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Reconstruction of lower limb defects is a constant challenge for surgeons, the etiology of the defect can be very variable from diabetic ulcers, traffic accidents, fall from height, oncological resections and many others. Free flaps have always been an important option because it has great results in complex reconstructions in lower limbs, it is a microvascular technique, so it has a higher level of complexity. This technique is usually reserved for extensive perilesional wide defects. On the other hand, the propeller flap, which is considered less invasive and easier as it does not involve microvascular surgery. An 18-year-old patient who had a fracture of the right tibial pylon due to a 7-meter drop, who after orthopedic treatment had a defect with exposure of ostesynthesis material of 3 cm in circumference in the medial malleolus. This defect was first managed with a propeller flap complicated with necrosis at 48 hours which was treated with sub atmospheric pressure system for 5 days and later with an ultra-thin anterolateral flap of the pelvic limb. Complete pedicled propeller flap failure is very rare but, because necrosis develops distally, even partial necrosis can expose bone, tendons, or other tissue. Some surgeons consider that propeller flap placement is risky in this location, especially the distal third of the lower leg a prefer to use free flaps. Whenever any pelvic member reconstruction plan fails in the distal third, the best and safest is the use of microsurgery even with the failure of a previous micro vascular flap.
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Objective To evaluate the clinical results of the thumb dorsoradial flap and the greater thenar flap for coverage of thumb soft tissue defect,and to provide guidance on clinical selection of flaps.Methods From January,2013 to June,2014,23 thumb dorsoradial flaps and 20 greater thenar flaps were used to repair the soft tissues defects in thumbs and were followed up to compare the results.Patient satisfaction,cold intolerance scores,TAM of the reconstructed thumb,sensation (pain and temperature sensation,Semmes-Weinstein monofilament test,static two-point discrimination) and blood perfusion of the flaps were recorded and analyzed statistically.Results Thumb dorsoradial flaps group:patient satisfaction was (36.97 ± 7.70)％,cold intolerance score was 58.96 ± 12.47,TAM of the thumb was (87.57 ± 12.83)°,median Semmes-Weinstein monofilament test was 3.61mm,static two-point discrimination was (14.22 ± 2.84)mm,and blood perfusion was (98.41 ± 15.66) PU.Greater thenar flaps group:patient satisfaction was (50.00 ± 10.80)％,cold intolerance score was 60.45 ± 14.10,TAM of the thumb was (95.00 ± 14.58)°,median Semmes-Weinstein monofilament test was 4.31mm,static twopoint discrimination was (20.70 ± 2.56)mm,and blood perfusion was (104.74 ± 14.12)PU.The greater thenar flap had a larger degree of satisfaction than the dorsoradial flap (P ＜ 0.05).Both pain and temperature sensation of the flap were regained in all cases,but the dorsoradial flap presented better Semmes-Weinstein monofilament score and static two-point discrimination(P ＜ 0.05).No differences were found regarding TAM of the thumb,cold intolerance score and blood perfusion of the flap (P ＞ 0.05).Conclusion The dorsoradial flap is suitable for repairing the thumb pulp defect due to its good sensation.For the small defect of non-functional dorsal area,the greater thenar flap will be a satisfactory method.
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Objective To investigate the clinical effects of the sural nerve and saphenous nerve nutrient vascular island flaps in repairing pediatric ankle or foot soft tissue defect.Methods From June 2009 to January 2013,19 cases of heel soft tissue defect were collected in hospitalized children,in which 10 cases of ankle or foot soft tissue defects were repaired with reversed sural nerve nutrient vascular island flaps and 9 cases with ankle or foot soft tissue defects with reversed saphenous nerve nutrient vascular island flaps.The skin defect areas were from 3 cm× 5 cm～5 cm× 13 cm.Results All neurocutaneous vascular flaps survived after transplantation,the wound of donor area and recipient area healed,and texture and color of flap were good.The postoperative follow-up for 3-30 months (an average 14 months) showed no secondary infection,sensory recovery for S3-S4,texture and color were similar to normal skin,and the limb shape and function were satisfactory.Conclusions The sural nerve and saphenous nerve nutrient vascular island flaps are reliable of blood supply,which do not damage the main vessel,and could reconstruct feeling.Such flaps are ideal to repair foot or ankle soft tissue defects.
