Versatilidad del colgajo nasogeniano basado en perforantes de la arteria facial en reconstrucción facial / Versatility of the nasolabial flap based on facial artery perforators in facial reconstruction

Se conocen varios colgajos locales basados en la arteria facial al momento de reconstruir unidades estéticas faciales. Levantar estos colgajos basados en las ramas perforantes de la arteria facial, los hace más finos, móviles, fiables, y adaptables, y la posibilidad de realizarlos en un solo tiempo quirúrgico. El propósito de este estudio es demostrar nuestra experiencia con el colgajo perforante de la arteria facial en reconstrucciones faciales de defectos hasta tamaño de 5x4cm, utilizando su pedículo superior o su pedículo inferior. Método. Realizamos un estudio longitudinal retrospectivo con 15 pacientes de ambos sexos, con edades comprendidas entre 40 a 60 años, a quienes se realizó el colgajo perforante facial en un solo tiempo quirúrgico. Los defectos faciales tratados fueron de tamaño pequeño a mediano, localizados en subunidades de la mejilla, nariz, pliegue nasolabial, labios superior e inferior. Resultados. De los 15 pacientes de nuestro estudio, 13 evolucionaron sin complicaciones (84.6%); 1 paciente concurrió con leve dehiscencia de herida (7.7%) y 1 paciente al que se le realizó un colgajo de 5x4cm concurrió con una mínima necrosis en la parte distal del colgajo (7.7%). Estas complicaciones fueron leves y con resolución ambulatoria, sin requerir otro tiempo quirúrgico. Conclusiones: Gracias a su libertad de movimiento, este colgajo nos permite reconstruir varias unidades estéticas, y por su delgado espesor, mínimas complicaciones y una cicatriz de la zona dadora que se camufla en el surco nasogeniano, los resultados tanto funcionales como estéticos son superiores comparados con los tradicionales colgajos locales miocutáneos nasolabiales.

Several local flaps based on the facial artery are well known when reconstructing facial aesthetic units. Making these flaps based on the perforating branches of the facial artery makes them thinner, more mobile, reliable, and adaptable, and the possibility of performing them in a single surgical time. The purpose of this study is to demonstrate our experience with the perforating vessel of the facial artery flap, in facial reconstructions of defects up to a size of 5x4 cm, using its upper or lower pedicle. Method. We carried out a retrospective longitudinal study with 15 patients of both sexes, aged between 40 and 60 years, who underwent the facial artery perforator flap in a single surgical time. The facial defects treated were small to medium in size, located in subunits of the cheek, nose, nasolabial fold, upper and lower lips. Results. The complications that we obtained when doing this flap were hematoma, partial dehiscence of the suture and slight venous congestion. All of these were mild and with outpatient resolution, without requiring another surgical time. Conclusions. Due to its freedom of movement, this flap allows us to reconstruct several aesthetic units, and due to its thin thickness and with minimal complications, both functional and aesthetic results are superior compared to traditional nasolabial myocutaneous flaps.

Comparative Analysis of the Treatment of Skin Lesions of the Lower Limbs with Sural Flap versus Propeller Flap / Análise comparativa do tratamento de lesões cutâneas dos membros inferiores com retalho sural versus retalho propeller

Abstract Objective The objective of the present study was to prospectively compare the sural and propeller flaps for soft-tissues coverage of the lower extremity. The following variables were evaluated: incidence of complete or partial flap loss and donor area morbidity (primary closure versus skin graft). Methods Prospective and randomized analysis of data collected from all patients presenting with soft tissue defects of the lower third of the leg and heel treated with reverse sural or propeller flaps. Results Twenty-four patients aged between 4 and 60 years old were evaluated between 2011 and 2017. Complete coverage was obtained in 22 of the 24 patients (91.6%). Two flaps failed (8.4%). The sural flap, being the most popular option, continues to represent a safe and versatile alternative for skin defects of the lower third of the leg and heel region. Likewise, the propeller flap was a comparable option to treat these challenging defects. Conclusion Sural and propeller flaps are good options for soft tissues coverage of the lower extremity, with low complication rates (partial or total flap loss).

Resumo Objetivo O objetivo do presente estudo foi comparar prospectivamente os retalhos sural e propeller para cobertura de partes moles da extremidade inferior. Foram avaliadas as seguintes variáveis: incidência de perda total ou parcial do retalho e morbidade da área doadora (fechamento primário versus enxerto de pele). Métodos Análise prospectiva e randomizada de dados coletados de todos os pacientes apresentando defeitos em tecidos moles da extremidade distal da perna e do retropé submetidos aos retalhos em questão. Resultados Foram avaliados 24 pacientes com idades entre 4 e 60 anos, entre 2011 e 2017. Cobertura completa foi obtida em 22 dos 24 pacientes (91,6%) e observamos falha em 2 retalhos (8,4%). O retalho sural, sendo a opção mais popular, continua a representar uma alternativa segura e versátil para defeitos cutâneos do terço distal da perna e da região do calcanhar. O retalho propeller, da mesma maneira, mostrou-se uma opção comparável para o tratamento destas lesões desafiadoras. Conclusão Os retalhos sural e propeller são boas opções para a cobertura de partes moles da extremidade inferior, demostrando baixas taxas de complicações como perda parcial ou total do retalho.

