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Background: In LASIK (laser in situ keratomileusis), a hinged corneal flap is made, which enables the flap to be lifted and the excimer laser to be applied to the stromal bed. If the hinge of the corneal flap detaches from the cornea, the flap is called a free cap. A free cap is a rare intra-operative complication of LASIK most commonly associated with the use of a microkeratome on corneas with flat keratometry, which predisposes to a small flap diameter. Free caps are preventable and treatable. Rarely does the complication lead to a severe or permanent decrease in visual acuity. Purpose: As free caps are avoidable, prevention is critical. Our video gives some tips and tricks on how to avoid a free flap and also focuses on how to manage a cut through a free flap. Synopsis: If a free cap is created, the surgeon must decide whether to continue with excimer laser ablation or to abort the procedure. When to abort: If the stromal bed is irregular, the flap is replaced without applying laser ablation. Without ablation, generally, there is no change in refractive error or significant loss of visual acuity. When to continue: If the stromal bed is regular and the cap is of normal thickness, the surgeon may proceed with ablation. To prevent desiccation, the free cap should be handled with caution and should be placed on a drop of balanced salt solution. The free cap should be placed epithelial facing up, along with a bandage contact lens. The endothelial cell pump mechanism typically allows the cap to re-adhere tightly. Highlights: Risk factors for a free cap are generally anatomic or mechanical. Especially in flat corneas, an appropriate ring and stop size should be chosen looking at the nomogram on the basis of the keratometry values. Deep orbits and deep-seated eyes should be looked for as PRK is a better option in such cases. Inadequate suction should be dealt with a lot of care, and once this is done, the vacuum should be stopped. Re-docking of the microkeratome with suction can be done again. Prior testing of the microkeratome and a good verbal anesthesia are a few more such important points to be pondered upon. This video gives us such tips and is a comprehensive video for a novice surgeon performing microkeratome LASIK
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RESUMEN Antecedentes: debido al aumento en la expectativa de vida, se ha incrementado la incidencia de tumores de cabeza y cuello en pacientes añosos. Objetivo: evaluar los resultados de la reconstrucción con colgajos microquirúrgicos luego de la resección radical (RRMC) de tumores de cabeza y cuello en pacientes de 70 años o mayores. Material y métodos: se analizó una serie de pacientes sometidos a RRCM por tumores de cabeza y cuello en el período 2000-2020. Se dividió la muestra en dos grupos: G1: ≥ de 70 años y G2: < de 70 años. Se analizaron variables demográficas, quirúrgicas, posoperatorias y factores de riesgo de trombosis del colgajo en los pacientes ≥ de 70 años. Resultados: se incluyó un total de 178 pacientes, 61 en G1 y 117 en G2. Ambos grupos fueron homogéneos respecto del sexo, IMC (índice de masa corporal), alcoholismo, tabaquismo, tratamiento neoadyuvante e incidencia de HPV (virus del papiloma humano). Hubo mayor cantidad de pacientes con riesgo ASA ≥ III en G1 vs. G2; (p: 0,005). En G1, 33 (54%) correspondieron a estadio oncológico ≥ III vs. 99 (87%) en G2 (p: 0,001). Cuarenta y dos (69%) pacientes en G1 recibieron adyuvancia vs. 94 (83%) en G2 (p: 0,02) y no hubo diferencias en la morbimortalidad global y en fallas del colgajo. El sexo femenino fue el único factor de riesgo de trombosis del pedículo vascular (p: 0,05). Conclusión: la RRCM para tumores de cabeza y cuello es factible y segura en pacientes añosos, con una incidencia de morbimortalidad similar a la del resto de la población.
