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RESUMEN Antecedentes: los colgajos perforantes perimamarios son de gran utilidad en la reconstrucción mamaria inmediata en cirugía conservadora. Objetivo: describir los resultados del empleo de un algoritmo sobre colgajos perforantes perimamarios en la reconstrucción mamaria inmediata después de cirugía conservadora por cáncer de mama. Material y métodos: se llevó a cabo un estudio retrospectivo descriptivo. Se revisaron las historias clínicas de las pacientes operadas entre enero de 2020 y diciembre de 2022 por carcinoma de mama con cirugía conservadora y que requirieron reconstrucción con colgajos perimamarios. Las indicaciones incluyeron déficit de volumen, defecto de contorno y asimetría. Se evaluó el pedículo vascular del colgajo mediante Doppler color en todos los casos, lo que permitió seguir un algoritmo para la selección de la mejor opción de colgajo. Resultados: se realizaron 20 colgajos en 19 pacientes. Promedio de edad: 52 años ± 11 (rango 30-76). No existieron complicaciones intraoperatorias. Una paciente requirió reoperación por compresión del pedículo vascular del colgajo por hematoma, con la pérdida parcial, y otro colgajo sufrió epidermólisis superficial. No hubo pérdidas totales de ningún colgajo. Todas recibieron radioterapia posoperatoria y no experimentaron pérdida de volumen ni retracciones. Con un promedio de seguimiento de 15 meses, las pacientes valoraron los resultados a 6 meses como excelente en 7, bueno en 11 y regular en 2. Conclusión: la selección de colgajos perforantes locales para corregir defectos mamarios después de cirugía conservadora, mediante el examen con Doppler color preoperatorio para la identificación del pedículo vascular y un algoritmo específico, permitió obtener resultados estéticos satisfactorios sin requerir elementos aloplásticos ni revisiones posteriores.
ABSTRACT Background: Chest wall perforator flaps are a good option for immediate breast reconstruction after conservative surgery. Objective: The aim of this study was to describe the clinical results of an algorithm for using chest wall perforator flaps for breast reconstruction after breast-conserving surgery for breast cancer. Material and methods: We conducted a descriptive and retrospective study. The information was retrieved from the medical records of the patients diagnosed with breast cancer who underwent breast-conserving surgery and required reconstruction using chest wall perforator flaps between January 2020 and March 2022. The indications included volume deficit, contour defect and asymmetry. The vascular pedicle of the flap was evaluated by color Doppler ultrasound in all cases, which allowed us to follow an algorithm for selecting the best flap option. Results: Twenty flaps were made in 19 patients. Mean age: 52 years ± 11 (range 30-76). There were no intraoperative complications. One patient required reoperation due to a hematoma with compression of the vascular pedicle of the flap with partial flap loss, and another flap presented superficial epidermolysis. There were no cases of complete flap loss. All the patients underwent postoperative radiation therapy without loss of volume or retractions. Mean follow-up was 15 months. At 6 months, patients rated the results as excellent, good, and fair in 7, 11, and 2 cases, respectively. Conclusion: The selection of local perforator flaps to correct breast defects after conservative surgery, using preoperative color Doppler ultrasound to identify the vascular pedicle and a specific algorithm, allowed us to obtain satisfactory aesthetic results without the need for alloplastic elements or subsequent revisions.
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Neck dissection and reconstruction are two important aspects of oral cancer treatment.There are various surgical methods for neck dissection and reconstruction,but all of them are performed by open surgery.This article reports a full endoscopic neck dis-section through the retroauricular hairline approach,the radical resection of the intraoral tumor and the repair of the defect by superfi-cial circumflex iliac artery perforator flap with in situ vascular anastomosis intraorally.The incision is located in the hairline,hidden and invisible,and there is no exposed surgical scar on the neck after surgery.This paper introduces the technique of scarless neck dissection combined with free skin flap repair for the treatment of oral cancer and discusses its advantages and disadvantages.
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Objective To explore the efficacy and safety of perforator flap eyelid reconstruction surgery for eyelid repair and reconstruction in patients with eyelid tumors after surgery.Methods Totally 80 patients(80 eyes)who re-ceived eyelid tumor surgery and planned to undergo the perforator flap eyelid reconstruction surgery in our hospital from January 2012 to December 2022 were included.All of them have early-stage and mid-stage eyelid tumors with no orbital or systemic metastasis.A perforator flap eyelid reconstruction surgery was conducted to treat the eyelid defects.The differ-ence in height and length of the palpebral fissure,aesthetic function scores and levels of depression and anxiety of patients before and after repair were compared;the clinical efficacy,adverse reactions and prognosis of patients were evaluated.Results Among the 80 eyes,there were 35 eyes with significant effect,35 eyes with effective impact,and 10 eyes with no effect,with a total effective rate of 87.5％.The height and length of palpebral fissure of patients after repair were(1.49±0.47)mm and(1.43±0.55)mm,respectively,which were significantly lower than those before repair[(2.55± 0.35)mm and(2.38±0.49)mm](both P＜0.01).The aesthetic function score before repair was 0.91±0.23,and that after repair was 1.87±0.19,with a significant difference(P＜0.01).The scores of the Self-rating Anxiety Scale and Self-rating Depression Scale after repair were 40.14±6.54 and 39.45±7.65,respectively,which were significantly lower than those before repair(59.56±8.23 and 57.93±8.19)(both P＜0.01).Among the 80 patients,the total incidence of compli-cations was 27.5％(22/80).All patients were followed up for 6-36 months,with an average follow-up time of(12.39± 6.17)months.No tumor recurrence was found during the follow-up.All composite flaps survived without infection,necro-sis or displacement.Conclusion The perforator flap eyelid reconstruction surgery has a good and safe therapeutic effect on repairing full-layer eyelid defects in patients who underwent eyelid tumor surgery.