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Objective To investigate the effects of changing the arteriovenous pressure difference on the survival area of reverse island flap in New Zealand white rabbits models.Methods The saphenous artery and saphenous vein of New Zealand rabbits were selected to design experimental models of reverse island flap.Experi mental rabbits were randomly divided into 4 groups:group A:control group (reserved pedicle integrity of superficial veins);group B:part anastomosis of saphenous artery group (the distal saphenous artery of the flap was cut,then trimmed its original diameter to half and done end-to-end anastomosis);group C:part anastomosis of vein group (distal superficial veins was cut,then trimmed its original diameter to half and done end-to-end anastomosis);group D:ligated superficial veins group (pedicle superficial veins was ligated).After surgery,the flaps were measured by general observation.Blood distribution at different times of the flaps was detected by radionuclide scans.Survival area of the flap was measured to compare the survival rate of flap.Distribution of blood vessels and the state of blood cells were observed by Histological examination.Results The flap survival rate was (82.27-± 11.71)％ in group B,showing significant differences when compared with that group A (47.70-± 11.18)％,group C (47.70 ± 11.18)％ and group D (47.70 ± 11.18)％ (P ＜ 0.05).Radionuclide scans showed that the radioactive material in group B could be seen clearly,the radioactive material in groups A,C and D were a transient existence.Ten days postoperatively,histological observation showed that group B had more capillary regeneration and blood cells remain compared with other groups.Conclusion Increase the blood supply can increase the survival area of the reverse island flap,and simply promote the venous drainage can not effectively improve the survival rate of the flap.
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Objective To explore a surgical treatment of skin defects on the thumb by reverse-flow island flaps on dorsal thumb web with dorsoulnar artery of thumb as a pedicle.Methods The origin,courses and distribution of dorsoulnar artery of thumb from 70 adult cadaveric hand specimens perfused by red latex were explored.Skin defects on the thumb of 8 cases were repaired with reverse-flow island flaps on dorsal thumb web.The cut areas of flaps vary from 4.5 cm × 3.0 cm to 7.5 cm × 4.0 cm.Results There were 4 types of the dorsoulnar artery of thumb basing on the origin and courses.Type Ⅰ was outside the first dorsal interosseous muscle type,which was the dorsoulnar artery of thumb mainly originated from the first dorsal metacarpal artery and cross through the surface of the first dosal interosseous muscle(42.9％).Type Ⅱ was under the first dorsal interosseous muscle type,which was from the thumb principal artery or deep branch of radial artery and run under the first dorsal interosseous muscle(41.4％).Type Ⅲ was mixed type from the anastomose point of above two arteries at the level of the first metacarpophalangeal joint(11.4％).Type Ⅳ was absence type (4.3％).Eight flaps fully survived.Excellent texture and satisfying appearance of the flaps as well as normal thumb web function were verified after 8 months' follow-up.Conclusion It is significant to determine the type of dorsoulnar artery of thumb to decide different operations due to the artery's considerable variation.The reverse-flow island flap on dorsal thumb is an ideal method to repair soft tissue defect on the thumb for its convenient operating and little effect in the donor area.
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ObjectiveTo analysis the clinic outcome(similarities & differences, indication and caution)of repairing fingertip soft tissue defect with two kind of reverse digital artery island flaps with the palmar cutaneous branch of proper digital nerve.MethodsFrom January 2000 to Auguest 2008, all 500cases (514 fingers) were repaired with reverse homodigital artery island flap (263 fingers of 250 cases) and reverse cross finger digital artery island flap(251 fingers of 250 cases).All cases were followed up from 3-8years,compared with flap range,finger extension,sensory rehabilitation,et al. ResultsAll flaps (A & Bgroup) of 500 cases (514 fingers) survived.According to flap range,cross finger flap was better than homodigital flap (P ＜ 0.05); according to finger extension,homodigital flap better than cross finger flap (P ＜0.05); according to sensory rehabilitation,homodigital flap little better than cross finger flap(P ＜ 0.05); according to long-term follow-up, all had no obviously different (P ＞ 0.05).ConclusionHomodigital flap can cover distal soft tissue defect less than 2.0 cm× 2.5 cm, cross finger flap is a better choice for more than 2.0cm×3.0cm of distal soft tissue defect. According to the flap cover area, cross finger flap is first choice,and to finger extension & sensory rehabilitation,homodigital flap is first choice; accoding to finger movements,two kinds of flaps are all good choice.
