Application of the plasmatrix in alveolar ridge preservation / 口腔疾病防治

@#After tooth extraction, significant absorption occurs in the soft and hard tissues of the alveolar ridge. The goal of alveolar ridge preservation is to maintain the volume and shape of the alveolar ridge's soft and hard tissues as much as possible so as to provide suitable conditions for implant placement. Currently, there are challenges in classifying the socket for alveolar ridge preservation, such as the difficulty in directly guiding the selection of graft materials and clinical procedures and the insufficient space for particle xenograft maintenance, resulting in poor bone regeneration. Plasmatrix is an autologous blood derivative that effectively enhances tissue regeneration. This article introduced the characteristics of soft and hard tissue defects after tooth extraction and the primary applications of plasmatrix for alveolar ridge preservation (liquid plasmatrix, solid plasmatrix membrane/plug, and plasmatrix bone blocks) as well as the proposed methods for the reclassification of sockets for alveolar ridge preservation based on soft and hard tissue defects at the extraction site to facilitate the creation of clinical recommendations. The proposed classifications are as follows: Class I, extraction socket without bone defect, with or without soft tissue defect; Class Ⅱ, extraction socket with bone defect, both sides with bone wall defect less than 50%, with or without soft tissue defect; Class Ⅲ, extraction socket with bone tissue defect, at least one side with bone wall defect greater than 50%, with or without soft tissue defect. For the Class I socket, a solid plasmatrix membrane or plug is inserted, followed by injection of liquid plasmatrix, using a double-layer solid plasmatrix membrane for socket closure; for the ClassⅡ socket, plasmatrix bone blocks are inserted, followed by injection of liquid plasmatrix and secondary solidification, using absorbable collagen membrane and double-layer solid plasmatrix membrane for socket closure; for the ClassⅢ socket, tenting screws are used to maintain height, followed by implantation of plasmatrix bone blocks, injection of liquid plasmatrix and secondary solidification, using absorbable collagen membrane and double-layer solid plasmatrix membrane for socket closure. The aim of this article is to provide comprehensive knowledge of plasmatrix for oral clinicians to serve as a reference to simplify the clinical decision-making process and procedures for alveolar ridge preservation.

Ischemia-reperfusion injury of free tissue flaps, airway management, and prognosis in oral cancer patients / 口腔疾病防治

@#Free tissue flap transplantation is the preferred option for repairing and reconstructing postoperative defects in oral and maxillofacial-head malignant tumors. However, challenges remain for oral and maxillofacial-head and neck oncology surgeons in terms of ischemia-reperfusion (I/R) injury, airway management, quality of life and prognosis. I/R injury is an inevitable complication of free-flap transplantation surgery. In addition to shortening the vascular anastomosis time as much as possible during the surgical process, many studies have attempted to further prevent and treat free-flap I/R injury using physical intervention therapy, antioxidant and reactive oxygen species (ROS) scavenger therapy, hyperbaric oxygen therapy, etc. However, there is a lack of large-scale clinical randomized controlled trial evidence to further support these methods. Postoperative tracheal management of patients receiving free tissue flap transplantation is very important. In recent years, delayed extubation has been proposed as an alternative to traditional tracheostomy. This method can facilitate wound care for patients, reduce infections, speed up patient recovery, and reduce the incidence of vascular crises. In the future, such management is expected to improve the practicality and safety of delayed extubation by formulating more appropriate patient selection criteria and intensive care plans. Preoperative selection of suitable free tissue flaps according to the defect for repair and reconstruction is beneficial for improving the quality of life and survival rate of patients. At the same time, for patients who require postoperative radiotherapy, reducing the complications of postoperative radiotherapy and improving the quality of life of patients can be achieved through intraoperative nerve anastomosis, preradiation oral hygiene maintenance, early speech training, and other methods.

A V-Y shaped flap with digital artery nerve at metacarpophalangeal joint was used to repair the defect of middle and distal phalanx / 中国骨伤