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Objective:To investigate the application of 3-D ultrasonography enabled by a wide band linear matrix array volume transducer in the localisation of perforating vessels of a free anterolateral thigh perforator flap (ALTPF) before surgery, and to guide microsurgeons in precise design and harvest of a ALTPF.Methods:From May 2020 to October 2022, a retrospective study was carried out on 35 patients who had soft tissue defects and undertaken free ALTPF surgery in Department of Foot and Ankle Surgery, Wuxi No.9 People's Hospital Affiliated to Soochow University. ALTPFs were transfered for reconstruction of soft tissue defects of foot in 25 patients and of ankle in 10 patients. The age of patients were 20 to 66 years old. The defects were 11.0 cm×8.0 cm-28.0 cm×9.0 cm in size. The sizes of ALTPFs were at 12.0 cm×9.0 cm-29.0 cm×10.0 cm. Before surgery, ultrasound scans with a wide band linear matrix array volume transducer were performed to locate the perforating vessels. The 3-D ultrasound images showing the perforating vessels of ALTPFs were acquired and the number, location and classification of the perforating vessels were saved. After the appropriate perforating vessels had been determined, ALTPFs were designed for precisely intraoperative incision. The accuracy of preoperative location of perforating vessels by the linear matrix array volume ultrasound transducer was investigated in surgery. All patients received the scheduled postoperative follow-up at outpatient clinics.Results:Of the 72 perforating vessels discovered in surgery, 70 matched with those being located by ultrasound before surgery. It was found that a total of 67 perforating vessels located before surgery by ultrasonography were consistently mapped with the perforators discovered in surgery. Of the 67 consistently mapped perforating vessels, 19 were Kimura type I, 27 of Kimura type II and 21 of Kimura type III perforators. The rate of sensitivity and positive prediction were 95.7% and 93.1%, respectively, in the preoperative localisation of perforating vessels of ALTPFs with a wide band linear matrix array volume ultrasound transducer. Twenty-five ALTPFs were harvested subfascially and 10 superfascially. Average size of ALTPFs was 17.7 cm × 8.6 cm. The perforating vessels revealed during the harvest of all ALTPFs were basically consistent with the preoperative 3-D ultrasound. All flaps survived after surgery without any incident. The postoperative follow-up lasted 8 to 20 months, with 12.7 months in average.Conclusion:The 3-D ultrasonography with a wide band linear matrix array volume ultrasound transducer can accurately locate the perforating vessels of ALTPF before surgery. This technique has many advantages in the design and harvest of super-thin ALTPFs.
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Objective:To evaluate the viability and clinical effect of polyfoliate anterolateral thigh perforator flap (ALTPF) in reconstruction of large soft tissue defect around ankle.Methods:From June 2019 to October 2022, large soft tissue defects around ankle of 11 patients were reconstructed with ALTPF in the Department of Orthopaedics of the First Affiliated Hospital of Nanchang University. The causes of injury were traffic accident in 8 patients and heavy objects in 3 patients. All wounds were large defects (15.0 cm×14.0 cm-30.0 cm×20.0 cm) and combined with various degrees of infection. Intraoperatively, polyfoliate ALTPFs sized 16.0 cm×14.5 cm-23.0 cm×18.5 cm were used in reconstruction of the defects. Deep dead spaces were filled with antibiotic bone cement, and direct suture was performed to close the donor sites or by skin grafting repair. Postoperative follow-ups were scheduled at 1, 3 and 6 months, and 6 monthly thereafter at outpatient clinics and via telephone interviews. The appearance and colour of the flaps and healing of donor sites were recorded together with evaluation of the recovery of ankle motor function according to the ankle-hindfoot rating scale of American Orthopaedic Foot and Ankle Society (AOFAS).Results:All flaps survived. No haematoma or secondary infection occurred at the recipient site after surgery. All donor sites healed primarily. One patient had venous occlusion at the distal end of the polyfoliate ALTPF. The flap survived completely at 1 week after distal venous bloodletting. Postoperative follow-ups lasted 6-24 (15.27±5.21) months. All flaps had good blood supply with satisfactory appearance, similar colour and texture to the recipient sites, and without obvious bloat nor ulceration. Only a linear scar or few skin graft scar was left at the flap donor sites in concealed locations. The mean AOFAS ankle-hindfoot score was (88.36±10.21) point. There were 6 cases of excellent, 4 cases of good, and 1 case of fair.Conclusion:A polyfoliate ALTPF is an ideal flap for reconstruction of soft tissue defects around ankle by converting the length of a flap to the width.