External Delta Fixator in the Postoperative Management of Microsurgical Flaps in the Lower Limb: Experience of a Tertiary Hospital / Fixador externo tipo delta no manejo pós-operatório de retalhos microcirúrgicos no membro inferior: Experiência de um hospital terciário

Abstract Objective To evaluate the use of external fixators in the delta-type kickstand configuration as an adjuvant method in the postoperative period of patients submitted to free flaps in the lower limbs. Methods A total of 17 external delta fixators were used in patients submitted to free flaps in the lower limbs. The surgical technique was performed in a standardized manner, with the distal pin located 6 cm proximally to the anastomosis, and the proximal pin, 6 cm distally to the anterior tuberosity of the tibia. Results The mean age of the sample was of 34.76 years (range: 15 to 66 years). In total, 11 men and 6 women were selected. The posterior tibial artery was used in 14 cases, and the anterior tibial artery, in 3 cases. The mean time of use of the external fixators was of 3.88 weeks. The rate of reoperation was of 17.64%; that of retail loss was of 11.76%; that of success rate was of 88.23%; and the rate of infection was of 5.9%. Conclusion The use of delta-type fixators as an adjunct method in the postoperative period is reliable; however, more studies are needed to evaluate its true role in the postoperative period.

Resumo Objetivo Avaliar o uso de fixadores externos, na configuração kickstand do tipo delta, como método adjuvante no período pós-operatório de pacientes submetidos a retalhos livres nos membros inferiores. Métodos Ao todo, 17 fixadores externos do tipo delta foram utilizados em pacientes submetidos a retalhos livres nos membros inferiores. A técnica cirúrgica foi realizada de forma padronizada, com o pino distal localizado 6 cm proximal à anastomose, e o pino proximal, 6cm distal à tuberosidade anterior da tíbia. Resultados A idade média da amostra foi de 34,76 anos (variação: 15 a 66 anos). Foram selecionados 11 homens e 6 mulheres. Utilizou-se a artéria tibial posterior em 14 casos, e a tibial anterior, em 3 casos. O tempo médio de uso dos fixadores externos foi de 3,88 semanas. A taxa de reoperação foi de 17,64%; a de perda do retalho foi de 11,76%; a de sucesso foi de 88,23%; e a taxa de infecção foi de 5,9%. Conclusão O uso de fixadores do tipo delta como método adjuvante no pós-operatório é confiável; porém, mais estudos são necessários para avaliar seu verdadeiro papel no pós-operatório.

Effects of expanded frontal-parietal pedicled flap in reconstructing cervical scar contracture deformity in children after burns / 中华烧伤杂志

Objective: To explore the effects of expanded frontal-parietal pedicled flap in reconstructing cervical scar contracture deformity in children after burns. Methods: A retrospective observational study was conducted. From January 2015 to December 2020, 18 male children with cervical scar contracture deformity after burns who met the inclusion criteria were admitted to Zhengzhou First People's Hospital, aged 4 to 12 years, including 10 cases with degree Ⅱ cervical scar contracture deformity and 8 cases with degree Ⅲ scar contracture deformity, and were all reconstructed with expanded frontal-parietal pedicled flap. The surgery was performed in 3 stages. In the first stage, a cylindrical skin and soft tissue expander (hereinafter referred to as expander) with rated capacity of 300 to 500 mL was placed in the frontal-parietal region. The expansion time was 4 to 6 months with the total normal saline injection volume being 2.1 to 3.0 times of the rated capacity of expander. In the second stage, expander removal, scar excision, contracture release, and flap transfer were performed, with the flap areas of 18 cm×9 cm to 23 cm×13 cm and the secondary wound areas of 16 cm×8 cm to 21 cm×11 cm after scar excision and contracture release. After 3 to 4 weeks, in the third stage, the flap pedicle was cut off and restored. The rated volume of placed expander, total normal saline injection volume, type of vascular pedicle of flap, survival of flap and reconstruction of scar after the second stage surgery were recorded. The neck range of motion and cervico-mental angle were measured before surgery and one-year after surgery. The appearance of neck, occurrence of common complications in the donor and recipient sites of children, and satisfaction of children's families for treatment effects were followed up. Data were statistically analyzed with paired sample t test. Results: All the patients successfully completed the three stages of operation. The rated volume of implanted expander was 300 mL in 6 children, 400 mL in 9 children, and 500 mL in 3 children, with the volume of normal saline injection being 630 to 1 500 mL. The type of vascular pedicle of flap was double pedicle in 13 cases and was single pedicle in 5 cases. All the flaps in 17 children survived well, and the secondary wounds after neck scar excision and contracture release were all reconstructed in one procedure. In one case, the distal blood supply of the single pedicled flap was poor after the second stage surgery, with necrosis of about 2.5 cm in length. The distal necrotic tissue was removed on 10 days after the operation, and the wound was completely closed after the flap was repositioned. In the follow-up of 6 months to 3 years post operation, the cervical scar contracture deformity in 18 children was corrected without recurrence. The flap was not bloated, the texture was soft, and the appearances of chin and neck were good. The range of motion of cervical pre-buckling, extension, left flexion, and right flexion, and cervico-mental angle in one year after operation were improved compared with those before operation (with t values of 43.10, 22.64, 27.96, 20.59, and 88.42, respectively, P<0.01). The incision in the frontal donor site was located in the hairline, the scar was slight and concealed. No complication such as cranial depression was observed in expander placement site, and the children's families were satisfied with the result of reconstruction. Conclusions: Application of expanded frontal-parietal pedicled flap in reconstructing the cervical scar contracture deformity in children after burns can obviously improve the appearance and function of neck, with unlikely recurrence of postoperative scar contractures, thus it is an ideal method of reconstruction.