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objective To explore a new method of repairing skin defects complicated with fracture and tendon rupture at the middle and distal sections of the second to fifth fingers. Methods The reversed dorsal metacarpal island flap was designed to be pedicled on the digital proper artery-common digital artery-fingerweb artery-dorsal metacarpal artery-cutaneous branch of dorsal metacarpal artery.In repairing digital palmar skin defects,after the flap was dissected,the proximal incision was extended along the direction of dorsal metacarpal nerve to harvest an enough length of the nerve so that the dorsal metacrppal nerve can be anastomosed with the digital proper nerve to restore the sensation of finger pulp.From the June 2003 to March 2009,the flap was used to repair 26 fingers in 24 patients with middle and distal digital skin defects complicated with fracture and tendon rupture.They were 17 men and 7 women,aged from 16 to 63 years (average,37 years).There were 15 cases of palmar skin defect and 9 cases of dorsal skin defect.In the 2 cases of combined tendon defects,a section of the extensor tendon of index(or little) finger was dissected together with the flap to repair the tendon rupture. Results The areas of the flap ranged from 3.1 cm ×1.6 cm to 6.0 cm × 4.0 cm.The flaps survived in all 24 cases without any vascular crisis.Twenty-two patients obtained an average follow-up of 14 months (from 4 to 32 months) but 2 were lost to the follow-up.The flaps were fine in texture,colour and appearance.The finger pulps appeared full and recovered sensations of pain and temperature.The average two-point discrimination was 7.5 mm (from 5 to 9 mm).Sensory function evaluation revealed an outcome of S3 + ～ S4.Tendon adhesion occurred in 4 cases which recovered digital function following secondary lysis 3 to 6 months postoperation. Conclusion Application of the reversed dorsal metacarpal island flap pedicled on the digital proper artery is a good way to repair skin defects complicated with fracture and tendon rupture at the middle and distal sections of the second to fifth fingers.
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Objective To explore the effects of applying microsurgical technique in the one-stage urethroplasty for hypospadias with longitudinal preputial island flaps of dorsum penis. Methods Forty-two hypospadias cases with obvious phallocampsis were reviewed. The patients aged from 1 to 19 years (median, 6.4 years). Among them, 6 cases were of coronary suleus type, 28 cases of pe-nis body type, and 8 cases of penis and scrotum type. All patients went through the operative proce-dures by microscope with four-times magnification and microsurgical instruments. Longitudinal prepu-tial island flaps of dorsum penis was employed for the treatment of 33 cases of these patients, and 9 cases underwent longitudinal preputial island flaps of dorsum penis combined scrotal septal pedicle flaps. Results Thirty-eight cases were cured by one-time surgery (90.5%). One case with urethral fistula after operation was cured by surgical repair of urethral fistula. Two cases with urethral meatus stricture after operation and one with urethral stoma stricture were cured by dilatation. Patients were followed for 9 to 52 months (mean, 27 months). Conclusion Use of microsurgical technique with longitudinal preputial island flaps of dorsum penis in one-stage urethroplasty for hypospadias improved the success rate of surgery with few complications.
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Objective To propose the cause and management of necrosis in reversed island flap or distally-pedicled flap. Methods From June 2000 to June 2009, 120 cases with skin and soft tissue defect were repaired using reversed island flap or distally-pedicled flap. In 12 cases the flaps partial necrosis, to analysis the cause of necrosis. Results One hundred and eight cases survived completely in 120 patients,flap necrosis in 12 cases. 3 cases fully necrosis, in which venous disorders cause flap necrosis in 2 cases, arterial blood disorder caused necrosis of flap in 1 case. Partial necrosis in 9 cases, in which dorsal metacarpal artery reversed island flap in 1 case, digital artery reversed island flap in 1 case, posterior tibial artery reversed island flap ankle epithelial branch in 4 cases, medial leg perforating branches of reversed island flap in 1 case, superficial peroneal nerve vascular reversed island flap island flap in 1 case, distally-pedicled based sural neurocutaneous flap in 1 case, after debridement and dressing change subeschar healed in 7 cases, by the other flaps were cut close to rerepair necrotic wounds in 2 cases. Conclusion Blood circulation barrier is the main reason to flap necrosis, improper handling of pedicle is another important reason of flap necrosis,which cannot be ignored.
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PURPOSE: The lower leg often has poor vascularity, proximity to bone, and insufficient soft tissue. The island flaps offer a feasible one stage reconstruction and has a remarkable vascularization and high quality results for soft tissue defect with or without bony problems to occur on regions below the knee. So we reported our experience of island flaps with review of the literatures. METHODS: We reconstructed 29 cases of soft tissue and 2 cases of bony defect on regions below the knee by using various island flaps at our hospital from December, 1991 to January, 2006. We used 2 fibular osteocutaneous island flaps, 15 reverse sural island flaps, 6 extensor digitorum brevis muscular island flaps, 2 medial plantar island flaps, 5 saphenous island flaps, and a dorsalis pedis island flap. RESULTS: Partial necrosis was developed in 4 out of 15 reverse sural island flaps and 1 out of 5 saphenous island flaps, but they were healed with secondary skin graft. There was partial loss of skin graft on the donor sites in 2 cases. CONCLUSION: Island flaps are very useful for reconstruction of regions below the knee because island flaps have good vascularity and less risk of infection. Generous flap size, easy operative technique, lower cost, shorter operative time, and minimal morbidity at the donor site are other advantages. We attained satisfactory results.