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Objective:To investigate the feasibility and clinical effects of the application of augmented reality (AR) navigation on assisted design of the chimeric twin-paddled anterolateral thigh perforator flap (ALTPF) in reconstruction of soft tissue defects in extremities.Methods:From June 2017 to June 2023, 8 patients with soft tissue defects in extremities received reconstruction of chimeric twin-paddled ALTPF designed with the assistance of AR navigation in Department of Hand & Foot Microsurgery Orthopaedics, Guigang City People’s Hospital. All of them were traffic accidents or machine injuries, with 3 cases of calf, 2 cases of ankle, 1 case of foot, and 2 cases of hand defects. All the wounds were wide or irregular (defect sized 14 cm×14 cm-25 cm×13 cm). The images of bilateral thighs were acquired by CT angiography preoperatively. The dominant side and dominant perforators were selected. Three dimensional reconstruction was performed by Mimics software. AR technology was applied to guide the design and harvest of the chimeric twin-paddled ALTPF. Flap area was 15 cm × 16 cm to 26 cm × 14 cm. The donor site was sutured directly. Follow-up with outpatient visits or WeChat images and videos at 1, 3, 6 and 12 months postoperatively to record the appearance, colour, texture, recurrence of infection, and knee extension function of the flap donor site.Results:According to the preoperative design, the perforator flaps were harvested and transferred in all the 8 patients. All flaps survived and the recipient and donor sites healed in one stage. All patients entered postoperative follow-up for 3 to 12 (mean, 8.6)months. The colour and texture of the flaps were excellent, and the appearance of donor and recipient sites was satisfactory. Two patients with hand injuries were evaluated using the brief Michigan Hand Outcomes Questionnaire (MHQ), with scores of 43.74 and 81.25, respectively. Six patients with lower limb injuries were evaluated using the Maryland foot score, with scores of 2 excellent, 3 good and 1 fair.Conclusion:The application of AR navigation can effectively assist the design of a chimeric twin-paddled ALTPF. It also provides an effective basis for clinical personalised flap design.
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Objective:To explore the clinical effects of end-to-side anastomosis of non-primary perforating vessels carried by free anterolateral thigh perforator flap (ALTPF) in reconstruction of soft tissue of limb.Methods:Between February 2020 and July 2021, 14 patients with soft tissue defect of limb were admitted in the Department of Hand and Foot Surgery, the First Affiliated Hospital of Wannan Medical College. The patients were 12 males and 2 females, aged between 30 and 69 years old, with a median age of 52 years old. One defect was found in left hand, 7 in left foot and ankle and 6 in right foot and ankle. Wound sizes were 7 cm×7 cm-9 cm×22 cm, all accompanied with exposed tendons, nerves or bone tissue. The size of flaps ranged from 8 cm×8 cm to 10 cm×23 cm. ALTPFs carrying non-primary source vessels were applied in reconstruction of soft tissue defects. The non-primary perforating vessels of ALTPF was anastomosed with the artery in recipient site in an end-to-side fashion and the vein of ALTPF was end-to-end anastomosed with the accompanying vein of the recipient artery. All donor sites were sutured directly. The follow-up was conducted by online reviews via WeChat or by visit of outpatient clinics. Appearance of flap and donor site were observed and the aesthetic satisfaction of the patients recipient sites were assessed subjectively using Likert scale.Results:All 14 ALTPFs survived uneventfully. Wound exudation occurred in 1 flap, and healed after dressing change and drainage. All patients received 9-18 (mean 12.6) months of follow-up. The ALTPFs were in good texture and shape. According to the Likert scale, appearance were excellent in 4 flaps, good in 8 flaps and fair in 2 flaps.Conclusion:Application of free ALTPF of non-primary source vessels with end-to-side anastomosis is not only effective in the reconstruction of limb defects, but also has advantages of reliable blood perfusion and cosmetic appearance.