Effects of transient receptor potential vanilloid type 4-specific activator on human vascular endothelial cell functions and blood supply of rat perforator flap and its mechanism / 中华烧伤杂志

Objective: To analyze the effects of transient receptor potential vanilloid type 4 (TRPV4) activation on the function and endothelial-to-mesenchymal transition (EndMT) of human umbilical vein endothelial cells (HUVECs), as well as to explore the effects of TRPV4 activation on blood perfusion and survival of rat perforator flap and the mechanism. Methods: The experimental research methods were used. The 3rd to 6th passages of HUVECs were used for experiments and divided into 0.5 μmol/L 4α-phorbol 12, 13-didecanoate (4αPDD) group, 1.0 μmol/L 4αPDD group, 3.0 μmol/L 4αPDD group, 10.0 μmol/L 4αPDD group, and phosphate buffer solution (PBS) group, which were cultivated in corresponding final molarity of 4αPDD and PBS, respectively. The cell proliferation activity at 6 and 12 h of culture was detected using cell counting kit-8 (CCK-8). Another batch of cells was acquired and divided into PBS group, 1 μmol/L 4αPDD group, and 3 μmol/L 4αPDD group, which were treated similarly as described before and then detected for cell proliferation activity at 6, 12, 24, and 48 h of culture. The residual scratch area of cells at post scratch hour (PSH) 12, 24, and 48 was detected by scratch test, and the percentage of the residual scratch area was calculated. The number of migrated cells at 24 and 48 h of culture was detected by Transwell experiment. The tube-formation assay was used to measure the number of tubular structures at 4 and 8 h of culture. The protein expressions of E-cadherin, N-cadherin, Slug, and Snail at 24 h of culture were detected by Western blotting. All the sample numbers in each group at each time point in vitro experiments were 3. A total of 36 male Sprague-Dawley rats aged 8 to 10 weeks were divided into delayed flap group, 4αPDD group, and normal saline group according to the random number table, with 12 rats in each group, and iliolumbar artery perforator flap models on the back were constructed. The flap surgical delay procedure was only performed in the rats in delayed flap group one week before the flap transfer surgery. Neither rats in 4αPDD group nor normal saline group had flap surgical delay; instead, they were intraperitoneally injected with 4αPDD and an equivalent mass of normal saline, respectively, at 10 min before, 24 h after, and 48 h after the surgery. The general state of flap was observed on post surgery day (PSD) 0 (immediately), 1, 4, and 7. The flap survival rates were assessed on PSD 7. The flap blood perfusion was detected by laser speckle contrast imaging technique on PSD 1, 4, and 7. The microvascular density in the flap's choke vessel zone was detected by immunohistochemical staining. All the sample numbers in each group at each time point in vivo experiments were 12. Data were statistically analyzed with analysis of variance for factorial design, analysis of variance for repeated measurement, one-way analysis of variance, least significant difference t test, and Bonferroni correction. Results: At 6 and 12 h of culture, there were no statistically significant differences in cell proliferation activity in the overall comparison among PBS group, 0.5 μmol/L 4αPDD group, 1.0 μmol/L 4αPDD group, 3.0 μmol/L 4αPDD group, and 10.0 μmol/L 4αPDD group (P>0.05). At 6, 12, 24, and 48 h of culture, there were no statistically significant differences in cell proliferation activity in the overall comparison among PBS group, 1 μmol/L 4αPDD group, and 3 μmol/L 4αPDD group (P>0.05). At PSH 12, the percentages of the residual scratch area of cells in 1 μmol/L 4αPDD group and 3 μmol/L 4αPDD group were close to that in PBS group (P>0.05). At PSH 24 and 48, compared with those in PBS group, the percentages of the residual scratch area of cells in 3 μmol/L 4αPDD group were significantly decreased (with t values of 2.83 and 2.79, respectively, P<0.05), while the percentages of the residual scratch area of cells in 1 μmol/L 4αPDD group showed no significant differences (P>0.05). At 24 h of culture, the number of migrated cells in 1 μmol/L 4αPDD group