Apply ultra-thin lobulated anterolateral thigh perforator flap in repairing of large soft tissue defect in foot: a report of 8 cases / 中华显微外科杂志

Objective:Exploring the clinical efficacy of using ultra-thin lobulated anterolateral thigh perforator flap(ALTPF) with retrograde separation of perforating vessels from the superficial and deep junction layer of the superficial fascia to repair large soft tissue defects in the foot.Methods:From August 2021 to November 2022, 8 patients (5 males and 3 females) were admitted to the Second Department of Hand and Foot Surgery, the Affiliated Central Hospital of Dalian University of Technology. The patients were 28 to 52 years old in age. The soft tissue defects were located in dorsal and plantar foot. At the plantar foot, the wound involved the weight-bearing area with explosion of bone, tendon or internal fixtures. The area of soft tissue defects was 6.0 cm × 5.0 cm - 16.0 cm × 8.0 cm, and the sizes of ALTPF were 8.0 cm ×5.5 cm - 18.0 cm × 8.5 cm. Preoperative high frequency CUD combined with CTA angiography were employed to locate the 2 flap perforator vessels. By keeping the perforator vessels at center and according to the soft tissue defect area and the wound shape, an ALTPF with a proper size and shape was designed in anterolateral thigh. The perforator were separated in the boundary layer between superficial and deep fascia, where it helped to obviously thin the flap. After the flap was harvested, it was further lobulated between the 2 perforators into 2 lobes after having confirmed the effective blood supply. Finally the lobulated ALTPF was transferred to covered the defect in foot. Cautions should be taken to ensure that the flap covered the weight-bearing area of foot. All the donor sites were directly sutured. Postoperative follow-up was conducted to observe the survival of flaps and the functional recovery of the reconstructed site, also to evaluate the clinical effect. Postoperative follow-up included outpatient visits and reviews over WeChat or telephone. Recovery of the ankle motor function was evaluated according to the American Orthopedic Foot and Ankle Societ (AOFAS) ankle-hind foot score scale.Results:All 8 ALTPF survived. Over 6 to 18 months (10.8 months in average) of follow-up, the transferred flaps had good blood supply, soft in texture, with good elasticity and thin in appearance. Appearance and function of donor sites recovered well, except 1 patient who had mild scar hyperplasia. The plantar flap had good abrasion resistance. No flap damage, bleeding or granulation tissue hyperplasia occurred when walking. The mean score of AOFAS ankle-hind foot score achieved 95.6.Conclusion:The application of ultra-thin lobulated ALTPF with retrograde separation of perforating vessels from the superficial fascia at the junction layer for repairing large soft tissue defects in the foot has good clinical efficacy.

Novel application and evaluation of superficial circumflex iliac artery perforator flap / 中华显微外科杂志