ABSTRACT Background: The higher life expectancy has increased the incidence of head and neck tumors in elder patients. Objective: the aim of this study was to evaluate the outcomes of free flap reconstructions after radical resection (FFRR) of head and neck tumors in patients aged 70 years or older. Material and methods: We analyzed a series of patients undergoing FFR due to head and neck tumors between 2000-2020. The patients were divided into two groups: G1: ≥ 70 years, and G2: < 70 years. The demographic, operative and postoperative variables and the risk factors for flap thrombosis in patients ≥ 70 years were analyzed. Results: A total of 178 patients were included, 61 in G1 and 117 in G2. Both groups were homogeneous regarding sex, BMI (body mass index), alcohol consumption, smoking habits, neoadjuvant treatment, and incidence of HPV (human papillomavirus). The incidence of ASA grade ≥ III was significantly higher in G1 vs. G2; (p: 0,005). In G1, 33 patients (54%) corresponded to cancer stage ≥ III vs. 99 (87%) in G2 (p: 0.001). Forty-two (69%) patients in G1 received adjuvant therapy vs. 94 (83%) in G2 (p = 0.02) and there were no differences in overall morbidity and mortality and in flap failure. Female sex was the only predictor of vascular flap thrombosis (p = 0.05). Conclusion: FFRR in head and neck tumors is feasible and safe in elderly patients, with morbidity and mortality rates similar to those of the general population.
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Abstract Introduction Free flaps have been the preferred method for reconstruction after resection of oral cavity cancer. However, pedicled flaps remain valuable alternatives in appropriate settings. Objective The main objective of the present study was to compare surgical complications, hospital costs, and functional outcomes of oral cavity cancer patients who underwent soft tissue reconstruction with pedicled flaps or free flaps. Methods A total of 171 patients were included in the study. Ninety-eight underwent reconstruction with a pectoralis major, submental, temporalis, or supraclavicular pedicled flap, and in 73 patients, a radial forearm or anterolateral thigh free flap had been used. The cases were retrospectively reviewed, and a comparative analysis was carried out between the two groups. Results Recipient site and flap complications, speech, and swallowing functions did not differ between groups, but donor site complications, operative time, hospital stay, and costs were significantly reduced in the pedicled flap group compared with the free flap group. However, the pectoralis major flap reconstruction resulted in a more inferior swallowing function than the free flap reconstruction. Conclusions With comparable complications and functional outcomes, while decreasing in costs, pedicled flaps are a useful alternative to free flaps in oral cavity cancer reconstruction. However, in an extensive defect (> 70 cm2), free flaps are the reconstruction of choice for the preservation of swallowing function.
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Objective:To explore an early mobilization plan for oral cancer patients after free flap reconstruction and evaluate the application effect of the plan.Methods:This study was a prospective randomized controlled trial. A total of 173 patients undergoing free flap reconstruction surgery from December 2018 to December 2021 in the second ward of Peking University School and Hospital of Stomatology were selected. The patients were randomly divided into the control group (87 cases) and the intervention group (86 cases) by cluster randomized grouping. The control group received the routine nursing plan, that was, head immobilization for 4 days after surgery, and patients performed sat up and off-bed activity on the 5th day. The intervention group received the early mobilization plan, that was, patients sat up on the 2nd day after surgery and performed off-bed activity on the 3rd day. The incidence of vascular compromise, postoperative complications, sleep time in the first 5 days after surgery, catheter removal time, hospitalization duration and expenses were compared between the two groups.Results:The incidence of postoperative pulmonary infection, the daily sleep time in the first 5 days after surgery, the time for removing nasogastric tube, trachea cannula, and urinary catheter were 7.0%(6/86), (5.0 ± 1.0) h/d, (11.8 ± 7.3) d, (6.1 ± 3.2) d, (3.6 ± 0.6) d in the intervention group, and 13.8%(12/87), (4.4 ± 1.3) h/d, (14.2 ± 5.8) d, (7.3 ± 1.7) d, (4.0 ± 0.9) d in the control group, all differences were statistically significant ( χ2 = 3.89, t values were -3.57 - -2.44, all P<0.05). There was no significant difference in the incidence of rascular compromise, hospitalization duration and expenses between the two groups (all P>0.05). Conclusions:For patients undergoing free tissue flap reconstruction, it is safe to sit up on the 2nd day and get out of bed on the 3rd day, which can reduce the incidence of pulmonary infection, improve patient sleep, and shorten the indwelling time of nasogastric tube, trachea cannula and urinary catheter.