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Objective:To evaluate the clinical effectiveness of the reconstruction of multiple digit-tip defects with transfer of polyfoliate perforator flaps of the fibular hallux.Methods:From January 2019 to June 2022, 15 patients had undergone reconstruction surgery for multiple digit-tip defects using polyfoliate perforator flaps of ipsilateral fibular hallux, with the first dorsal metatarsal artery as the pedicle, in the Department of Upper Limb Repair and Reconstruction Surgery, Guizhou Hospital of Beijing Jishuitan Hospital. The patients were 10 males and 5 females and aged 20 to 45 years old. Eight patients had the defects of thumbs and index fingers, 4 of thumbs and middle fingers, 2 of thumb, index and middle fingers and 1 of thumb, index and ring fingers. All the 15 digit injuries had nail bed defects to which reconstructive surgery were required. For the flaps of dorsal artery, flaps were 1.8 cm×2.0 cm-2.0 cm×3.1 cm in size and for those of plantar artery, the flaps sized 1.5 cm×2.0 cm-2.5 cm×3.0 cm. Donor site defects in the hallux were reconstructed with free superficial circumflex iliac perforator flaps. Postoperative follow-up lasted until 30th June 2023 and included visits to the outpatient clinic, WeChat and telephone reviews to assess the appearance, function and sensation recovery of the digits.Results:All the 15 flaps survived. During the 6 to 24 months (16 months in average) of postoperative follow-up, the appearance and texture of all flaps were found close to the healthy digits, with good nail growth and without deformity. TPD were found between 8.0 mm and 12.0 mm. The donor sites on the great toes that reconstructed with superficial circumflex iliac artery flaps were all survived well, and the incisions were satisfactorily healed without the functions of walking, running or jumping being significantly affected.Conclusion:The use of polyfoliate perforator flaps of fibular hallux for reconstruction of multiple digit-tip defects is an ideal surgical method due to the consistency of vascular anatomy, ease with flap harvest, similarity in the normal digital skin texture, and the capability to include a nail bed with the flap. A single donor from the hallux can simultaneously reconstruct two defects of digit-tip, making it an excellent treatment in the reconstruction of small-to medium-sized composite tissue defects in multiple digits.
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Introdução: A reconstrução oncológica de defeitos extensos em cabeça e pescoço impõe ao cirurgião plástico a difícil decisão entre o uso de retalhos livres e retalhos pediculados. O retalho supraclavicular é um dos principais exemplos de retalho pediculado, sendo versátil, com espessura delgada e cor semelhante à região a ser reconstruída. Método: Um estudo retrospectivo foi realizado através da coleta de dados de prontuário de pacientes internados no Instituto do Câncer do Estado de São Paulo, entre dezembro de 2010 e março de 2020. Resultados: Dentre os 62 pacientes reconstruídos com retalho supraclavicular, 37 eram do sexo masculino e 25 do sexo feminino. Cinquenta e oito pacientes (93,5%) possuíam alguma comorbidade associada. Ao todo, 27 complicações relacionadas ao retalho (43,5%) foram registradas, sendo 5 necroses totais (8%). Conclusão: O retalho supraclavicular possui importante papel nas reconstruções oncológicas de cabeça e pescoço e deve ser considerado como opção em pacientes maus candidatos a retalhos microcirúrgicos.
Introduction: The oncological reconstruction of extensive defects in the head and neck requires the plastic surgeon to make a difficult decision between the use of free flaps and pedicled flaps. The supraclavicular flap is one of the main examples of a pedicled flap, being versatile, with a thin thickness and similar color to the region to be reconstructed. Method: A retrospective study was carried out by collecting data from medical records of patients admitted to the Cancer Institute of the State of São Paulo between December 2010 and March 2020. Results: Among the 62 patients reconstructed with a supraclavicular flap, 37 were male and 25 female. Fifty-eight patients (93.5%) had some associated comorbidity. In total, 27 complications related to the flap (43.5%) were recorded, 5 of which were total necrosis (8%). Conclusion: The supraclavicular flap plays an important role in head and neck oncological reconstructions and should be considered as an option in patients who are poor candidates for microsurgical flaps.
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Introdução: A hidradenite supurativa (HS) é uma doença inflamatória crônica que afeta preferencialmente a pele intertriginosa e está associada a numerosas comorbidades sistêmicas. A área perineal é a segunda área mais comumente afetada depois da axila. A excisão ampla é o tratamento que tem maior probabilidade de atingir melhores resultados com menor risco de recorrência. Com a excisão cirúrgica extensa, o fechamento com retalho oferece maior probabilidade de tratamento definitivo. Alguns retalhos são descritos para reconstruir defeitos da região perineal após câncer, porém poucos deles são estudados no tratamento da HS. Relato de Caso: Mulher de 43 anos, com HS perineal, submetida a ressecção das lesões e reconstrução com retalho fasciocutâneo medial da coxa em V-Y bilateral como tratamento da doença. O retalho permitiu o fechamento completo do períneo total sem complicações graves. Conclusão: Este caso mostra que é útil e prático utilizar o retalho fasciocutâneo medial da coxa em V-Y para reconstrução perineal após ressecções amplas de pele, glândulas apócrinas e folículos pilosos no tratamento da HS, oferecendo boa cobertura de pele, e tecido celular subcutâneo com suprimento vascular confiável, que evita sequelas associadas a sacrifício de músculos e alcança dimensões maiores do que outros retalhos, podendo ser considerado em casos selecionados como uma alternativa no tratamento cirúrgico da HS perineal.
Introduction: Hidradenitis suppurativa (HS) is a chronic inflammatory disease that preferentially affects the intertriginous skin and is associated with numerous systemic comorbidities. The perineal area is the second most commonly affected area after the armpit. Wide excision is the treatment most likely to achieve better results with a lower risk of recurrence. With extensive surgical excision, flap closure offers a greater likelihood of definitive treatment. Some flaps have been described to reconstruct defects in the perineal region after cancer, but few have been studied in treating HS. Case Report: A 43-year-old woman with perineal HS underwent resection of the lesions and reconstruction with a bilateral V-Y medial thigh fasciocutaneous flap to treat the disease. The flap allowed complete closure of the total perineum without serious complications. Conclusion: This case shows that it is useful and practical to use the V-Y medial thigh fasciocutaneous flap for perineal reconstruction after wide resections of skin, apocrine glands, and hair follicles in the treatment of HS, offering good skin coverage and subcutaneous cellular tissue with supply reliable vascular flap, which avoids sequelae associated with muscle sacrifice and reaches larger dimensions than other flaps, and can be considered in selected cases as an alternative in the surgical treatment of perineal HS.