OBJECTIVE@#To explore a surgical method for the reconstruction of volar soft tissue defect and sensory and vascular repair in middle and far phalangeal digits.@*METHODS@#From January 2016 to January 2020, a total of 14 patients , 9 males and 5 females, ages ranging from 22 to 69 years old, and with volar soft tissue defects in the middle and distal digits 2 to 4, underwent surgical reconstruction using the V-Y shaped flap with digital artery and nerve at the metacarpophalangeal joint. The defect area was (2.0~2.5) cm×(1.5 ~2.0) cm. The procedure involved the harvest of a V-Y shaped flap with the digital artery and nerve from the metacarpophalangeal joint. Flap design, dissection of blood vessels and nerves, and anastomosis with the digital artery and nerve were performed according to a standardized protocol., Functional exercise of affected finger was initiated 3 weeks postoperatively. Subsequent assessments were conducted to evaluate finger pulp sensation, shape and other relevant parameters. According to the upper extremity functional evaluation standard set up by Hand Surgery Branch of Chinese Medical Association, the surgical outcomes were evaluated.@*RESULTS@#All 14 cases demonstrated successful tissue transplantation, , with immediate recovery of sensation observed in 10 cases with distal finger pulp defects. Four patients with middle phalangeal defects experienced gradual sensory recovery within 2 to 3 months postoperatively. Thirteen patients were followed up for a mean duration of (8.8 ± 4.49) months, during which satisfactory outcomes were observed. The average two-point resolution of the finger pulp was 4-6mm, and sensory function evaluation yielded a score of S3 or above. Patients exhibited realistic finger shape, normal skin color and temperature, good wear resistance, and cold resistance. Furthermore, finger joint function was essentially normal.@*CONCLUSION@#The V-Y shaped flap with digital artery and nerve at the metacarpophalangeal joint offers a suitable solution for repairing the defect of the middle or distal phalangeal finger. This technique is characterized by its simplicity, low risk, and favorable outcomes, including restored finger shape, blood supply and sensation. Moreover, high patient satisfaction was achieved.

Clinical application of Flow-through bridge anterolateral thigh flap in repair of complex calf soft tissue defects / 中国修复重建外科杂志

OBJECTIVE@#To investigate the effectiveness of Flow-through bridge anterolateral thigh flap transplantation in the treatment of complex calf soft tissue defects.@*METHODS@#The clinical data of the patients with complicated calf soft tissue defects, who were treated with Flow-through bridge anterolateral thigh flap (study group, 23 cases) or bridge anterolateral thigh flap (control group, 23 cases) between January 2008 and January 2022, were retrospectively analyzed. All complex calf soft tissue defects in the two groups were caused by trauma or osteomyelitis, and there was only one major blood vessel in the calf or no blood vessel anastomosed with the grafted skin flap. There was no significant difference between the two groups in general data such as gender, age, etiology, size of leg soft tissue defect, and time from injury to operation ( P>0.05). The lower extremity functional scale (LEFS) was used to evaluate the sufferred lower extremity function of the both groups after operation, and the peripheral blood circulation score of the healthy side was evaluated according to the Chinese Medical Association Hand Surgery Society's functional evaluation standard for replantation of amputated limbs. Weber's quantitative method was used to detect static 2-point discrimination (S2PD) to evaluate peripheral sensation of the healthy side, and the popliteal artery flow velocity, toenail capillary filling time, foot temperature, toe blood oxygen saturation of the healthy side, and the incidence of complications were compared between the two groups.@*RESULTS@#No vascular or nerve injury occurred during operation. All flaps survived, and 1 case of partial flap necrosis occurred in both groups, which healed after free skin grafting. All patients were followed up 6 months to 8 years, with a median time of 26 months. The function of the sufferred limb of the two groups recovered satisfactorily, the blood supply of the flap was good, the texture was soft, and the appearance was fair. The incision in the donor site healed well with a linear scar, and the color of the skin graft area was similar. Only a rectangular scar could be seen in the skin donor area where have a satisfactory appearance. The blood supply of the distal limb of the healthy limb was good, and there was no obvious abnormality in color and skin temperature, and the blood supply of the limb was normal during activity. The popliteal artery flow velocity in the study group was significantly faster than that in the control group at 1 month after the pedicle was cut, and the foot temperature, toe blood oxygen saturation, S2PD, toenail capillary filling time, and peripheral blood circulation score were significantly better than those in the control group ( P<0.05). There were 8 cases of cold feet and 2 cases of numbness on the healthy side in the control group, while only 3 cases of cold feet occurred in the study group. The incidence of complications in the study group (13.04%) was significantly lower than that in the control group (43.47%) ( χ 2=3.860, P=0.049). There was no significant difference in LEFS score between the two groups at 6 months after operation ( P>0.05).@*CONCLUSION@#Flow-through bridge anterolateral thigh flap can reduce postoperative complications of healthy feet and reduce the impact of surgery on blood supply and sensation of healthy feet. It is an effective method for repairing complex calf soft tissue defects.