and 3 μmol/L 4αPDD group were close to that in PBS group (P>0.05). At 48 h of culture, the number of migrated cells in 1 μmol/L 4αPDD group and 3 μmol/L 4αPDD groups were significantly greater than that in PBS group (with t values of 6.20 and 9.59, respectively, P<0.01). At 4 h of culture, the numbers of tubular structures of cells in 1 μmol/L 4αPDD group and 3 μmol/L 4αPDD group were significantly greater than that in PBS group (with t values of 4.68 and 4.95, respectively, P<0.05 or <0.01). At 8 h of culture, the numbers of tubular structures of cells in 1 μmol/L 4αPDD and 3 μmol/L 4αPDD groups were similar to that in PBS group (P>0.05). At 24 h of culture, compared with those in PBS group, the protein expression level of E-cadherin of cells in 3 μmol/L 4αPDD group was significantly decreased (t=5.13, P<0.01), whereas there was no statistically significant difference in the protein expression level of E-cadherin of cells in 1 μmol/L 4αPDD group (P>0.05); the protein expression level of N-cadherin of cells in 3 μmol/L 4αPDD group was significantly increased (t=4.93, P<0.01), whereas there was no statistically significant difference in the protein expression level of N-cadherin of cells in 1 μmol/L 4αPDD group (P>0.05); the protein expression levels of Slug of cells in 1 μmol/L 4αPDD group and 3 μmol/L 4αPDD group were significantly increased (with t values of 3.85 and 6.52, respectively, P<0.05 or P<0.01); and the protein expression level of Snail of cells in 3 μmol/L 4αPDD group was significantly increased (t=4.08, P<0.05), whereas there was no statistically significant difference in the protein expression level of Snail of cells in 1 μmol/L 4αPDD group (P>0.05). There were no statistically significant differences in the protein expression levels of E-cadherin, N-cadherin, Slug, or Snail of cells between 1 μmol/L 4αPDD group and 3 μmol/L 4αPDD group (P>0.05). The general condition of flaps of rats in the three groups was good on PSD 0. On PSD 1, the flaps of rats in the three groups were basically similar, with bruising and swelling at the distal end. On PSD 4, the swelling of flaps of rats in the three groups subsided, and the distal end turned dark brown and necrosis occurred, with the area of necrosis in flaps of rats in normal saline group being larger than the areas in 4αPDD group and delayed flap group. On PSD 7, the necrotic areas of flaps of rats in the 3 groups were fairly stable, with the area of necrosis at the distal end of flap of rats in delayed flap group being the smallest. On PSD 7, the flap survival rates of rats in 4αPDD group ((80±13)%) and delayed flap group ((87±9)%) were similar (P>0.05), and both were significantly higher than (70±11)% in normal saline group (with t values of 2.24 and 3.65, respectively, P<0.05 or P<0.01). On PSD 1, the overall blood perfusion signals of rats in the 3 groups were basically the same, and the blood perfusion signals in the choke vessel zone were relatively strong, with a certain degree of underperfusion at the distal end. On PSD 4, the boundary between the surviving and necrotic areas of flaps of rats in the 3 groups became evident, and the blood perfusion signals in the choke vessel zone were improved, with the normal saline group's distal hypoperfused area of flap being larger than the areas in delayed flap group and 4αPDD group. On PSD 7, the blood perfusion signals of overall flap of rats had generally stabilized in the 3 groups, with the intensity of blood perfusion signal in the choke vessel zone and overall flap of rats in delayed flap group and 4αPDD group being significantly greater than that in normal saline group. On PSD 7, the microvascular density in the choke vessel zone of flap of rats in 4αPDD group and delayed flap group were similar (P>0.05), and both were significantly higher than that in normal saline group (with t values of 4.11 and 5.38, respectively, P<0.01). Conclusions: After activation, TRPV4 may promote the migration and tubular formation of human vascular endothelial cells via the EndMT pathway, leading to the enhanced blood perfusion of perforator flap and microvascular density in the choke vessel zone, and therefore increase the flap survival rate.