Objective:Verstaile free superficial circumflex iliac artery perforator flap(SCIAPF) were adopted for various reconstructive scenarios, and its clinical effect and value was evaluated.Methods:Retrospective analysis was performed on 42 patients with tissue defects admitted in the Department of Orthopeadic of the Second Affiliated Hospital of Wenzhou Medical University from January 2015 to May 2019. Nine patients had injury in the foot, 8 in ankle, 8 in calf, 7 in forearm, 9 in hand, and 1 in the mouth. All of the defects were repaired by SCIAPF, including 28 single soft tissue defect wounds, 8 multiple soft tissue defect, and 6 composite defects. The size of soft tissue defect were 1.2 cm×1.8 cm-14.0 cm×20.8 cm. The size of flaps were 1.5 cm×2.0 cm-15.3 cm×22.3 cm. The patients entered follow up by outpatient clinic visit and telephone reviews to observe the survival of the flaps, functional recovery and complications.Results:In this series, there were 28 flaps, including 18 pedicled with superficia branch of superficial circumflex iliac artery, 2 pedicled with deep branch of superficial circumflex iliac artery, and 8 pedicled with 2 branches. Six were chimeric flaps. Among them, 4 flaps were iliac bone flaps with superficial branch of superficial circumflex iliac artery flaps, and 2 were superficial iliac circumflex artery flap with sartorius muscle flap. Eight cases were resurfaced with lobulated SCIAPF. Arterial anastomoses: end-to-side in 35 arteries and end-to-end in 7 arteries. Venous anastomosis: end-to-end in 27 veins and end-to-side in 15 veins. Venous return through superficial iliac circumflex vein in 25 flaps, through venae comitantes in 12 flaps and through both in 5 flaps. All flap donor sites were sutured directly. All flaps survived uneventfully except for one that compromised with end-to-side anastomotic dehiscence and bleeding, and survived after re-anastomosis. All flaps and donor sites healed primarily. During the follow-up of 6-24(mean, 11.5) months, the pliable flaps were ruddy in colour and soft in texture, without obvious bloatness and pigmentation. The donor site healed well with linear scars in 35 cases and mild scar hyperplasia in 7 cases. The donor hip function were normal. Three patients suffered a numbness of the thigh caused by intraoperative injury lateral femoral cutaneous nerve and it disappeared completely after 3 months.Conclusion:New applications of lobulated or chimeric SCIAPF, based on the SCIA vasculature or its branches, can meet most of the clinical repair requirement.

Effectiveness of lobulated pedicled rectus abdominis myocutaneous flap for repairing huge chest wall defect / 中国修复重建外科杂志

OBJECTIVE@#To explore the effectiveness of lobulated pedicled rectus abdominis myocutaneous flap to repair huge chest wall defect.@*METHODS@#Between June 2021 and June 2022, 14 patients with huge chest wall defects were treated with radical resection of the lesion and lobulated pedicled rectus abdominis myocutaneous flap transplantation for reconstruction of chest wall defects. The patients included 5 males and 9 females with an average age of 44.2 years (range, 32-57 years). The size of skin and soft tissue defect ranged from 20 cm×16 cm to 22 cm×22 cm. The bilateral pedicled rectus abdominis myocutaneous flaps in size of 26 cm×8 cm to 35 cm×14 cm were prepaired and cut into two skin paddles with basically equal area according to the actual defect size of the chest wall. After the lobulated pedicled rectus abdominis myocutaneous flap was transferred to the defect, there were two reshaping methods. The first method was that the skin paddle at the lower position and opposite side was unchanged, and the skin paddle at the effected side was rotated by 90° (7 cases). The second method was that the two skin paddles were rotated 90° respectively (7 cases). The donor site was sutured directly.@*RESULTS@#All 14 flaps survived successfully and the wound healed by first intention. The incisions at donor site healed by first intention. All patients were followed up 6-12 months (mean, 8.7 months). The appearance and texture of the flaps were satisfactory. Only linear scar was left at the donor site, and the appearance and activity of the abdominal wall were not affected. No local recurrence was found in all tumor patients, and distant metastasis occurred in 2 breast cancer patients (1 liver metastasis and 1 lung metastasis).@*CONCLUSION@#The lobulated pedicled rectus abdominis myocutaneous flap in repair of huge chest wall defect can ensure the safety of blood supply of the flap to the greatest extent, ensure the effective and full use of the flap tissue, and reduce postoperative complications.

Repair of multiple defects of foot and ankle with lobulated chimeric perforator flap pedicled with descending branch of lateral femoral circumflex artery: Report of 6 cases / 中华显微外科杂志