Repair of soft tissue defect at flap donor site with keystone flap in 12 cases / 中华显微外科杂志

Objective:To explore the clinical effect of keystone flap (KF) on repair of soft tissue defects at the donor site after flap transfer.Methods:From October 2020 to December 2022, in the Department of Microsurgical Rapair of First Affiliated Hospital of Xinjiang Medical University, 12 patients were repaired with KF after transfer of flaps. There were 3 donor sites for lateral thigh myocutaneous flap, 3 for sural nerve nutrient vascular flap, 4 for latissimus dorsi myocutaneous flap and 2 for medial supramalleolar island flap. Size of the KF was 15.0 cm × 12.0 cm-30.0 cm × 20.0 cm. Types of KF were: 3 of type I, 5 of type IIA, 2 of type IIB and 2 of type Sydney Melanoma Unit (SMU) modification KF design. Four patients were reviewed by telephone follow-up, 5 by WeChat and 3 with outpatient clinic visits to observe the appearance of the transferred KF and postoperative complications. Appearance of flaps was scored and analysed using Vancouver Scar Scale (VSS) and Scar Cosmesis Assessment and Rating (SCAR) .Results:The average follow-up period was 15.9 (2-27) months. The colour and texture of the transferred KF were similar to that of the surrounding skin, together with good sensation recovery. No complication such as osteofascial compartment syndrome, necrosis, wound dehiscence and venous congestion occurred in all patients. At the final follow-up, the scores for VSS was 2.17±0.58 and the score for SCAR was 5.33±1.23, with satisfactory repairing outcomes.Conclusion:As a relay flap, the KF is a simple and effective flap for reconstruction of the defects at the donor site and it can avoid complications that can be caused by direct closure of the soft tissue defect or a wound dehiscence after skin grafting.

Flap of distal cutaneous perforator of medial plantar artery in reconstrution of destructive defect in the base plane of proximal phalange of great toe / 中华显微外科杂志

Objective:To investigate the clinical effect of perforator flap of distal cutaneous perforator of medial plantar artery in recon struction of destructive defect in the base plane of proximal phalange of great toe.Methods:Twenty-six patients were treated in the Department of Foot and Ankle Surgery of Xuzhou Renci Hospital from September 2017 to December 2021. The patients were 24 males and 2 females, aged 26 to 60 years old. There were 12 defects in left foot and 14 in right foot. All the defects were the residual wounds at the first metatarsophalangeal joint with the defect at 2.0 cm × 3.0 cm - 4.0 cm × 5.0 cm in size. The flaps pedicled with distal cutaneous perforator of the medial plantar artery were used to repair the defects, with a size at 3.2 cm× 4.2 cm in average. Skin grafts were employed to repair the donor sites. Postoperative patient management including lifting the affected limbs and keeping warm, anti-infection, detumescence, anti-coagulation and pain relief.Results:All patients were entered in postoperative follow-up at outpatient clinic for 1-3 years. Twenty-two flaps survived after surgery, except 4 that had dark purple edge indicating venous congestion. Blood supply of the flap was regained after the tension of the flap was relieved by interval suture removal. Appearance of flaps was good, without obvious swelling nor pigmentation, good in elasticity, in hard texture and with good wear resistance. Patients showed no limp of the affected limbs, and without restriction in wearing shoes or walking. The function of feet was evaluated according to the American Orthopedic Foot and Ankle Societ (AOFAS) I50, with 24 patients in excellent and 2 in good.Conclusion:The anatomy of the flap pedicled with distal cutaneous perforator of the medial plantar artery is relatively constant. It provides a blood supply and does not affect the trunk of major artery. The flap has a thick skin cuticle hence it is wear-resistant. This flap provides a choice to the repair of a defect at proximal segment of great toe.

3D reconstruction assisted preoperative optimal design of anterolateral abdomen cross-region free perforator flap for repair of soft tissue defects in limbs / 中华显微外科杂志

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.

Short term efficacy of 3D printed individualized prosthesis for precise reconstruction of bone and joint defects after upper limb microsurgical repair / 中华显微外科杂志