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Objective@#To investigate the application value of 3D microscope in vascular anastomosis in oral and maxillofacial surgery, to provide a reference for clinicians. @*Methods @#Eighty-seven cases of free flap reconstruction in oral and maxillofacial surgery were retrospectively included, including 30 cases in the 3D microscope group and 57 cases in the optical microscope group. The differences in intraoperative vascular anastomosis time, postoperative flap survival rate and doctor evaluation scores between the 3D microscope group and the optical microscope group were compared and statistically analyzed, and the feasibility of using three-dimensional microscope in surgery was evaluated. @*Results @#The arterial anastomosis time was (26.53±3.83) min/root in the 3D microscope group and (24.88 ± 2.97) min/root in the optical microscope group, and the difference was statistically significant (P<0.05). The venous anastomosis time was (30.68 ± 3.51) min/root in the three-dimensional microscope group and (28.70 ± 2.91) min/root in the optical microscope group, and the difference was statistically significant (P<0.05). There was no significant difference in the survival rate of flaps between the 3D microscope group (n = 28, 93.33%) and the optical microscope group (n = 53, 92.98%) (P>0.05). The doctor's evaluation scores of visual fatigue, training and learning, operative difficulty index, image sharing in the three-dimensional microscope group were higher than those in the optical microscope group, and the differences were statistically significant (P<0.05). @* Conclusion @# 3D microscope has good reliability and safety in surgery, a strong sense of three-dimensionality, and the convenience of teaching and training. It can be well applied to vascular anastomosis in oral and maxillofacial surgery.
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Abstract Objectives: The Lateral Arm Free Flap (LAFF) offers advantageous features like variable thickness and minimal hair growth. LAFF is primarily used in orofacial and pharyngeal reconstructions, with limited reports on tracheal/esophageal applications. Also, the psychological prognosis and quality of life in patients with LAFF reconstruction are lacking. Methods: This retrospective case series presents outcomes of LAFF reconstruction for head and neck surgical defects which included 19 patients. The disease type, location of reconstruction, TNM staging, tumor size, chemoradiation status, anxiety, depression, quality of life and detailed perioperative information of the LAFF reconstruction surgery were presented in a descriptive pattern. Subgroup analysis was conducted using Mann-Whitney U and Pearson r test Conclusions: The lateral arm free flap exhibits remarkable versatility and multifunctionality, providing advantageous outcomes in head and neck reconstruction. Level of evidence: Level 4 according to OCEBM.
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【Objective】 To study the effect of perioperative allogeneic blood transfusion on patients with oral squamous cell carcinoma (OSCC) after first-stage free flap transplantation. 【Methods】 A total of 306 OSCC patients who accepted primary repair and reconstruction using free flap admitted to our affiliation from January 2010 to January 2019 were selected as the research objects and retrospectively analyzed. According to their clinical data, they were divided into three groups: no transfusion group (n=98), 1-2 U transfusion group (n=131) and 3 + U transfusion group (n=77), respectively. The incidence of complications including flap infection, blood circulation disorder and hematoma in the three groups were compared. The five-year survival rate of the three groups was calculated by Kaplan-Meier analysis, and the relative risk of death was analyzed by Cox regression. 【Results】 There was no statistically significant difference among the three groups of patients (P>0.05) regarding such baseline data as embracing gender, age, primary location, degree of differentiation, adjuvant radiotherapy and chemotherapy. The complication rate of patients with 3 + U transfusion (25.97%) was significantly higher than that of no transfusion (6.12%) and 1-2 U transfusion (10.86%) (P<0.05); and the five-year survival rate of patients with 3 + U transfusion (51.95%) was significantly lower than that of no transfusion (69.38%) and 1-2 U transfusion (62.60%) (P<0.05). The results of univariate analysis showed that age, adjuvant radiotherapy, degree of tissue differentiation, collateral infiltration, vascular invasion and blood transfusion were all factors influencing the quality of prognosis after repair and reconstruction of first-stage free flap transplantation treating OSCC (P<0.05). The results of multivariate analysis showed that adjuvant chemoradiotherapy was an independent protective factor for the prognosis and survival quality of postoperative OSCC patients (P<0.01); the degree of differentiation, vascular invasion and blood transfusion were independent risk factors for the prognosis and survival quality of postoperative OSCC patients (P<0.05). 【Conclusion】 Perioperative allogeneic transfusion in OSCC patients can increase the risk of postoperative complications and directly affect their prognostic quality. It can be regarded as an important risk factor for OSCC patients.