Objective:To investigate the clinical effect of lobulated chimeric perforator flap pedicled with descending branch of lateral circumflex femoral artery (d-LCFA) in repair of multiple composite tissue defects of the foot and ankle.Methods:From February 2017 to March 2021, a total of 6 patients with foot and ankle multiple site deficiency injuries were treated in the Department of Hand Surgery, Shenzhen Hospital of Integrated Traditional Chinese and Western Medicine. The area of the soft tissue defect was 14.0 cm×9.0 cm~28.0 cm×9.0 cm. The size of the flap were 15.0 cm×10.0 cm-29.0 cm×10.0 cm. In all the cases, the wounds were complicated with bone defects and different degrees of infection. After primary debridement, VSD was used for continuous lavage and drainage. In the second stage, the defect was repaired with a lobulated chimeric perforator flap of d-LCFA. The colour, texture and sensory recovery of flap were observed in the scheduled postoperative follow-up.Results:All flaps survived smoothly without vascular crisis. After 10-12 months of follow-up, no recurrence of infection was found. The flaps had no pigmentation, soft in texture, with non-bloated appearance, good wear resistance, and recovered part of sensation. According to the British Medical Research Council (BMRC) hand sensory function evaluation standard, the sensation recovered to S 1-S 2. Conclusion:The lobulated chimeric perforator flap pedicled with d-LCFA only requires microanastomosis with 1 vascular pedicle. It simultaneously covers wounds in different depths at multiple sites and is also anti-infective. It is an ideal flap for repairing multi-site composite tissue defects of foot and ankle.

Computer assisted design of lobulated perforator flap based on descending branch of lateral circumflex femoral artery in reconstruction of heel defects / 中华显微外科杂志

Objective:To investigate the feasibility and clinical effect of the computer assisted design of the lobulated perforator flap based on the descending branch of lateral circumflex femoral artery(d-LCFA) to reconstruct the soft tissue defects of heel.Methods:From October 2014 to November 2016, a computer assisted virtual technology was used to simulate the process of pre-operative design, isolation, and harvest of d-LCFA perforating flaps. This method was used to guide the design and harvest of the flap of d-LCFA in the repair of large-area soft tissue defects of the heel in all of the 5 patients. One patient received a combine flap of the d-LCFA flap and the perforating branch of the inferior abdominal artery flap(DIEPF). Heel appearance and function were reconstructed in phase I together with the repair of the defect. Donor site was directly sutured. The recovery effect was followed-up in the clinic.Results:The 3D visualised model of the vessels in the donor area for quadriceps artery was successfully established in all 5 patients, and the design and removal of the perforating flap were successfully guided. All the 10 flaps survived successfully in 5 patients, except 1 patient had a backflow disorder at the distal end of the inferior epigastric artery perforator flap, with partial necrosis and II grafting. After 6 to 12 months of follow-up(mean, 8.7 months), the flap showed good in colour and texture, with satisfactory heel appearance. The donor site was left with a linear scar.Conclusion:Computer assisted design technology can effectively help in the design of the polyfoliate perforator flap pedicled with d-LCFA, using this technique to assist the design and repair of large area soft tissue defect of heel could reconstruct the shape of heel in phase I and restore the function of the heel to the maximum extent.

3D-CTA assisted anterolateral thigh lobulated perforator flap in repairing soft tissue defect of limb:11 cases report / 中华显微外科杂志

Objective To investigate the effectiveness of preoperative 3D-CTA in assisting the preparation of free thinned anterolateral thigh lobulated perforator flap with nerve in repairing soft tissue defect of limb. Methods Between February, 2010 and May, 2018, free super-thin anterolateral thigh lobulated perforator flap with nerve was transferred to repair soft tissue defect of limbs in 11 cases. There were 8 males and 3 females with an average age of 35 (range, 22-56) years.The defect area was 8.0 cm×11.0 cm-9.0 cm×23.0 cm. Preoperation CT scan of the free flap donor site was performed to obtain 3D images of the region with arterial blood supply by digital 3D reconstruction CT, and to determine the origin, direction, classification, length, diameter and the position of pedicle perforator.Postopera鄄tive regular followed-up was carried according to the Upper Limb Function Evaluation Trial Standards of Chinese Medical Association of Hand Surgery and Enneking Evaluation System. Results All 11 flaps survived. No vascular crisis happened.All 11 cases were followed-up for 3 to 12 (average, 5) months.The flaps were supple and elastic with near normal color.There was no bulkiness.Sensory function was recovered well and two point discrimination was 3.0-6.0 mm. According to the Upper Limb Function Evaluation of Upper Limb of Chinese Medical Association of Hand Surgery, the results were excellent in 1 case, good in 3 cases and fair in 1 case.The Enneking system was used to as鄄sesse the lower limbs recovery.The average score was 21, an average of 70% of limb function restored. Conclusion The free super-thin anterolateral thigh lobulated perforator flap with nerve offers advantages to the traditional antero鄄lateral thigh flap. The survived flaps are ideal in terms of covering limb defects and restoring functions. Preoperative 3D-CTA in the anterolateral thigh perforator flap transplantation is an accurate and useful method.It helps a safer and successful operation with optimal outcome.