Clinical effects of en bloc resection and debridement combined with gluteus maximus muscle flap in the treatment of ischial tubercle pressure ulcer complicated with chronic osteomyelitis / 中华烧伤杂志

Objective: To investigate the clinical effects of en bloc resection and debridement combined with gluteus maximus muscle flap in the treatment of ischial tubercle pressure ulcer complicated with chronic osteomyelitis. Methods: A retrospective observational study was conducted. From May 2018 to February 2020, 8 patients with pressure ulcers on the ischial tuberosity combined with chronic osteomyelitis who met the inclusion criteria were admitted to Fuyang Minsheng Hospital, including 5 males and 3 females, aged 38-69 years, with unilateral lesions in 6 patients and bilateral lesions in 2 patients. According to the anatomical classification of Cierny-Mader osteomyelitis, there were 6 patients (7 sides) with focal type, and 2 patients (3 sides) with diffuse type. The wound areas were 3 cm×2 cm to 12 cm×9 cm on admission. The pressure ulcer and chronic osteomyelitis lesions were completely removed by en bloc resection and debridement. The chronic infectious lesions were transformed into sterile incisions like fresh wounds by one surgical procedure, and the gluteus maximus muscle flaps with areas of 10 cm×6 cm to 15 cm×9 cm were excised to transfer and fill the ineffective cavity. The wounds of 5 patients were sutured directly, and the wounds of 3 patients were closed by local flap transfer. The intraoperative blood loss volume and blood transfusion, and length of hospital stay of patients were recorded. The incision healing and flap survival of patients were observed after operation. The recurrence of pressure ulcer and osteomyelitis, the appearance of the affected area, and the secondary dysfunction and deformity of the muscle flap donor site of patients were observed during followed up. Results: The intraoperative blood loss volume of the 8 patients was 220 to 900 (430±150) mL; 5 patients received intraoperative blood transfusion, of which 2 patients received 3 U suspended red blood cells and 3 patients received 2 U suspended red blood cells. The length of hospital stay was 18 to 29 (23.5±2.0) d for the 8 patients. In this group of patients, the incisions of 7 patients healed, while in one case, the incision suture was torn off during turning over and healed after secondary suture. The flaps survived well in 3 patients who underwent local flap transfer. During the follow-up period of 6-20 months, no recurrence of pressure ulcer or osteomyelitis occurred in 8 patients, the affected part had skin with good texture, mild pigmentation, and no sinus tract formation, and no secondary dysfunction or deformity occurred in the donor site. Conclusions: The en bloc resection and debridement combined with gluteus maximus muscle flap has good clinical effects on ischial tubercle pressure ulcer complicated with chronic osteomyelitis. Neither pressure ulcer nor osteomyelitis recurs post operation. The skin texture and appearance of the affected area are good, and the donor site has no secondary dysfunction or deformity.

Clinical application of three-dimensional printed preformed titanium mesh combined with free latissimus dorsi muscle flap in the treatment of squamous cell carcinoma with skull defect in the vertex / 中华烧伤杂志

Objective: To explore the clinical effects of three-dimensional printed preformed titanium mesh combined with latissimus dorsi muscle flap free transplantation in the treatment of wounds with skull defect after radical surgery of squamous cell carcinoma in the vertex. Methods: A retrospective observational study was conducted. From January 2010 to December 2019, 5 patients with squamous cell carcinoma in the vertex accompanied with skull invasion who met the inclusion criteria were admitted to the Department of Burns and Plastic Surgery of the Second Affiliated Hospital of Air Force Medical University, including four males and one female, aged 50 to 65 years. The original lesion areas ranged from 5 cm×4 cm to 15 cm×8 cm. The titanium mesh was prefabricated via three-dimensional technic based on the result the scope of skull resection predicted with computerized tomography three-dimensional reconstruction before surgery. During the first stage, the soft tissue defect area of scalp (8 cm×7 cm to 18 cm×11 cm) after tumor enlargement resection was repaired with the preformed titanium mesh, and the titanium mesh was covered with latissimus dorsi muscle flap, with area of 10 cm×9 cm to 20 cm×13 cm. The thoracodorsal artery/vein was anastomosed with the superficial temporal artery/vein on one side. The muscle ends in the donor site were sutured together or performed with transfixion, and then the skin on the back were covered back to the donor site. On the 10th day after the first-stage surgery, the second-stage surgery was performed. The thin intermediate thickness skin graft was taken from the anterolateral thigh to cover the latissimus dorsi muscle flap. The duration and intraoperative blood loss of first-stage surgery were recorded. The postoperative muscle flap survival after the first-stage surgery and skin graft survival after the second-stage surgery was observed. The occurrence of complications, head appearance, and recurrence of tumor were followed up. Results: The average first-stage surgery duration of patients was 12.1 h, and the intraoperative blood loss was not more than 1 200 mL. The muscle flaps in the first-stage surgery and the skin grafts in the second-stage surgery all survived well. During the follow-up of 6-18 months, no complications such as exposure of titanium mesh or infection occurred, with good shape in the recipient sites in the vertex, and no recurrence of tumor. Conclusions: Three-dimensional printed preformed titanium mesh combined with latissimus dorsi muscle flap free transplantation and intermediate thickness skin graft cover is an effective and reliable method for repairing the wound with skull defect after extended resection of squamous cell carcinoma in the vertex. This method can cover the wound effectively as well as promote both recipient and donor sites to obtain good function and appearance.

Clinical effects of free transplantation of expanded thoracodorsal artery perforator flaps in reconstructing cervical cicatrix contracture deformity after burns / 中华烧伤杂志

