer and to simplify the operative procedures.Methods From March 2002 to March 2005, 11 cases of sacral ulcer were repaired by distal perforatorbased gluteus maximus muscle flaps. The area of sacral ulcer ranged from 13 cm×11 cm to 18 cm×14 cm. Of 11 cases, 7 were female and 4 were male,whose age ranged from 21 to 69 years, and the disease course was 8 months to 3 years.A triangular flap was designed to create a V-Y advancement flap.The length of the base was made almost equal to the diameter of the defect.The apex of the tringle was located near the great trochanter. The medial part of the flap was elevated as a fasciocutaneous flap by dissecting the layer between the fascia and the muscle.The distal part ofthe flap was elevated by dissecting the layer between the gluteus maximus muscle and the fascia of the deeper muscle group.The flap was advanced to the defect. Results All the flaps survived. After a follow-up of 5 months to 3 years, the bilateral buttocks were symmetry and whose appearance was satisfactory. Except for 1 case dying of other disease, no recurrence of ulcer was observed.All the flaps survived. Conclusion The distal perforatorbased fasciocutaneous V-Y flap for treatment of sacral ulcers is a simple and reliable technique, which has several advantages over the conventional V-Y flap technique,such as excelent excursion,viable coverage with the fasciocutaneous component, high flap reliability, preservation of the contralateral buttock, and preservation of the gluteus maximus muscle function.