Objective:To evaluate the efficacy of 3D printed individualised prosthesis in treating bone and joint defects in upper limbs remained after earlier microsurgical repairs.Methods:From June 2019 to September 2021, 12 patients were treated in the Institute of Orthopaedic Trauma of PLA, the 80th Group Army Hospital for bone and joint defects in upper limb that had been remained after earlier repairs with soft tissue flaps. The defects were: 1 in completely severed wrist, 2 defects of digit metacarpal bone, 4 defects of interphalangeal joint, 4 defects of bones in radiocarpal joint and 1 defect of lunate bone. The area of soft tissue defect ranged from 1.5 cm×3.0 cm to 12.0 cm×18.0 cm, and the length of bone defects ranged from 2.5 to 8.5(average 3.64) cm. For incompletely severed and completely severed limbs, replantation of severed limbs (digits) were performed in the primary surgery and the repair of soft tissue defects were performed in the second stage surgery. The remaining defects of bone and joint were reconstructed by 3D printed individualised prostheses in the third stage surgery. Finger soft tissue defects were covered with a local flap in the primary surgery, and bone and joint defects were reconstructed with a 3D printed prosthesis in the second surgery. Finger soft tissue defects were covered with a local flap in the first phase, and bone and joint defects were reconstructed with a 3D printed prosthesis in the second phase. After the surgery, the bone integration between the broken end of the bone joint defect and the prosthesis was determined based on the X-ray results and the Paley fracture healing score standard. Simultaneously measured the Total Active Motion(TAM) of the forearm and hand joints. At 1, 2, 3, 6, 9 and 12 months after hospital discharge. Follow-up X-ray examinations were taken followed by examinations on the recovery of soft tissues and bones. The upper limb function was graded according to the Evaluation Trial Standards of Upper Limb Partial Functional of Hand Surgery of Chinese Medical Association.Results:Postoperative follow-up at outpatient clinic lasted for 6 to 26 months, with an average of 11.5 months. All flaps were free from necrosis and infection, also there was no infection in bones and joints. According to the Paley fracture healing scale, 10 patients were in excellent and 2 in good. In addition, according to the Evaluation Trial Standards of Upper Limb Partial Functional of Hand Surgery of Chinese Medical Association, 5 patients achieved upper limb function in excellent, 5 in good and 2 in fair. The ranges of motion of the affected wrists were 30°-42°(average 37.3°) for the implanted prostheses of distal end of radius and the radial shaft. Wrist flexion 40° to 55°(average 43.5°). The range of motion of finger and wrist was 60° to 70°(average 65.7°) with a metacarpal and phalangeal bone prosthesis.Conclusion:3D printed individually customised prostheses are safe, accurate and effective in repair of the remained bone and joint defects in upper limbs after primary and early stages of microsurgical flap repairs. It can effectively restore anatomical structures of bone and joint in upper limbs.

Progress in application of propeller flap in reconstruction of soft tissue defect of oral and maxillofacial-head and neck / 中华显微外科杂志

Oral and maxillofacial-head and neck soft tissue defects affect the appearance of patients, as well as pronunciation, swallowing and other functions. Introduction of the propeller flap in 1991 has improved reconstruction procedures for oral and maxillofacial-head and neck soft tissue defects. A propeller flap has several advantages over traditional local flaps. It improves mobility, colour and texture matching for maxillofacial defect, surgical procedure, and individual satisfaction. Therefore, it can be used as a complement to the traditional flap by providing surgeons with more options. This paper reviews the classification, surgical procedures, and recent clinical applicatiosn and indications of the propeller flap.

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.

Discussion on the concept of "precision flap surgery" / 中华显微外科杂志

There are great variations in tissue defects and vascular anatomy. How to find the best solution for pre-repair of tissue defect is a challenge of flap surgery. "Precision flap surgery" is based on high-throughput and high-accuracy imaging information, comprehensive evaluation of recipient and potential donor sites, selection of the best repair plan, accurate implementation of precise surgical procedures, therefore to achieve precise and personalised repair of tissue defects. Precision flap surgery is the continuation and development of traditional flap surgery, and must comply with the bases of theory, surgical procedures and principles applied in current flap surgery. This paper describes the concept, connotation, thinking mode and method of "precision flap surgery" with examples.

Anatomy of the perforator propeller flap of superior lateral genicular artery and its clinical application in repair of soft tissue defect of anterolateral knee / 中华显微外科杂志