Objective: To explore the clinical effects of free transplantation of expanded thoracodorsal artery perforator flaps in reconstructing cervical cicatrix contracture deformity after burns. Methods: A retrospective observational study was conducted. From May 2018 to April 2021, 11 patients with cervical cicatrix contracture deformity after burns who met the inclusion criteria were admitted to the First Affiliated Hospital of Air Force Medical University, including 3 males and 8 females, aged 5 to 46 years, with a course of cervical cicatrix contracture deformity of 5 months to 8 years. The degree of cervical cicatrix contracture deformity was degree Ⅰ in one patient, degree Ⅱ in nine patients, and degree Ⅲ in one patient. In the first stage, according to the sizes of neck scars, one rectangular skin and soft tissue expander (hereinafter referred to as expander) with rated capacity of 200 to 600 mL was placed in the back. The expansion time was 4 to 12 months with the total normal saline injection volume being 3.0 to 3.5 times of the rated capacity of expander. In the second stage, free expanded thoracodorsal artery perforator flaps with areas of 10 cm×7 cm to 24 cm×13 cm were cut out to repair the wounds with areas of 9 cm×6 cm to 23 cm×12 cm which was formed after cervical cicatectomy. The main trunk of thoracodorsal artery and vein were selected for end-to-end anastomosis with facial artery and vein, and the donor sites were directly closed. The survival of flaps and healing of flap donor sites were observed on the 14th day post surgery. The appearances and cicatrix contracture deformity of the flaps, recovery of cervical function, and scar hyperplasia of donor sites were followed up. Results: On the 14th day post surgery, the flaps of ten patients survived, while ecchymosis and epidermal necrosis occurred in the center of flap of one patient and healed 2 weeks after dressing change. On the 14th day post surgery, the flap donor sites of 11 patients all healed well. During the follow-up of 6-12 months post surgery, the flaps of ten patients were similar to the skin around the recipient site in texture and color, while the flap of one patient was slightly swollen. All of the 11 patients had good recovery of cervical function and no obvious scar hyperplasia nor contracture in the flaps or at the donor sites. Conclusions: Application of expanded thoracodorsal artery perforator flaps can restore the appearance and function of the neck, and cause little damage to the donor site in reconstructing the cervical cicatrix contracture deformity after burns, which is worthy of clinical reference and application.

Clinical effects of free transplantation of expanded ilioinguinal flaps in the reconstruction of severe scar contracture deformity after extensive burns / 中华烧伤杂志

Objective: To investigate the clinical effects of free transplantation of expanded ilioinguinal flaps in the reconstruction of severe scar contracture after extensive burns. Methods: A retrospective observational study was conducted. From August 2017 to October 2021, 7 patients with severe scar contracture deformity caused by extensive burns were hospitalized in Tongren Hospital of Wuhan University & Wuhan Third Hospital, including 5 males and 2 females, aged 26-65 years, with scar area of 20 cm×4 cm-34 cm×14 cm. In the first stage, the rectangular skin and soft tissue expander (hereinafter referred to as the expander) with rated capacity of 500-600 mL were embedded above the inguinal ligament, and then normal saline was injected after stitch removal for expansion to meet the needs of repair surgery. In the second stage, the scar was removed by surgical excision to correct the deformity and release the adhesion and contracture; after the removal of the expanders, the expanded ilioinguinal free flaps were harvested. When a larger flap was needed, the paraumbilical perforator flap was harvested at the same time, and the flaps were transplanted to the secondary wound after scar resection. The number of embedded expanders, the total amount of injected normal saline, the expansion time, the complications of skin and soft tissue expansion, the number, area, thickness, and anastomotic vascular pedicles of the expanded ilioinguinal flaps being resected, the type of flaps used, the repair method of flap donor sites, and the survival of flaps after operation were observed and recorded. The long-term repair effect and donor site condition were followed up. At the last follow-up, the patients' satisfaction with the curative effect of each surgical site was investigated according to the grade 5 score of Likert scale. Results: A total of 10 expanders were embedded in 7 patients, of which 4 patients had 1 each and 3 patients had 2 each. The total volume of normal saline injected was 800-1 800 (1 342±385) mL, and the expansion time was 4-24 (11±5) months. One patient had the expander exposed due to infection after the expander being inserted, while the other patients had no complications of skin and soft tissue expansion. Totally 10 expanded ilioinguinal flaps with the area of 22 cm×6 cm-36 cm×16 cm ((326±132) cm2) and the thickness of 0.6-1.1 (0.77±0.16) cm were harvested. Among the 10 expanded ilioinguinal flaps, 5 were pedicled with the superficial circumflex iliac artery, 3 with the superficial abdominal artery with relatively large caliber, 1 with the common trunk of the superficial circumflex iliac artery and the superficial abdominal artery, and 1 flap was anastomosed with the superficial circumflex iliac artery and bridged the superficial abdominal artery for intra-arterial supercharge. Unilateral expanded ilioinguinal flap combined with ipsilateral paraumbilical perforator flap were harvested in 4 cases, bilateral expanded ilioinguinal flaps were harvested in 1 case, and unilateral expanded ilioinguinal flap was harvested in 2 cases. Except for 1 case being transplanted with autologous split-thickness scalp to repair the flap donor site after combined resection of bilateral expanded ilioinguinal flaps, the donor sites of the other patients were sutured directly. All the flaps survived after operation without tip necrosis or wound residue. Follow-up for 3-30 (15±10) months showed that the flap was soft and not bloated, the function and appearance of the recipient area were significantly improved compared with those before operation, and the appearance of the donor sites was good. At the last follow-up, the patients' satisfaction with the treatment effect of the surgical site scored 4-5 (4.5±0.4). Conclusions: The expanded ilioinguinal flap can be obtained in a large area. It has the advantages of rich blood supply, less damage to the donor site, concealed location, and being convenient to be resected and transplanted in combination with the paraumbilical perforator flap. It is suitable for the clinical reconstruction and treatment of severe scar contracture deformity after extensive burns.