Transplantation of lobulated free latissimus dorsi flap for repairing irregular soft tissue defect of shank / 中华显微外科杂志

To investigate the feasibility and clinical effects of lobulated free latissimus dorsi flap in repairing severe shank trauma with irregular soft tissue defect. Methods Eight patients with soft tissue defect of shank due to trauma were treated from February, 2013 to November, 2018, which were 5 males and 3 females. All wounds were irregular.The size of soft tissue defect ranged from 11.0 cm×15.0 cm to 15.0 cm×23.0 cm, with different degrees exposure of deep tissue such as bone and tendon. Five cases out of 8 were infected wound, 3 cases of which had internal fixation bracket exposed. Five infected wounds were firstly treated with negative pressure after debride-ment, then repaired with flap transplantation until the infection were completely controlled. Other wounds were re-paired directly after debridement. The free lobulated latissimus dorsi flap was designed and applied to repair the ir-regular soft tissue defect of shank.The lobulated latissimus dorsi flap with the outer branch of the thoracodorsal artery ranged from 14.0 cm×7.0 cm to 24.0 cm×8.5 cm.The lobulated latissimus dorsi flap with the inner branch of the tho-racodorsal artery ranged from 10.0 cm×5.0 cm to 15.0 cm×7.0 cm. When cutting the flap, the branch vessels should be protected to insure the continuity of the thoracodorsal artery. After spliced the 2 lobulated flaps, the thoracodorsal arteriovenous was anastomosed with the recipient region arteriovenous. All the donor sites were sutured directly. All patients were followed-up by outpatient and telephone regularly. Results Seven flaps survived well.Only 1 case of partial necrosis appeared at the distal edge of the lobulated flap and healed after wound care. All patients were fol-lowed-up from 3 to 30 months, averaged of 14 months. The texture of flap was flexible and the appearance was well. Only a linear scar was left in the donor site. The shoulder joint retained good mobility. Conclusion The lobulated latissimus dorsi flap has rich blood supply, concealed donor area and high survival rate after transplantation, which can flexibly repair the irregular soft tissue defect of the shank, and effectively prettify the appearance of the recipient area. This strategy has little effect on the appearance and function of the donor area, and worthy of promoting in clinic.

3D-CTA assisted anterolateral thigh lobulated perforator flap in repairing soft tissue defect of limb: 11 cases report / 中华显微外科杂志