Objective:To study the anatomy of the perforator propeller flap of superior lateral genicular artery, and to explore a surgical method and clinical application in repair of the soft tissue defect of anterolateral knee with the flap.Methods:From September 2019 to September 2021, 8 knees of 4 chilled fresh specimen of adults were studied. The perforators of the superior lateral genicular artery were observed. The length, outer diameter of the perforators, and the locations of the skin perforation were recorded. The superior lateral genicular artery perforator propeller flaps were then applied clinically to 5 patients(3 males and 2 females) with soft tissue defects of anterolateral knee. Two of the patients had combined ligament injury and(or) bone joint exposure. The age of patients ranged from 25 to 48 years old, at 33.4 years old in average. The sizes of soft tissue defects ranged from 4.0 cm×4.0 cm to 8.0 cm×5.0 cm. The sizes of perforator propeller flaps of superior lateral genicular artery were 10.0 cm×5.0 cm to 13.0 cm×6.0 cm. The superior perforating vessels of the superior lateral genicular artery were found and marked at the points of skin perforation. Preoperative contrast-enhanced ultrasound were performed to confirm the dominant perforating vessels and had the skin perforating points marked. Intraoperative CDU were further performed to confirm the points of dominant perforating vessels. Perforator propeller flaps were designed depending on the size of the anterolateral soft tissue defect, and flaps were prepared and transferred to the defect sites. Postoperative follow-ups were conducted at outpatient clinic. The survival of the flap and knee function were observed according to the Bai-ly knee scoring.Results:The anatomy showed that an average pedicle length of the superior lateral genicular artery perforator was(8.2±0.9) cm, with an average starting outer diameter at(1.1±0.2) mm. All 5 flaps survived during the follow-up that lasted for 10 to 24 months, with an average of 15.3 months. All flaps healed in 2 weeks after surgery without complications such as soft tissue infection, bone and joint infection were observed. At the last follow-up, no obvious bloated appearance of the flaps were observed. The colour and elasticity of the flaps were similar to the surrounding skin. The knee function was assessed: 4 patients were in excellent and 1 in good. The range of knee flexion and extension was from 100° to 150°. The patients were satisfied with the appearance and function of the knees.Conclusion:The size of the perforator of superior lateral genicular artery and the pedicle length are ideal. The propeller flap can be used to repair the soft tissue defect around the anterolateral knee, with satisfactory functional recovery of a knee. It is a good method to repair the soft tissue defect around anterolateral knee.

Comparison between free wrist crease flap pedicled with superficial palmar branch of radial artery and traditional free toe flap in reconstruction of hand soft tissue defects: A study on clinical efficacy / 中华显微外科杂志

Objective:To compare the difference in clinical efficacy between a free wrist crease flap pedicled with superficial palmar branch of the radial artery flap (SPBRAF) and a traditional free toe flap (TFTF) in reconstruction of hand soft tissue defects, and to provide reference for the treatment of small-to medium-sized hand soft tissue defects.Methods:Data of 37 patients who received hand surgery in Department of Hand Surgery, No.971 Hospital of the PLA Navy from December 2016 to December 2019 for small-to medium-sized hand soft tissue defects were retrospectively studied. Among the 37 patients, there were 32 males and 5 females, aged between 18 and 65 years old, with 41.5 years old in average. According to the reconstructive surgical procedure, patients were divided into SPBRAF group (22 cases) and TFTF group (15 cases). Regular follow-ups were conducted after surgery. The difference in curative effect at the last follow-up between the 2 groups was evaluated by the comparison of data acquired in follow-up. SPSS 25.0 was used to analyse the data statistically. The evaluation indicators included flap survival, long-term recovery of flap, recovery effect at donor site, total active movement(TAM) of the affected digit, time of hospital stay and the time return to work. P<0.05 was considered a statistically significant. Results:All free flaps survived. All patients were entered 6-18 (mean, 10) months of postoperative follow-up to comprehensively evaluate the therapeutic effect. According to the Evaluation Trial Standards of Upper Limb Partial Function of Hand Surgery of Chinese Medical Association, in the SPBRAF group, 20 flaps were found in excellent, and 2 in good; in the TFTF group, 14 flaps were found in excellent, 1 in good. There was no statistical difference between the 2 groups( P>0.05). The colour, texture and thickness of flaps between the 2 groups were either in excellent or good. There was no statistical difference between the 2 groups( P>0.05). TPD in the TFTF group (5-6 mm) was better than that in SPBRAF group (6-7 mm) with statistical difference between the 2 groups ( P<0.05). Texture at donor sites between the 2 groups was either in excellent or good ( P>0.05). In terms of appearance, sensation and recovery time of donor site, it was found that the SPBRAF group(mean, 6 weeks) was significantly better than those in the TFTF group(mean, 8 weeks) and there was statistical difference between the 2 groups ( P<0.05). In terms of recovery of TAM in single-digit, excellent or good were shown in both groups and there was no statistical difference between the 2 groups ( P>0.05). In terms of hospitalisation and time for return to work, the SPBRAF group(mean, 8 days and 17 weeks) was significantly better than that of TFTF group(mean, 12 days and 24 weeks), and there was statistical difference between the 2 groups ( P<0.05). Conclusion:SPBRAF has an ideal effect on reconstruction of small-to medium-sized hand soft tissue defects in hand. Although the flap is still inferior in sensation and appearance compared with the TFTF, the advantages in terms of donor site recovery, patient satisfaction of the donor site and reduced time of hospitalisation and return to original work are more obvious. SPBRAF provides a good complement to surgical procedures reconstructing a digit defect.