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Introduction: Fournier's gangrene is characterized by tissue necrosis, which requires treatment employing debridement and antibiotics with wounds of varying sizes. The objective is to standardize the surgical techniques of reconstructions with flaps used to treat wounds after Fournier's gangrene. Method: A study was conducted by searching the PubMed/Medline, SciELO, and LILACS databases. Results: In wounds with skin loss of 25% to 50%, a local advancement cutaneous flap or a pudendal flap from the thigh was used; in wounds, greater than 50%, a superomedial thigh flap or myocutaneous flap from the gracilis muscle was used, with the aim of to enable proper reconstruction. Conclusion: Advancement and pudendal thigh flaps were used for wounds with up to 50% loss of scrotal skin substance, while the myocutaneous gracilis flap and supero-medial flap of the thigh were indicated for wounds with more than 50% of the total scrotal surface affected, after Fournier gangrene.
Introdução: Gangrena de Fournier é caracterizada por necrose tecidual, que necessita de tratamento por meio de desbridamento e antibióticos, com feridas de dimensões variadas. O objetivo é padronizar as técnicas cirúrgicas de reconstruções com retalhos utilizadas no tratamento das feridas após gangrena de Fournier. Método: Realizou-se estudo por meio da busca nas bases de dados PubMed/Medline, SciELO e LILACS. Resultados: Nas feridas com perdas cutâneas de 25% a 50%, foram utilizados retalho cutâneo local de avanço ou retalho pudendo da coxa, nas maiores de 50% foram necessárias as confecções do retalho superomedial da coxa ou retalho miocutâneo do músculo grácil, com intuito de possibilitar a reconstrução adequada. Conclusão: Os retalhos de avanço e pudendo da coxa foram utilizados para feridas com perda de substância cutânea escrotal de até 50%, enquanto os retalhos miocutâneo de músculo grácil e superomedial da coxa foram indicados para as feridas com mais de 50% da superfície escrotal total acometida, após gangrena de Fournier.
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Objective To construct a perioperative management program for breast reconstruction with deep inferior epigastric perforator flap with breast cancer,and to provide references for clinical practice.Methods The databases at home and abroad were searched to obtain the relevant literature,and the perioperative management program of breast reconstruction with inferior epigastric artery perforator flap for breast cancer was preliminarily constructed.3 rounds of expert inquiries were conducted by Delphi method from October 2022 to January 2023 to determine the final content of the program.14 patients who received breast reconstruction with deep inferior epigastric perforator flap in a tertiary hospital in Zhejiang Province from January to May in 2023 were selected as application subjects to implement the modified program and evaluate the clinical effect.Results A total of 15 experts completed 3 rounds of consultation.In the third round of consultation,the Kendall's concordance coefficient of the importance of the first-level indicators was 0.347(P<0.05);the Kendall's concordance coefficients of the importance of the second and third-level indicators were 0.388 and 0.200(P<0.001);the coefficient of variation of each indicator was 0～0.224.The final program included 3 first-level indicators,18 second-level indicators and 67 third-level indicators.The incidence of flap complications in 14 patients decreased by 11.9%.Conclusion The perioperative management program of breast reconstruction with deep inferior epigastric perforator flap for breast cancer is preliminarily applied in clinical practice,which is scientific,reliable and practical,and it can provide references for clinical nursing.
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Objective To investigate the clinical effect of free posterior interosseous artery perforator flap combined with muscle fascia for repairing soft tissue and extensor tendon defect of hand.Methods Fifteen cases of hand skin soft tissue and extensor tendon defect admitted to Ningbo No.6 Hospital from December 2017 to December 2020 were repaired with free posterior interosseous artery perforator flap combined with extensor carpi ulnaris muscle fascia transplantation,and curative effect was observed.Results All flaps survived and patients were followed up for 6-24 months.The texture and thickness of the flap were satisfactory,and the recovery of the finger extension and flexion function were good.The excellent and good rate of hand tendon repair was 66.7%.In three cases with nerve anastomosis,the skin flap sensation recovered to S3.Conclusion The free posterior interosseous artery perforator flap combined with muscle fascia has a good clinical effect in repairing hand skin soft tissue and tendon defect.