Objective@#To investigate the effectiveness of preoperative 3D-CTA in assisting the preparation of free thinned anterolateral thigh lobulated perforator flap with nerve in repairing soft tissue defect of limb.@*Methods@#Between February, 2010 and May, 2018, free super-thin anterolateral thigh lobulated perforator flap with nerve was transferred to repair soft tissue defect of limbs in 11 cases. There were 8 males and 3 females with an average age of 35 (range, 22-56) years. The defect area was 8.0 cm×11.0 cm-9.0 cm×23.0 cm. Preoperation CT scan of the free flap donor site was performed to obtain 3D images of the region with arterial blood supply by digital 3D reconstruction CT, and to determine the origin, direction, classification, length, diameter and the position of pedicle perforator. Postoperative regular followed-up was carried according to the Upper Limb Function Evaluation Trial Standards of Chinese Medical Association of Hand Surgery and Enneking Evaluation System.@*Results@#All 11 flaps survived. No vascular crisis happened. All 11 cases were followed-up for 3 to 12 (average, 5) months. The flaps were supple and elastic with near normal color. There was no bulkiness. Sensory function was recovered well and two point discrimination was 3.0-6.0 mm. According to the Upper Limb Function Evaluation of Upper Limb of Chinese Medical Association of Hand Surgery, the results were excellent in 1 case, good in 3 cases and fair in 1 case. The Enneking system was used to assesse the lower limbs recovery. The average score was 21, an average of 70% of limb function restored.@*Conclusion@#The free super-thin anterolateral thigh lobulated perforator flap with nerve offers advantages to the traditional anterolateral thigh flap. The survived flaps are ideal in terms of covering limb defects and restoring functions. Preoperative 3D-CTA in the anterolateral thigh perforator flap transplantation is an accurate and useful method. It helps a safer and successful operation with optimal outcome.

A Human Cadaveric Study On Incidence And Morphology Of Anatomical Variations Of Kidney And Ureter With Emphasis On Its Embryological, Genetic And Clinical Significance

Background: Kidneys are amongst the common sites of congenital abnormalities and anatomical variations.Congenital anomalies of kidney and urinary tract (CAKUT) constitute approximately 20 to 30% of all anomaliesidentified in the prenatal period and a leading cause of renal failure in children. The common variationspertaining to kidney are polycystic kidney, unascended kidney, horseshoe kidney with fused upper or lower pole,atrophic kidney, lobulated kidney, malrotated kidney, bifid pelvis or ureter, most common being bifid pelvis andpancake kidney is a very rare variant.Materials and Methods: Fifty human adult cadavers were included in our study; observed and studied over aperiod of three years in the Department of Anatomy, Grant Govt. Medical College, Mumbai, during routinedissection.Results: In our study we found, 01.01% of renal agenesis, 01.01% of fused pelvic or pancake kidney, 01.01% ofmalrotated kidney, 02.02% of unascended kidneys, 05.05% hypoplastic or atrophic kidneys, 07.07% lobulatedkidneys, 05.05% polycystic kidneys, 02.02% of bifid pelvis and 03.03% of triplicate pelvis.Embryological basis: The development of kidney begins at the fourth week of gestation; the failure of properinductive interaction between the ureteric bud and the metanephric blastemal can lead to various congenitalanomalies. Anomalies can result due to abnormal development, ascent, rotation and migration.Genetic basis: CAKUT are either sporadic, familial, syndromic or non-syndromic. Transcription factor ‘WT1’produced by mesenchyme of the metanephric blastemal helps in epithelialization of ureteric bud. Congenitalabnormality occurs when there is mutation of genes that regulates the expression of WT1.Conclusion: Renal anomalies are one of the commonest anomalies which may remain unnoticed till adulthood.The knowledge of anatomical variations of kidney and ureter is of utmost importance for surgical anduroradiological interventions. Hence an early detection and proper follow-up may be helpful in better managementand increased survival rates.

Free lobulated lateral circumflex femoral artery perforator flap for foot and ankle defect at non-weight bearing area / 中华整形外科杂志