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@#Intraosseous hemangioma is a benign, rare neoplasm that accounts to 0.5 - 1% of all benign tumors of bones.1, 2 While most hemangiomas arise from soft tissues, it is uncommon for it to arise from bones.2 The most common sites of growth are in the vertebral body and the calvarium with frontal bone making up approximately 45% of calvarial cases.2,3 However, they are also encountered in the head and neck with sites such as the skull (53%), mandible (10.7%), nasal bones (9%), and cervical spine (6%).4 In the mandible, the body is mostly affected and 65% are found in the molar and premolar region.1 They are more common in adult females with peaks at the second and fifth decades of life.1-3 Hemangioma of the mandible is difficult to diagnose due to its nonspecific clinical presentation and radiographic features. It mimics various mass lesions in the mandible such as giant cell granuloma, fibrous dysplasia, multiple myeloma, osteosarcoma, ameloblastoma and keratocysts. Therefore, a comprehensive history taking and physical examination plus examination of the imaging studies available and tissue biopsy all play important roles in arriving at the final diagnosis.5 We present the case of an aggressive mandibular hemangioma in a young boy and our management involving a failed fibular free flap reconstruction.
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Sirolimus , SirolimusABSTRACT
In March 1973, the Department of Hand Surgery and Oral Surgery of Huashan Hospital Affiliated to Shanghai First Medical College (now Huashan Hospital Affiliated to Fudan University) jointly carried out the first case of free flap transfer in China. In the past 50 years, Chinese colleagues have been constantly exploring and innovating in the field of microsurgery, and have made great progress, always leading the world. On the occasion of the 50th anniversary celebration, it would like to pay tribute to the predecessors who made contributions to Chinese microsurgery, and also encourage the colleagues in microsurgery to take Professor Yang Dongyue as an example, forge ahead, scale brave heights, and make new contributions to the healthcare of mankind.
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Abstract Objectives: Airway management following maxillofacial microvascular reconstruction is a fundamental part of the perioperative management. In oral cavity microvascular reconstruction, the airway is potentially compromised by airway edema, flap edema or bulkiness, hematoma formation, or upper airway sequelae from surgery. Classical teaching advocates elective tracheostomy in patients undergoing maxillofacial free flap reconstruction, while others keep patients intubated overnight (delayed extubation). The optimal method for perioperative airway management is still debated. This study aim was to evaluate the morbidity associated with elective tracheostomy in patients undergoing maxillofacial microvascular reconstruction and to recognize those patients who can avoid elective tracheostomy. Methods: Retrospective review of patients who underwent maxillofacial microvascular free flap reconstruction, between November 1st 2010 and October 31st 2019 in our center. Results: One-hundred and nine patients underwent microvascular reconstruction in the maxillofacial region. Sixty-one patients underwent an elective tracheostomy upon the primary surgery. Forty-eight patients were left intubated overnight. Seven patients underwent a late tracheostomy which was performed upon a neck re-exploration for postoperative complications, except for one patient which was due to failed extubation attempt. Conclusions: Our results suggest, the routine use of elective tracheostomy in maxillofacial microvascular free flap reconstruction is unnecessary. Elective tracheostomy should be considered on case-to-case basis. Level of evidence: 4. HIGHLIGHTS Airway management following maxillofacial microvascular reconstruction is complex. Lack of consensus exists regarding the optimal airway management perioperatively. Routine use of tracheostomy is unnecessary. Tracheostomy should be considered on a case-to-case basis.