Coryoint flap of lower abdominal wall for covering extremely large soft tissue circular defects on limbs / 中华显微外科杂志

Objective:To investigate the results of coryoint flap harvested from lower abdominal wall for covering extremely soft tissue circular defects on limbs.Methods:From March 2018 to June 2020, 15 patients who suffered from severe degloved injury were admitted into the Department of Hand Surgery, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University. The injuries were characterised as extreme circular defects on limbs. The dimension of defects ranged from 25.0 cm×9.0 cm to 30.0 cm×18.0 cm. All wounds were taken through emergency debridement and managed by VSD. Using lower abdomen as a donor site, a conjoined flap was dissected when the wound surface became granulating. The perforator vessels of the flaps included vessels of deep inferior epigastric artery(DIEA), superficial inferior epigastric artery(SIEA) and superficial circumflex iliac artery(SCIA). The donor sites were primary closed. Postoperative follow-ups were conducted by the surgeons in the same surgical team at outpatient clinic.Results:Fourteen flaps survived completely without significant complications. Distal necrosis occurred in 1 flap, which healed with a skin graft in the second stage surgery. All flaps were reviewed during the postoperative follow-up that lasted for 18-24(mean 20) months. The aesthetic outcomes were achieved on the recipient site without hairy nor hyper-pigmentation. A concealed linea scare left at the donor sites without hernia and limited function. At the last follow-up, 5 patients were in excellent and 2 in good evaluated by following the Disabilities of the arm, shoulder and hand(DASH). With the Lower extremity functional scale(LEFS), 5 patients were in excellent and 3 in good.Conclusion:The simultaneous reconstruction of extremely large soft tissue circular defects on limbs with best possible salvage surgery can be achieved by a conjoined flap. A conjoined flap offers a concealed donor site, easy to design, flexible perforators design and larger size of soft tissue.

Pedicled latissimus dorsi flap in reconstruction of large soft tissue defect around elbow: An efficacy evaluation / 中华显微外科杂志

Objective:To evaluate the efficacy of pedicled latissimus dorsi flaps in reconstruction of large soft tissue defects around elbow.Methods:From January 2012 to January 2022, 12 patients with large soft tissue defects around elbow received reconstructive surgery with pedicled latissimus dorsi flaps in Department of Microreconstructive Surgery, The First Affliliated Hospital of Xinjiang Medical University. Partial latissimus dorsi flaps were employed to reconstruct The soft tissue defects around the posterolateral side of elbow in 6 patients. Functional reconstruction of anteromedial soft tissue defect around elbow with functional latissimus dorsi myocutaneous flap combined with biceps muscle dynamic reconstruction was performed on other 6 patients. All patients were males and aged 18 to 57 years old, at 31.4 years old in average. Causes of injury: machine strangulation in 5 patients, traffic accident in 4 patients, machine crush in 2 patients, and fall from height in 1 patient. Injured sites: 5 patients had injury on right elbow and 7 on the left. The size of soft tissue defect ranged from 18.0 cm×10.0 cm to 51.0 cm×13.0 cm. The size of the flaps were at 30.0 cm×7.0 cm-55.0 cm×14.0 cm. The wounds at donor site were directly sutured. Follow-up included postoperative reviews via telephone, WeChat and visit to outpatient clinic. Mayo elbow performance scores(MEPS) at the last follow-up were recorded.Results:All 12 flaps survived, and all donor and recipient sites healed at stage I. The follow-ups lasted for 3 months to 2 years for all patients, with 18 months in average. Three months after operation, 1 patient underwent additional surgery for flap reduction due to a bloated flap and poor appearance. Six patients who received dynamic reconstruction myocutaneous flaps achieved grade IV in elbow flexion. Six patients with lateral elbow repaired with partial latissimus dorsi myocutaneous flap showed that the appearance of the flap was not bulky and had no effect on the flexion and extension function of the elbow joint. All flaps survived well at the last follow-up, with soft texture and colour close to the surrounding normal skin. All donor sites healed well, leaving only linear scars. Motion of all elbows was good. The MEPS at the final follow-up was(90.6±6.4), with 10 patients in excellent and 2 in good.Conclusion:According to the location of elbow joint soft tissue defect, different types of latissimus dorsi myocutaneous flaps are used for reconstruction, which can achieve good clinical results.

