ABSTRACT
Objective:To investigate the clinical effect of a 3D reconstruction assisted preoperative optimal design of anterolateral abdomen cross-region free perforator flaps for repair of soft tissue defects of limbs.Methods:Twenty patients who were treated for soft tissue defects of hand, forearm, foot and ankle in the Department of Hand Surgery, the Sixth Hospital of Ningbo from October 2017 to January 2020 were included in this study. Among the patients,17 had soft tissue defects in hand and forearm and 3 with composite tissue defects including ankle and soft tissue defect of foot. The sizes of soft tissue defects in limbs ranged from 6 cm × 8 cm - 36 cm × 18 cm. Twenty free cross-area perforator flaps were optimal designed with CTA and 3D assisted reconstruction before surgery. Following combinations of flaps were designed: (1) Free perforator flap with inferior abdominal artery and superior abdominal artery; (2) Free perforator flap with superficial iliac circumflex artery and deep iliac circumflex artery; (3) Free perforator flap with superficial iliac circumflex artery and inferior abdominal wall perforator artery; (4) Free perforator flap with perforators of superficial iliac circumflex artery plus superficial abdominal artery; (5) Free perforator flap with perforating artery of lower abdominal wall and superficial artery of abdominal wall. The overall nutritional area of a combined flap were 272.3 cm 2± 12.5 cm 2, 107.4 cm 2± 9.3 cm 2, 193.6 cm 2± 24.2 cm 2, 155.2 cm 2± 20.1 cm 2 and 203.7 cm 2± 16.3 cm 2, respectively. All the donor sites were sutured directly in one stage. The appearance, texture, blood supply, colour, joint movement of affected limbs, recovery and function of donor sites were observed through postoperative follow-up visits at the outpatient clinic. Results:Among the 20 anterolateral transventral perforator flaps, 18 flaps survived successfully; One had partial necrosis after surgery, and healed after dressing change. Subcutaneous haematoma occurred in 1 flap, and survived after drainage. In this study, there was no postoperative infection of flap. A total of 19 flaps healed in one stage, except 1 that had a delayed healing and the flap wound was closed after dressing change for 1 week. According to Disability of Arm, Shouder and Hand (DASH) questionnaire evaluation, which is widely used in the world to evaluate the therapeutic effect after limb injury, combined with the 6-12 months of follow-up, the functional recovery of 17 patients with upper limbs iniury was 7 in excellent, 9 in good and 1 in poor. The overall excellent and good rate achieved 94.1%. All the 3 patients with foot injury recovered well, and the walking and jumping were not significantly affected. The results were all excellent according to the Maryland Foot Function Scoring. Sensation of flaps was evaluated according to the British Sensory Function Evaluation, it showed: 3 in S 2, 15 in S 3 and 2 in S 3+. All 20 flaps had good blood supply, in soft texture, good colour, feeling, thickness and movement. The donor sites all healed well. Conclusion:Combined with an optimal preoperative design, the perforator flap of anterior lateral wall cross-region can obtain a satisfactory clinical efficacy in repair of large area soft tissue defects. It is a feasible treatment method.
ABSTRACT
Objective:To investigate the microsurgical anatomy of thoracodorsal artery perforators, and the clinical effect in repairing the soft tissue defect of hand with the thoracodorsal artery perforator flap (TAP).Methods:From October, 2014 to November, 2014, the axillary arteries in 10 thoracodorsal specimens were perfused with red latex. The number and diameter of the perforators of the thoracodorsal arteries were mearsured. From January, 2015 to February, 2019, 52 cases of soft tissue defects in hand combined with bone and extensor tendon exposure were repaired with TAP. The patients were followed-up in outpatient department to observe the clinical efficacy.Results:The number of perforators of thoracodorsal artery was 2-4 mostly, and 3 perforators was the most. The diameter of perforators was 0.22-0.68 mm, and the distance between the perforating point and the posterior axillary wall was 5.2-11.8 cm. All the operations were completed successfully, and the donor sites were closed directly. In 52 cases, 48 flaps survived, 2 had partially necrosis, and 2 had completely necrosis. The patients were followed-up for 5 to 24 months. The blood supply of the flaps was good with soft texture and good appearance.Conclusion:The TAP is an ideal flap because of its thin in thickness, concealed donor area and no obvious scar after direct suture.
ABSTRACT
Objective To evaluate the significance of surgical exploration for the refractory arterial crisis daring the hypersensitive period (48 h to 96 h) after replantation of severed fingers.Methods One hundred and seventy-one patients experienced refractory arterial crisis during the hypersensitive period after replantation of the proximal thumb from February 1995 to February,2005 in our department.Eighty-seven of them were managed with surgical exploration,including incision injury (n=6),saw injury (n=17),rotation and avulsion injury (n=30), and crush injury (n=34).Eighty-four cases received conservative treatment,including incision injury (n=6),saw injury (n=16).rotation and avulsion injury (n=29),and crush injury (n=33).In the surgery group,the e- mergent explorations were performed as soon as the refractory arterial crisis arose,If arterial spasm or/and thrombosis were found,the involved parts were resected before the artery ends were anastomosed or the finger artery was repaired by cubital vein graft.In the other group,conservative managements were carried out by using intramuscular injection of 30 mg Papaverine and intravenous injection of 20,000-unit Urokinase in 20 mL normal saline.If symptums were not alleviated after half an hour,the procedures were repeated.The conservative managements also included abirritative antipsychotics and analgesia of anodyne.Meanwhile,the survival state of all the digital replants was observed. Results In the surgery group,78 fingers survived,the surviving rate being 89.7%.In the conservative group,41 fingers survived with a surviving rate of 48.8%.The difference was statistically significant (P＜0.01).No obvious complications happened in the two groups.Conclusion Since surgical exploration is crucial to management of refractory arterial crisis during the hypersensitive period after replantation of severed fingers,it should not be readily abandoned.