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Las lesiones graves de los dedos con pérdida de sustancia y exposición de estructuras nobles constituyen un desafío para evitar la amputación. Estas situaciones han impulsado el desarrollo de un gran número de colgajos axiales, locales, con el fin de salvar el dígito. Los colgajos libres, tomados a medida, también han sido descritos para dar coberturas adecuadas y de buena calidad. Se presenta el caso de un paciente con lesión grave de dedo anular con exposición ósea y daño tendíneo, con una pérdida de cobertura de 4 4 cm. El paciente fue sometido a una reconstrucción con un colgajo libre del pie, tomando como eje vascular la primera arteria intermetatarsiana. El paciente conservó su dedo con una movilidad a expensas de la articulación interfalángica proximal (IFP), con una piel de buena calidad, pinza firme y sin dolor. La zona dadora no presentó complicaciones. En manos de un equipo entrenado, con indicación adecuada, estos colgajos logran un buen resultado estético y funcional.
Severe finger injuries with loss of substance and exposure of noble structures are a challenge to avoid amputation. These situations have prompted the development of many local axial flaps to save the digit. Customized free flaps have also been described to provide adequate and good-quality coverage. We present the case of a patient with a severe injury to the ring finger with bone exposure and tendinous damage, with a coverage defect of 4 4 cm. The patient underwent reconstruction with a free flap from the foot, taking the first intermetatarsal artery as the donor vascular axis. The patient kept his finger with mobility at the expense of the proximal interphalangeal (PIP) joint, with good-quality skin, firm clamp, and no pain. The donor area did not present complications. In the hands of a trained team, with adequate indication, these flaps achieve a good esthetic and functional result
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Humans , Male , Adult , Surgical Flaps , Finger Injuries/surgery , Metatarsus/blood supplyABSTRACT
OBJECTIVES & AIMS: To determine whether the known risk factors such as comorbidities like diabetes &hypertension, or smoking increase the complications of flap transfer. Whether the type of flap transfer has any effect on flap related complications or onpost-operative rehabilitation of patients.METHODOLOGY:This is a retrospective study conducted at GCS Hospital, Ahmedabad, between January 2020to July 2021. Sample size is 63 patients with oral cavity cancer, out of which 21 underwentPMMC flap reconstruction, 21 underwent free ALT free flap reconstruction and 21underwent Radial free flap reconstruction.CONCLUSION:Risks have not increased complications in free flap or PMMC group in our study. Variousother studies have similar results however a larger patient pool may be needed to assess them.Though the flap related complications & donor site related complications are more withPMMC flap as compared to ALT & Radial free flap, statistically there is no significantdifference. Also, in the functional post-op outcomes there is no statistically significantdifference with PMMC flap, ALT free flap or Radial free flap.
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Supermicrosurgery is a hot topic in the field of microsurgery and reconstruction. The core concept of supermicrosurgery is precision and minimally invasive, which coincides with the concept of maxillofacial reconstruction. Oral and maxillofacial regions play an important role in aesthetics and function, and the structure of oral and maxillofacial tissues is complex. Various types of flaps, especially vascularised free flaps, are required for the repair of various complex maxillofacial defects. However, at present, conventional microsurgery does meet the requirement of mandibular reconstruction in special cases. Super microsurgical technique can further supplement the deficiency of conventional methods of repair and reconstruction in maxillofacial reconstruction. Under the guidance, many new methods of maxillofacial surgery have inevitably emerged. The application of supermicrosurgery in maxillofacial head and neck is still in its early stage, and there are still many difficulties to overcome and many technical issues to be furtherresolved. Supermicrosurgery is not only an advanced technique, but also an advanced concept in surgery. Supermicrosurgery is expected to show its clinical value in oral and maxillofacial reconstruction. In this paper, the application of supermicrosurgery in maxillofacial reconstruction is reviewed and its application prospect is prospected.