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Objective:To investigate clinical effect of free perforator flap pedicled on medial sural artery in reconstruction of defect in left foot of squamous cell carcinoma surgery.Methods:From June 2017 to December 2019, 7 patients with chronic wounds in feet were diagnosed with highly differentiated squamous cell carcinoma of foot. The patients were treated at the Department of Microsurgical Wound Repair Surgery of Hand and Foot, Traditional Chinese Medicine Hospital of Panyu District in Guangzhou. Surgery were performed to remove the cancer and the defects in the feet caused by surgery were reconstructed with transfers of ipsilateral free perforator flaps pedicled on medial sural artery. The patients were 4 males and 3 females, aged 24-68 years old, with an average of 37 years old. Sizes of wound after resection of cancer was 2.5 cm×5.5 cm to 4.0 cm×8.0 cm. The flaps sized 3.0 cm×6.0 cm to 4.5 cm×10.0 cm. All the donor sites were directly sutured. Scheduled postoperative follow-ups were conducted. Investigation items included colour and texture of flap, flap sensation, walking condition and donor site healing.Results:All 7 flaps survived after surgery. One patient had a marginal necrosis on flap after surgery, and the wound was healed after active dressing change. All patients had completed a 12-18 months follow-up, with 15.1 months in average. One patient had a marginal necrsis on flap after surgery, and the wound was healed after active dressing change. All flaps were soft in texture, in elastic and without bulky. All the feet had good load-bearing function. There were only linear scars in the donor sites without obvious dysfunction. All patients had normal gait. No infiltration, sinus or chronic ulcer was found in recipient sites, and there was no recurrence of cancer or lymph node metastasis. Three flaps with sutured cutaneous nerves showed protective senation.Conclusion:The use of a free perforator flap pedicled on medial sural artery to reconstruct the soft tissue defect wound after tumer resection of squamous cell carcinoma in foot can be performed in same surgical field. Anatomical location of the perforator vessels is relatively constant and the flap is relatively easy to take. Damage to the donor site is minimum. It is one of the effective methods for wound repair.
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Objective:To explore the surgical procedure and effect of reconstruction of soft tissue defects in the distal segment of dorsal finger with a perforator(joint branch) flap of proper palmar digital artery combined with a dorsal metacarpal artery flap.Methods:From January 2019 to June 2022, 9 patients with soft tissue defects in distal dorsal finger, mostly with avulsion at the extensor tendon insertion point, were treated in Department of Hand and Foot Microsurgery, the Affiliated Hospital of Qingdao University. The defect areas were 1.0 cm×1.0 cm-2.5 cm×2.0 cm. Steel wires were used to reconstruct the extensor tendon insertion point. The defects were reconstructed by a perforator(joint) flap of proximal phalanx artery and a dorsal metacarpal artery flap was used to repair the donor site for proximal flap. Postoperative follow-up and evaluation included flap survival, flap appearance, scars and function of interphalangeal and metacarpophalangeal joints, through outpatient clinical, WeChat and so on.Results:The flap of digital artery perforator (joint branch) and the fasciocutaneous flap of dorsal metacarpal artery all survived. One flap of the digital artery perforator(joint branch) appeared purple and tension blisters after surgery. The stitches of the pedicle of the flap were partially dismantled at 36-48 hours after surgery. The flap was then turned to ruddy in colour 7 days after surgery. The wounds of the distal finger joint and nail bed healed well without redness and infection. The postoperative follow-up lasted for 5 to 12 months, 9 months in average. The appearance, colour and texture of the skin at distal finger were similar to those at the dorsal proximal finger and dorsal palm. Sensation recovered well, all flaps exceeding S 3. The two-point resolution (TPD) was 8-10 mm, with an average of 9.5 mm. According to the Evaluation Standard of Upper Limb Partial Functional of Hand Surgery of Chinese Medical Association, 5 cases were in excellent and 4 in good. Conclusion:The perforator(joint branch) flap of proper palmar digital artery combined with a dorsal metacarpal artery flap is simple and safe treatment. It has a fast functional recovery with an aesthetic appearance in reconstruction of the soft tissue defect in distal segment of dorsal finger.
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Objective:To evaluated the options in selection of surgical procedures for treatment of the patients suffering from diabetic feet with chronic refractory wounds.Methods:From January 2020 to June 2021, 23 patients with diabetic feet complicated with refractory wounds were treated in Department of Hand Surgery, Shunde Heping Surgical Hospital. The patients were 15 males and 8 females, aged 51-86 years old and with an average age of 65 years old. All the patients had Type-II diabetes for over 5 - 22 years. Average blood glucose of the patients was found at 15.6 mmol/L on admission. Free anterolateral thigh perforator flaps (ALTPF) were used for reconstruction of the wound of diabetic feet in 19 patients, 2 patients received vascular bypass surgery and 2 had amputations. Regular outpatient follow-up were conduct on all patients after surgery.Results:Follow-up time lasted for 8 to 30 months, 12 months in average. At the last follow-up, the donor and recipient sites healed well in the 19 patients who received flap reconstruction, without an infection, necrosis and wound recurrence. Pains were significantly relieved after the surgery in the 2 patients who received vascular bypass surgery, and wounds all healed well after symptomatic treatment and dressing change without recurrence of wounds at the last follow-up. Average Maryland score of foot function was 84 for the patients who had limb salvage, and 2 patients were in excellent and 19 in good at the last follow-up. The 2 patients who had amputation successfully survived through the perioperative period, and the wounds healed well at the last follow-up.Conclusion:The treatment is complicated in the patient suffering from diabetic foot with chronic refractory wounds due to factors such as advanced age, co-existing and complicated underlying diseases together with the complex wounds. Most patients can achieve good prognosis in wound treatment of free flap transfer or vascular bypass surgery. However, a limb salvage is recommended with caution for the patients who have severe infections and dry gangrene.