Curative effect of wide pedicled double-vessel flap of posterolateral calf in repair of soft tissue defect in hind foot / 中华显微外科杂志

Objective:To explore the curative effect of wide pedicled with double-vessel flap of posterior lateral calf in repair of soft tissue defect in hind foot.Methods:From January 2018 to June 2021, 12 patients with soft tissue defects on hind foot were reconstructed with double-vessel flaps pedicled perforator of peroneal artery and sural nerve nutrient vessels in the Department of Trauma Orthopaedics, No.940 Hospital of Chinese People's Liberation Army Joint Service Support Force. The patients were 8 males and 4 females, aged 9-45(27.17±12.14) years old. Time after injury to admission was 6-24(10.17±4.80) hours. Six patients were with simple soft tissue defects, 2 with tendon defects, 3 with bone defects and 1 with postoperative infection due to an open fracture. The sizes of soft tissue defect ranged from 4 cm×5 cm-8 cm×12 cm. Soft tissue defects were reconstructed by transfer of posterolateral calf flaps, and the bone defects were repaired by phase I or phase II bone grafts or antibiotic cement and membrane induction according to the wound surface. For larger bone defects, stage-II bone transport was carried out to restore the length of the hind foot. Defects of Achilles tendon were reconstructed by direct suture or tendon transposition. Foot functions were evaluated by American Orthopaedic Foot and Ankle Surgery(AOFAS) ankle-posterior sufficient scale, visual analogue scale(VSA) score and flap healing. All patients were included in postoperative follow-up regularly through outpatient clinic or via WeChat.Results:All 12 patients had postoperative follow-up that lasted for 6-24(12.92±6.22) months. One flap developed dark purple colour with swelling at the distal end of the flap 3 days after surgery. It eventually healed after removed some sutures from the pedicle together with blood-letting on the flap surface. Three flaps developed local infection, and they were cured after debridement, dressing change and the use of sensitive antibiotics. The remaining 8 patients had achieved good appearance of flaps and normal ankle function. According to AOFAS, scores of ankle-posterior sufficiency scale increased from 14-45(25.25±5.42) before surgery up to 65-96(75.92±7.73) at the final follow-up. Of the 12 patients, 8 were in excellent, 2 in good and 2 in fair. The VAS scores decreased from 5-8(6.55±1.13) before surgery down to 0-4(1.55±1.37) at the final follow-up. The difference had statistics significance( P<0.01). All patients had satisfactory recovery of ankle function, with the extension at 15-20 degrees and plantar flexion of 30-40 degrees. The donor site healed well and all skin grafts survived. Conclusion:The double-vessel flap pedicled with perforating branch of peroneal artery and nutrient vessels of sural nerve can be used for reconstruction of soft tissue defect of hind foot. It achieved good surgical effects with reliable blood supply, smooth venous return, strong anti-infection ability, satisfactory appearance at donor site and flap itself, as well as a good recovery of foot function.

Therapeutic effect of exposed bone cement in treatment of infectious bone and soft tissue defect / 中华显微外科杂志

Objective:To evaluate the therapeutic effect of exposed bone cement in treatment of infectious bone and soft tissue defect by comparison with routine bone cement therapy.Methods:A retrospective analysis was carried out in 27 patients who had been treated from January 2016 to January 2020. Of the 27 patients, 12 were treated by exposed bone cement filling for bone defect at the first stage, followed by flap and bone grafting at the second stage. Other 15 patients were treated by routine bone cement filling and flap repair at the first stage, followed by bone grafting at the second stage. Regular dressing change was carried out after surgery. All patients entered follow-up by out-patient review for wound condition and X-ray. Infection rate of bone and soft tissue, time of bone union, flap survive rate and complication were compared between the 2 groups.Results:The follow-up lased for 9-24(16.5±3.9 ) months. The bone defects were all healed. The treatment time of bone defects in the group of exposed bone cement was 25-34(28.5±2.8) weeks. The treatment time of bone defect in the routine cement group was 25-36(29.6±3.4 )weeks. There was no statistical difference between the 2 groups( P<0.05). Two cases in each group had failed in infection control after bone cement implantation. With further debridement, cleaning and other treatment, the infection was under control. All flaps in the 2 groups survived. In the group of exposed bone cement, there were 3 flaps splitting, 2 hemorrhage(effusion) and 1 partial flap necrosis, In the routine bone cement group, there were 4 wound dehiscence, 8 hemorrhage(effusion) and 3 partial flaps necrosis. There was no significant difference in flap complications between the 2 groups( P>0.05). The healing of bone defect was evaluated by Samantha X-ray score, the scores of the 2 groups were 5.41±0.67 and 5.40±0.63, respectively, with no statistical significance. The Paley's approach was used to grade the bone healing and the function of adjacent joints. Paley bone defect healing evaluation results weve all excellent. Joint function assessment were as follow: in the group of exposed bone cement, 6 cases were excellent and 3 were good; in routine bone cement group: 6 cases were in excellent and 5 in good. There was no significant statistical difference. Conclusion:Compared with a routine bone cement treatment, the exposed bone cement in the treatment of infectious bone defects saw a fewer flap splitting and fewer hemorrhage/effusion, without an increase in bone and soft tissue infection. This procedure could be considered for further trials in the treatment of a composite defects of infected bone and soft tissue.