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OBJECTIVE@#To discover the factors that may affect the use of selective tracheostomy among patients who have undergone head and neck surgeries with free flap reconstruction, so that the patients will not need tracheostomy nor receive the unnecessary treatment.@*METHODS@#Five hundred and thirty-three patients who had undergone head and neck surgery with free flap reconstruction operated by the same team of surgery at Department of Oral and Maxillofacial Surgery at Peking University School of Stomatology from 2015 to 2016 were reviewed. Three hundred and twenty-one (60.2%) of these patients underwent selective tracheostomy. All the patients' demographic information, operation-related information, prior treatments, comorbidities and complications were recorded and analyzed.@*RESULTS@#The patients with defects of the tongue, mouth floor, oropharynx and bilateral mandible, who underwent neck dissection and with previous radiotherapy and smoking habit were more likely to get selective tracheostomy. Usage of bulky soft tissue flap might also add to the risk of airway obstruction and the need of selective tracheostomy, while other factors were not significantly related to the risk of postoperative airway obstruction and the patients could be kept safe without selective tracheostomy. Most cases without tracheostomy were kept safe except one case, while 8.39% of the patients with tracheostomy suffered from tracheostomy related complications, mainly pneumonia and hemorrhage of the tracheostomy wound, yet none led to serious consequences or even death.@*CONCLUSION@#Selective tracheostomy is not necessary for patients who have undergone head and neck surgeries with free flap reconstruction except that there are defects at the tongue, oropharynx and mandible. Neck dissection, bulky soft tissue flap reconstruction, previous radiotherapy and smoking habit may also add to the risk of postoperative airway obstruction, while a favorable decision would involve a combination of all the above factors to assure the safety of the postoperative airway for the patients undergone head and neck surgeries with free flap reconstruction.
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Humans , Airway Obstruction/surgery , Free Tissue Flaps , Head and Neck Neoplasms/surgery , Postoperative Complications/surgery , Plastic Surgery Procedures/adverse effects , Retrospective Studies , TracheostomyABSTRACT
Background: Extensive composite defects of the oromandibular site involve skin, mandible, soft tissue and oral mucosa. Though many opine that with the coming on of free flap surgery, the pedicled flap is an outdated surgical option, the latter still has its uses. Free flaps are criticized as being medically risky, expensive, and time-consuming. Combining both these flaps in a single surgery would bring in the baggage of all negatives along with the benefits of these flaps.Methods: Over a period of 3 years, 13 patients with expected large composite oral defects after ablative surgery for malignancy were included in the study requiring both skin cover and mucosal lining. A one-stage reconstructive procedure employing combination of free and pedicled flaps was used. Data was abstracted pertaining to cancer demography and surgical outcome.Results: The free fibula osteocutaneous flap (FFOCF)- deltopectoral fasciocutaneous flap (DPF) combination was most commonly used (n=5), secondly by free radial forearm flap (FRAFF)-DPF combination (n=4), FRAFF- pectoralis major myocutaneous flap (PMMF) amalgamation and FFOCF-PMMF (n=2). The complete flap survival rate was 88.5 percent with 3.8% percent total (1 of 26 flaps) and 7.7% partial (2 of 26 flaps) flap failures. Minimum follow-up period was 6 months with 2 (7.7%) recurrences and 2 (7.7%) mortalities.Conclusions: We believe that in combined use of free-flap and pedicled flap procedure for one-stage reconstruction of massive mandibular defects with through-and-through cheek defects is justified because it is safe and effective and improves the quality of life for these patients albeit a bit prolonged surgery which can effectively be shortened with 2 reconstructive team approach as in our study.