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Objective:To investigate the efficacy of digital reconstruction technology in assisted design of lobulated deep inferior epigastric perforator flap (DIEPF) for surgical reconstruction of large defect in lower extremity.Methods:From January 2017 to January 2022, a study was carried out to retrospectively analyse 8 patients who had massive soft tissue defects in lower extremities were admitted in the Department of Orthopaedic Surgery of the 920 Hospital of Joint Logistic Support Force of Chinese PLA. The size of defects varied from 16.0 cm×12.0 cm-28.0 cm×22.0 cm. CTA scans were performed over abdominal aorta and the arteries of lower extremities. Three-dimensional model of DIEPF and vascular pedicles were reconstructed by Mimics software. According to the shape and size of the wound, targeted perforators were determined on the 3D images, and precisely mapped in a digitised rectangular coordinate system. The lobulated flap was then digitally designed in the 3D coordinate system. Flaps were harvested according to preoperative digital designs for the reconstruction of large defects in the lower extremities. The donor site was sutured directly. The flaps and recovery of lower extremities were observed though postoperative follow-ups and were conducted through visits of outpatient clinics and distance interviews via telephone and WeChat. Recoveries of lower extremities were evaluated using Maryland ankle-foot function scoring system.Results:The 3D reconstructed models of the vessels in donor sites were successfully completed for all patients. The harvests of lobulated DIEPF were successfully guided by the digital designs. Fifteen lobes of lobulated DIEPF survived successfully in all 8 patients. All donor sites were closed in the stage-I. Necrosis occurred at the distal tip of a lobulated flap due to a local venous occlusion, and healed after debridement and re-suture. Four patients received further flap debulking surgery. Time of postoperative follow-ups had ranged 15-27 months, with an average of 20 months. At the last follow-up, all the flaps had satisfactory appearance with linear scars at the donor sites. All fractures were healed. Five patients achieved Maryland's ankle-foot function score in excellent, 2 in good, and 1 was acceptable.Conclusion:Digital reconstruction technology can accurately map the perforators and reasonably assist the design of lobulated flaps. A lobulated DIEPF offers a wider area for flap excision and allows a primary closure of the donor sites. Combination of the 2 advantages of a lobulated DIEPF can be effectively applied in reconstruction of a large-sized defect in lower extremity.
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Objective:To explore the clinical effect of the modified Quaba flap on reconstruction of the soft tissue defects in distal hand and foot.Methods:From August 2013 to March 2022, 36 cases of soft tissue defect in distal hand and foot were reconstructed by the modified Quaba flap in the Department of Microrepair and Reconstruction of Orthopaedic Centre, the First Affiliated Hospital of Xinjiang Medical University. There were 24 males and 12 females, aged 18 to 58 years old with an average age of 35.6 years old. The sizes of defect were 1.5 cm × 0.5 cm - 5.0 cm × 3.0 cm, including 28 in hand and 8 in foot. Of the defects, 26 were traumatic soft tissue defects, 5 were chronic hand infection and 5 were after resection of hand tumour. The sizes of flap employed were 5.0 cm × 1.5 cm - 10.0 cm × 6.5 cm. Method of optimization included: (1) Extended the paddle of propeller flap or made the rotation point being further; (2) Determined the perforator vessel that entered the pedicle, and made the perforating point as the location of rotation hence to maximise a blood flow; (3) Improved the pedicle mobility and reduced the angle of rotation of the flap; (4) The superficial vein in the pedicle was retained in the modified Quaba flap; (5) Properly retained the fascia tissue of the pedicle; (6) "Skinned-tail" design for the pedicle. All patients entered scheduled follow-up reviews at outpatient clinic and by telephone or WeChat interviews. Colour, texture, wound healing, complications at donor site and hand function were evaluated.Results:All flaps survived. The donor sites were directly closed in 27 patients, and skin grafts were applied in 9 patients. All patients were entered postoperative follow-up for 3-36(mean 24) months. All flaps had good colour and texture but with poor sensation. Wounds healed at the first attention. Hand functions(28 cases) were evaluated according to the Evaluation Trial Standards of Upper Limb Partial Functional of Hand Surgery of Chinese Medical Association. Hand function appeared excellent in 23 patients, good in 3 and fair in 2, with an excellent and good rate at 92.9%. Motion of all metacarpophalangeal joints were satisfactory. Flexion of metacarpophalangeal joints ranged from 65° to 90°, with an average of 80°. Dorsal extension ranged from 0° to 20° (mean 8°), without obvious joint pain. Foot functions(8 cases) were evaluated according to hallux metatarsophalangeal-interphalangeal scale of the American Orthopaedic Foot and Ankle Society (AOFAS), 6 patients were in excellent and 2 in good.Conclusion:Modified Quaba flap is easy to harvest and with stable and reliable blood circulation. The optimised methods can extend the length of the paddle of the flap and shorten the rotation point. They are very effective methods in reconstruction of the soft tissue defect in distal hand and foot.