Objective@#To investigate the feasibility and efficacy of free lobulated lateral circumflex femoral artery perforator flap for foot and ankle defect at non-weight bearing area.@*Methods@#From January 2008 to June 2016, 28 cases with foot and ankle skin and soft tissue defects at non-weight bearing area were treated, including 16 cases with traffic accident, 8 cases with machine injury, and 4 cases with falling injury. There were 10 cases with Achilles tendon exposure, 16 cases with dorsalis pedis tendons exposure and 12 cases with bone exposure. The defect size ranged from 10 cm×8 cm to 16 cm×13 cm. Doppler ultrasound detector was used to select two perforators of lateral femoral circumflex artery. The lobulated perforator flap was designed and harvested as one flap. After clip test was performed to make sure the blood supply of flap, the flap was segmented and repositioned to cover the wound. The width of lobulated flaps was less than 8cm, in order to close the defect at donor sites directly. Postoperative rountine anti-inflammatory, anticoagulant, anticonvulsive treatment and function exercise were adopted. The patients were followed up for 6-28 months.@*Results@#The flap size ranged from 9.0 cm×4.5 cm to 17.0 cm×7.0 cm. Partial necrosis happened at the end of one flap lobe due to pressure, which healed after dressing. All the other 27 flaps survived completely with satisfactory cosmetic and functional result. The wounds at donor sites all healed primarily.@*Conclusions@#Free lobulated lateral circumflex femoral artery perforator flap is one of the ideal flaps with high survival rate and low complication for foot and ankle defect at non-weight bearing area.

Lobulated Bowen's Disease with a Clear Cell Change

Bowen's disease usually manifests as a slowly enlarging erythematous scaly patch or plaque. An uncommon variant of Bowen's disease showing a verrucous appearance has been reported and a distinct variant with a prominent clear cell change on histopathology, in addition to a verrucous surface change, was also reported. We describe novel form of Bowen's disease having a cerebriform appearance and showing histopathologically a significant clear cell change and propose that the clinical term “lobulated Bowen's disease” would be compatible for the description of this unique clinical variant. From a histopathological point of view, the precise definition and etiopathogenesis of the clear cell change in Bowen's disease should be elucidated.

Clinical and Pathological Heterogeneity of Korean Patients with CAPN3 Mutations

PURPOSE: This study was designed to investigate the characteristics of Korean patients with calpainopathy. MATERIALS AND METHODS: Thirteen patients from ten unrelated families were diagnosed with calpainopathy via direct or targeted sequencing of the CAPN3 gene. Clinical, mutational, and pathological spectra were then analyzed. RESULTS: Nine different mutations, including four novel mutations (NM_000070: c.1524+1G>T, c.1789_1790inA, c.2184+1G>T, and c.2384C>T) were identified. The median age at symptom onset was 22 (interquartile range: 15-28). Common clinical findings were joint contracture in nine patients, winged scapula in four, and lordosis in one. However, we also found highly variable clinical features including early onset joint contractures, asymptomatic hyperCKemia, and heterogeneous clinical severity in three members of the same family. Four of nine muscle specimens revealed lobulated fibers, but three showed normal skeletal muscle histology. CONCLUSION: We identified four novel CAPN3 mutations and demonstrated clinical and pathological heterogeneity in Korean patients with calpainopathy.

Four Cases of Lobulated Intradermal Nevus: A Sign of Aging Melanocytic Nevus

Melanocytic nevi are subject to change with age in both clinical and histopathologic findings. In 1991, Cho et al. first reported three cases of lobulated intradermal nevi and suggested their cases represented an unusual form of regressing melanocytic nevus. Herein we report four cases of lobulated intradermal nevus and review previous literature.

A Case of Congenital Lobulated Intradermal Nevus / 대한피부과학회지

Lobulated intradermal nevus is a rare subtype which has distinct clinicopathological findings and is similar to a regressing melanocytic nevus. A 22-year-old female presented with a lobulated 6.5 x 8.5 cm sized black plaque on her right shoulder. This had been present since birth and had grown slowly with a darkening change in colour. A skin biopsy revealed a fatty infiltration within the nest of nevus cells, dermal fibrosis and neuroid differentiation of the nevus cells.

A Case of Congenital Lobulated Intradermal Nevus / 대한피부과학회지

Lobulated intradermal nevus is an unusual form of regressing melanocytic nevus. Clinically, it shows a lobulated plaque and biopsy specimens display fatty infiltration within nests of nevus cells, dermal fibrosis and neuroid differentiation of nevus cells. We report a case of lobulated intradermal nevus resembling linear epidermal nevus in a 45-year-old female patient.