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Background: Open fractures of leg classified under type IIIB, those requiring free flap cover could be done as emergency procedure. The ideal timing has still remained controversial. Although it appears imperative to operate early and reduce length of hospital stay, costs, disability adjusted life years and put the patient back on his feet, our study was necessitated in the context of differing views regarding ideal timing of free flap.Methods: The prospective observational study was conducted for duration of 4 years between October 2015 to September 2019. Patients were taken up for free flap cover after optimization for the major surgery. Details of flap complications and the procedures for salvage were noted. At the end of one year following the injury, patient quality of life (PQOL) was tabulated for all patients.Results: Most common mode of injury was road traffic accidents. Early flaps were done in 28 and primary flaps in 22 patients. One patient had partial flap necrosis while 7 others had sub flap collections and partial flap necrosis. Duration of hospitalization was significantly lower in early flap cover group. PQOL measured with EQ-5D (EuroQol 5D) was significantly higher in the early flap covers.Conclusions: From our study we concluded that timing of free flap cover positively influenced clinical outcome of reduced hospitalization, although there was no relation of timing of free flap to flap or bone complications. The functional outcome measured by PQOL was significantly higher in patients who had microvascular reconstruction early.
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The treatment of most fractures of the ulna and radius is usually performed by anatomical reduction and internal fixation, when damage is extensive and local soft tissue cannot provide a complete wound coverage, locoregional flaps present a suitable reconstructive benefit. A 35-year-old male patient suffered an exposed diaphysio-metaphyseal fracture with multi-fragmented distal radius. The patient was evaluated during a 10-day period at the National Institute of Rehabilitation, where the osteosynthesis material and a severe infectious process with necrosis were identified. Necrosectomy of the posterior compartment and removal of the osteosynthesis material was performed, a skin defect of approximately 22x16 cm was observed with a bone gap of 6 cm of radius and ulna. a fibula-free flap is placed to correct the skin defect and an external fixative used for bone alignment. The fibular free flap presents an excellent therapeutic alternative in the resolution of bone gaps with extensive skin defect. Whenever a trained microsurgery team is available, current scales of limb injury should be considered but not utilized for therapeutic approach, always trying to shift amputation as the first option, to the very last one of them.
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BACKGROUND: Wound complications probably result in severe soft tissue defects after total knee arthroplasty, which brings orthopedic surgeon a big challenge. Some treatment options, such as frequent sterile dressings changes, persistent drainage, minor or thorough debridement, negative pressure wound therapy and split-thickness skin grafts, fail to help those quite large and deep wounds around the knee, with exposed fascia or prosthesis, bone, joint, tendon, large vessels and nerve, heal by secondary intention. Under these situations, orthopedic surgeon should consult plastic surgery and propose flap re-construction. OBJECTIVE: To introduce some types of flaps for orthopedic surgeon, so as to help orthopedic surgeon understand and chose flaps logically, and reduce severe consequences caused by soft tissue defect wounds. METHODS: The first author retrieved databases of PubMed, Medline, Wanfang and CNKI for the articles concerning wounds repaired by flap transfer after total knee arthroplasty published before 2019. The key words were "flap, knee, wound" in Chinese and English, respectively. Initially 668 articles were retrieved and 45 eligible articles were included in accordance with the inclusion and exclusion criteria for analysis. RESULTS AND CONCLUSION: (1) Flap reconstruction is widely applied in plastic surgery. It is significant for orthopedic surgeon to recognize the characteristics of each flap. (2) Selecting and designing suitable type of flap according to the three-dimensional structure and position of wounds is helpful for repairing soft tissue defect, reducing the risks of prosthesis exposure, periprosthetic infection, prosthesis removal and even amputation after total knee replacement after total knee arthroplasty.