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Objective:To explore the clinical effect of a self-designed wound measurement grid on the design of lobulated perforator flap.Methods:From January 2019 to December 2022, soft tissue defects in limbs of 9 patients were reconstructed by lobulated perforator flaps in the Department of Orthopaedics and Traumatology of Shenzhen Hospital of Integrated Traditional Chinese and Western Medicine. The patients were 7 males and 2 females aged 21-55 years old with 40.3 years old in average. There were 6 upper limb defects and 3 lower limb defects. Self-designed wound measuring grids were applied to guide the design and excision of lobulated perforator flaps during surgery. Five patients were treated by lobulated perforator flap pedicled with the descending branch of lateral circumflex femoral artery and 4 by perforator flaps pedicled with dorsal interosseous artery. The areas of soft tissue defect were 4.0 cm×1.5 cm-26.0 cm×8.0 cm, and the sizes of the flaps were 4.5 cm×1.8 cm-22.0 cm×10.0 cm. After surgery, the blood supply of flaps, flap survival and wound healing were monitored. Flap survival, donor site recovery and limb function were observed at outpatient clinic over the postoperative follow-up, and the limb function was evaluated by the Evaluation Standard of Upper Limb Partial Functional of Hand Surgery of Chinese Medical Association and Lower Extremity Measure(LEM).Results:In this study, a total of 17 of 18 lobes of the lobulated perforator flaps survived after surgery. One flap had venous occlusion and after exploration and further treatment, a necrosis occurred in 1 lobe of the lobulated flap and then a free flap transfer was performed again. All the wounds achieved stage-I healing. Postoperative follow-up lasted for 3-18 months with 8.6 months in average. All flaps had good colour and texture, satisfactory appearance and only linear scars remained in the donor sites, without pain and scar contracture. The reconstructed upper extremity defect were evaluated according to the Evaluation Standard of Upper Limb Partial Functional of Hand Surgery of Chinese Medical Association, with 4 patients were in excellent and 2 in good. The reconstructed lower extremity defects were evaluated according to the LEM, and 2 patients were in excellent and 1 in good.Conclusion:The self-designed wound measurement grid was successfully applied in the design of lobed perforator flaps. It can accurately measure a wound surface and quickly extract a wound profile, and it is more convenient and intuitive to guide the design of flaps. It has a good effect in clinical application and further clinical trials are required.
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Objective:To investigate the efficacy of free superficial circumflex iliac artery perforator flap (SCIAPF) in reconstruction of the donor site of hallux nail flap.Methods:From December 2015 to December 2022, Section Ⅲ of Department of Hand Surgery of Hangzhou Plastic Surgery Hospital conducted thumb reconstruction surgery with free hallax nail flaps for 12 patients with traumatic defects of thumbs. Six patients had degloving injuries of thumb with intact bone scaffold and extensor-flexor tendon. Among the other 6 patients with thumb defects, 3 had grade I defect, 2 had grade II defect and 1 had grade Ⅲ defect, according to Gu Yudong's classification. Free SCIAPFs were used to reconstruct the donor sites of hallux nail flaps. Sizes of the flaps were 3.0 cm× 6.5 cm-9.0 cm ×7.0 cm. All donor sites in the abdomen were directly sutured. After surgery, functional evaluations of the reconstructed thumb were conducted through follow-ups at outpatient clinics and(or) by WeChat interviews, according to the Evaluation Trial Standards of Upper Limb Partial Functional of Hand Surgery of Chinese Medical Association, and the functional evaluation of donor feet was conducted according to the Maryland foot function evaluation standard.Results:Successful survival of the 9 cases of flap in the donor site of hallux nail flap. One patient had venous occlusion of flap and survived after timely surgical exploration. One flap had partial necrosis at the tip of flap, and the wound was eliminated with local transfer of a flap. One patient had necrosis over most of the flap with the base of the flap survived, and the wound was repaired by a stage-II skin grafting. The donor sites at groin healed in stage-I in all of 11 patients with a linear scar. One patient who had haematoma at the donor site was cured by removal of the haematoma and a re-suture. All the patients received a 3 to 24 months of postoperative follow-up. According to the Evaluation Trial Standards of Upper Limb Partial Functional of Hand Surgery of Chinese Medical Association, 10 patients were in excellent and 2 in good. All of the great toes remained with original length and recovered normal flexion and extension. No patient suffered pain while walking and running. According to the Maryland foot function evaluation standard, 10 patients were in excellent and 2 in good. All SCIAPFs were satisfactory in colour and texture. Five patients had bloated flaps and underwent Hacks in the stage-Ⅱ.Conclusion:Application of a free SCIAPF in reconstruction of the donor site for hallux nail flap can effectively preserve the appearance and function of the donor site. Meanwhile, the scar in the donor site of groin is concealed with little damage, therefore the groin meets the requirements as a donor site of a flap.