Clinical application of expanded internal mammary artery perforator flap combined with vascular supercharge in reconstruction of faciocervical scar / 中华烧伤杂志

Objective: To summarize the clinical experience of expanded internal mammary artery perforator (IMAP) flap combined with vascular supercharge in reconstruction of faciocervical scar. Methods: The retrospective observational study was conducted. From September 2012 to May 2021, 23 patients with postburn or posttraumatic faciocervical scars who met the inclusion criteria were admitted to Shanghai Ninth People's Hospital of Shanghai Jiao Tong University School of Medicine, including 18 males and 5 females, aged from 11 to 58 years, all of whom were reconstructed with expanded IMAP flaps. At the first stage, one or two skin and soft tissue expander (s) with appropriate rated capacity were implanted in the anterior chest area according to the location and size of the scars. The IMAP, thoracic branch of supraclavicular artery, and lateral thoracic artery were preserved during the operation. The skin and soft tissue expanders were inflated with normal saline after the operation. The flaps were transferred during the second stage. The dominant IMAP was determined preoperatively using color Doppler ultrasound (CDU) blood flow detector. The faciocervical scars were removed, forming wounds with areas of 9 cm×7 cm-28 cm×12 cm, and the perforators of superficial temporal artery and vein or facial artery and vein were preserved during the operation. The flaps were designed according to the area and size of the wounds after scar resection with the dominant IMAP as the pedicle. Single-pedicle IMAP flaps were used to repair small and medium-sized wounds. For larger defects, the blood perfusion areas of vessels in the anterior chest were evaluated by indocyanine green angiography (ICGA). In situations where the IMAP was insufficient to nourish the entire flap, double-pedicle flaps were designed by using the thoracic branch of supraclavicular artery or lateral thoracic artery for supercharging. Pedicled or free flap transfer was selected according to the distance between the donor areas and recipient areas. After transplantation of flaps, ICGA was conducted again to evaluate blood perfusion of the flaps. The donor sites of flaps were all closed by suturing directly. Statistics were recorded, including the number, rated capacity, normal saline injection volume, and expansion period of skin and soft tissue expanders, the location of the dominant IMAP, the total number of the flaps used, the number of flaps with different types of vascular pedicles, the flap area, the flap survival after the second stage surgery, the occurrence of common complications in the donor and recipient areas, and the condition of follow-up. Results: Totally 25 skin and soft tissue expanders were used in this group of patients, with rated capacity of 200-500 mL, normal saline injection volume of 855-2 055 mL, and expansion period of 4-16 months. The dominant IMAP was detected in the second intercostal space (20 sides) or the third intercostal space (5 sides) before surgery. A total of 25 expanded flaps were excised, including 2 pedicled IMAP flaps, 11 free IMAP flaps, 4 pedicled thoracic branch of supraclavicular artery+free IMAP flaps, and 8 free IMAP+lateral thoracic artery flaps, with flap areas of 10 cm×8 cm-30 cm×14 cm. After the second stage surgery, tip necrosis of flaps in three patients occurred, which healed after routine dressing changes; one patient developed arterial embolism and local torsion on the vascular pedicle at the anastomosis of IMAP and facial artery, and the blood supply recovered after thrombectomy and vascular re-anastomosis. Fourteen patients underwent flap thinning surgery in 1 month to 6 months after the second stage surgery. The follow-up for 4 months to 9 years showed that all patients had improved appearances of flaps and functions of face and neck and linear scar in the donor sites of flaps, and one female patient had obvious nipple displacement and bilateral breast asymmetry. Conclusions: The expanded IMAP flap is matched in color and texture with that of the face and neck, and its incision causes little damage to the chest donor sites. When combined with vascular supercharge, a double-pedicle flap can be designed flexibly to further enhance the blood supply and expand the flap incision area, which is a good choice for reconstruction of large faciocervical scar.

Aesthetic reconstruction of the scar contracture deformity in chin and neck with expanded flaps based on the "MRIS" principle / 中华烧伤杂志