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Objective: To investigate the effectiveness of free sensate intercostal artery perforator flap for the hand soft tissue reconstruction. Methods: Between March 2010 and September 2015, 19 cases of hand soft tissue defect were repaired with free sensate intercostal artery perforator flap, including 16 males and 3 females, aged from 18 to 53 years, with an average of 35.2 years. The defect was located in the dorsum of the hand in 15 cases and in the palm in 4 cases. The causes of injury were traffic accident injury in 8 cases, hot crush injury in 5 cases, strangulation injury in 4 cases, and avulsion injury in 2 cases. All of them were full-thickness skin and soft tissue defects of hand with exposure of phalanges, tendons, blood vessels, and nerves. The size of defect was 10.0 cm×7.0 cm to 17.0 cm×8.0 cm. There were 12 cases of emergency operation and 7 cases of selective operation. The thickness of flap was 10-25 mm, and the size of the flap ranged from 10.0 cm×7.5 cm to 17.0 cm×8.0 cm. The vascular pedicle of the flap was anastomosed with the snuff nest branch of the radial artery (12 cases), the main radial artery (7 cases), and there accompanying vein, and the intercostal nerve cutaneous branch of the flap was anastomosed with the lateral cutaneous nerve of the forearm. The donor site was closed directly (14 cases) or repaired with medium thickness skin graft (5 cases). Results: All of the flaps and skin grafts survived; the wounds in the donor and recipient sites healed by first intention. All 19 patients were followed up 10- 18 months, with an average of 12.7 months. After operation, the appearance and function of the hand recovered well, and there was no flap bloated. The two-point discrimination of the flap was 7-11 mm, with an average of 8.8 mm. Only linear scars left in the patients with direct closure of the donor site. The sensory function of the donor site was not significantly affected, and the hand function recovered satisfactorily. Conclusion: Free sensate intercostal artery perforator flap is a valuable and reliable technique for the hand soft tissue defect.
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OBJECTIVE@#To evaluate the effect of using free double- leaf perforator flap posterolateral calf peroneal artery in anatomical reconstruction of the oropharyngeal structure after ablation of advanced oropharyngeal carcinoma.@*METHODS@#Twenty-six patients with oropharyngeal defects after ablation of oropharyngeal malignancies were recruited, including 12 with carcinoma in the tongue base, 5 in the latenral pharyngeal wall and 9 in the soft palate. Between July, 2016 and July, 2018, the patients underwent surgeries for reconstruction of the oropharyngeal defects using flaps. The areas of tissue defects repaired by double-leaf perforator flaps ranged from 40.5 to 72.5 cm. Reconstruction was performed for oropharyngeal defects in the soft palate, pterygopalate, parapharyngeal, pterygo- mandibular, and tongue base tissues. The patients' outcomes including mouth opening, functions of deglutition, linguistic function, restoration of palatopharyngeal anatomical structure and postoperative survival were evaluated, and their quality of life was assessed using FACT-H&N scale (Chinese Edition).@*RESULTS@#All the 26 patients with transplantation of the free flaps survived. Six months after the operation, the oropharyngeal function and anatomical structure of the patients were basically restored. The questionnaire survey showed that the patients' physical, social/family, emotional and functional conditions, the total score of the core scale, items scores for the head and neck, and the total score of the scale all improved significantly after the operation compared with those before the operation ( < 0.05).@*CONCLUSIONS@#The free peroneal artery bilobate perforator flap in the posterolateral crus, which seldom has anatomical variations of the blood vessels, allows flexible design and contains rich tissue volume to facilitate defect repair with different approaches and ranges. The application of this flap, which is an ideal perforator flap for reconstruction of the oropharyngeal structure and function, can improve the quality of life of patients following operations for advanced oropharyngeal cancer.