Clinical observation on wound measurement grid and perforator flap design / 中华显微外科杂志

Objective:To investigate the application of self-designed wound measuring grid in the measurement of wound and the design of perforator flap.Methods:From February 2018 to February 2020, 31 cases of soft tissue defects of limbs were repaired by free transfer of perforator flap. During the operation, the self-designed membrane with measurement grid was used to measure the wound surface. The flaps were designed and harvested according to the accurate measurement of the wound. The flaps were reviewed at hospital clinic during follow-up.Results:All patients entered 3-15 months of follow-up with an average of 8 months. All 31 flaps survived, of which 2 flaps encountered vascular crisis and were rescued after surgical exploration. There was no infection of flaps and all flaps had stage I healing. The flaps were satisfactory in appearance with the sensation recovery to S 2 in 21 cases and S 3 in 10 cases. Only linear scars were left on the donor sites. Conclusion:The membrane with a measurement grid can accurately measure a wound, and help the design of the flap according to the measured size and profile of the wound. It can reduce the operation time and the risk as well as to improve the operation efficiency. The clinical application is satisfactory. Large scale and multi-centre studies are required to further prove the benefit of the measurement grid.

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.

Repair of complex soft tissue defect in calf by ALTF with a cross-limb bridged "Y" shape vascular anastomosis: a report of 33 cases / 中华显微外科杂志

Objective:To explore the clinical effect of ALTF transfer with cross-limb bridged "Y" shape vascular anastomosis in repair of complex soft tissue defects in calf.Methods:From August 2010 to September 2020, 33 patients(23 males and 10 females) with complex traumatic soft tissue defects in calf were treated. Preoperative angiography and intraoperative exploration confirmed that there was only 1 main vessel remained in the affected calf or the wound surface and the vessel could not be anastomosed with the vascular pedicle of the ALTF. The size of flap were 16 cm × 8 cm to 25 cm × 18 cm. Two patients received bilobed ALTFs. A "Y" shape anastomosis between the artery of ALTF vascular pedicle and the posterior tibial artery of the contralateral lower limbs was made in all 33 patients to establish the blood supply to the transferred free ALTF. The "Y" shape cross-limb bridged blood vessels at the proximal end of the vascular pedicle artery of the flap were embedded at both ends of the cut-off superior ankle posterior tibial artery of the contralateral lower limb. The vein of the flap was anastomosed with the saphenous vein that associates with the posterior tibial artery. The surface of the suspended blood vessel "bridge" was wrapped with a free skin craft, and the lower limbs were fixed in a straight and parallel position with an external fixation frame. The perfused area of the flap was directly sutured or covered with a free skin craft. The vascular bridge was kept for 3 to 6 weeks before being separated. Outpatient follow-up after discharge.Results:All the patients were entered the postoperative follow-up was 13 months to 7 years, in an average of 25 months. Among the 33 flaps, 31 survived completely, except 1 had necrosis and the other 1 had partial necrosis at the distal end of the flap. The flaps received good blood supply, hence with soft texture and satisfactory appearance. Doppler or DSA was performed after the surgery on the posterior tibial artery of the healthy limb, and the vascular pulsation and patency were found normal. Donor sites for the free skin graft healed well.Conclusion:The ALTF transfer with cross-limb bridged "Y" vascular anastomosis is one of the effective techniques and it was employed in the repair of complex defects of calf soft tissue. It solved the tissue that there was only 1 main vessel or even without a suitable vessel could be anastomosed with the pedicle of the flap.