Objective: The surgical reconstruction strategy for scar contracture deformity in chin and neck was explored, aiming to obtain better aesthetic outcome. Methods: A retrospective observational study was conducted. From December 2017 to April 2021, 34 patients with scar contracture deformity in chin and neck after burns were hospitalized in the Department of Plastic Surgery of the First Affiliated Hospital of Army Medical University (the Third Military Medical University), aged 12-54 years, including 13 males and 21 females, 4 cases with chin affected only, 7 cases with neck affected only, and 23 cases with both chin and neck affected. The scar areas were 48-252 cm2. All the patients were treated by operation with expanded flaps, following the "MRIS" principle of matching of the color and thickness of the repair flaps (match), reconstructing of the aesthetic features of subunits (reconstruction), design of incision according to the plastic principle (incision), and prevention of the surgical incision scar (scar). The rectangular or kidney shaped skin and soft tissue expander (hereinafter referred to as the expander) with rated capacity of 80-400 mL was embedded in the first stage, which was routinely expanded to 3-5 times of the rated capacity of the expander. In the second stage, scar resection and expanded flap excision were performed to repair the secondary wound, and the flap donor site was sutured directly. The expansion ratio of the expander (with average value being calculated), the type of flaps used, the reconstruction of local aesthetic morphology, the appearance of postoperative incision, the survival of flap, and the situation of donor and recipient sites observed during follow-up were recorded. Results: Among the 34 patients, the average expansion ratio of the implanted expander was 3.82 times of the rated capacity of the expander. Three cases were repaired by the expanded local pedicled flap only, 19 cases by the expanded shoulder and/or chest perforator pedicled flap only, 10 cases by the expanded local pedicled flap combined with the expanded shoulder and/or chest perforator pedicled flap, and 2 cases by the expanded local pedicled flap combined with the expanded free flap of the second intercostal perforator of internal thoracic artery. After scar resection, the shapes of lower lip and chin-lip groove were reconstructed in 10 cases, chin process reconstruction and chin lengthening were performed in 16 cases, and the cervico-mental angle and mandibular margin contour were reconstructed in 28 cases. The surgical incision was concealed, most of which were located at the natural junction or turning point of the chin and neck subunits. The vertical incision of neck was Z-shaped or fishtail-shaped. All the expanded flaps in 34 patients survived after operation, of which 8 patients had minor necrosis at the edge or tip of the expanded flaps 1-3 days after operation and healed after dressing change. During the follow-up of 3-18 months, little difference in color and thickness between the expanded flap and the skin of chin and neck was observed, and the aesthetic shape of chin and neck was significantly improved, with mild scar hyperplasia of surgical incision. Conclusions: Reconstruction of scar contracture deformity in chin and neck by using expanded flaps based on the "MRIS" principle is beneficial to improve the quality of surgery and achieve better aesthetic outcome.

Clinical application effects of two longitudes three transverses method in perforator location of thoracodorsal artery perforator flap and deep wound repair / 中华烧伤杂志

Objective: To explore the clinical application value of two longitudes three transverses method in the location of the perforator of thoracodorsal artery perforator and deep wound repair. Methods: The retrospectively observational study was conducted. From December 2018 to June 2020, 17 patients with deep wounds who were admitted to the Affiliated Hospital of Zunyi Medical University met the inclusion criteria and were included in this study, including 7 males and 10 females, aged 12 to 72 years. The wound areas of patients after debridement were 7 cm×3 cm to 11 cm×7 cm. Two longitudinal lines were located through the midpoint of the armpit, the posterior superior iliac spine, and the protruding point of the sacroiliac joint, and three transverse lines were located 5, 10, and 15 cm below the midpoint of the armpit between the two longitudinal lines, i.e. two longitudes three transverses method, resulting in two trapezoidal areas. And then the thoracodorsal artery perforators in two trapezoidal areas were explored by the portable Doppler blood flow detector. On this account, a single or lobulated free thoracodorsal artery perforator flap or flap that carrying partial latissimus dorsi muscle, with an area of 7 cm×4 cm to 12 cm×8 cm was designed and harvested to repair the wound. The donor sites were all closed by suturing directly. The number and location of thoracodorsal artery perforators, and the distance from the position where the first perforator (the perforator closest to the axillary apex) exits the muscle to the lateral border of the latissimus dorsi in preoperative localization and intraoperative exploration, the diameter of thoracodorsal artery perforator measured during operation, and the flap types were recorded. The survivals of flaps and appearances of donor sites were followed up. Results: The number and location of thoracodorsal artery perforators located before operation in each patient were consistent with the results of intraoperative exploration. A total of 42 perforators were found in two trapezoidal areas, with 2 or 3 perforators each patient. The perforators were all located in two trapezoid areas, and a stable perforator (the first perforator) was located and detected in the first trapezoidal area. There were averagely 1.47 perforators in the second trapezoidal area. The position where the first perforator exits the muscle was 2.1-3.1 cm away from the lateral border of the latissimus dorsi. The diameters of thoracodorsal artery perforators were 0.4-0.6 mm. In this group, 12 cases were repaired with single thoracodorsal artery perforator flap, 3 cases with lobulated thoracodorsal artery perforator flap, and 2 cases with thoracodorsal artery perforator flap carrying partial latissimus dorsi muscle. The patients were followed up for 6 to 16 months. All the 17 flaps survived with good elasticity, blood circulation, and soft texture. Only linear scar was left in the donor area. Conclusions: The two longitudes three transverses method is helpful to locate the perforator of thoracodorsal artery perforator flap. The method is simple and reliable. The thoracodorsal artery perforator flap designed and harvested based on this method has good clinical effects in repairing deep wound, with minimal donor site damage.

Effects of clinical application of free anterolateral thigh perforator lobulated flap in repair of electrical burn wounds on head based on the concept of donor site protection / 中华烧伤杂志

Objective: To explore the effects of clinical application of free anterolateral thigh perforator lobulated flap in repair of electrical burn wounds on head based on the concept of donor site protection. Methods: A retrospective observational study was conducted. Eight patients with electrical burns with huge scalp defects and exposed skulls were admitted to the First Affiliated Hospital of Zhengzhou University, from May 2017 to December 2019, who were all males, aged 21-57 (39±13) years, sustaining multiple deep partial thickness to full-thickness electrical burns to 5%-14% total body surface area. Among the scalp burn sites of the patients, 1 case was posterior occipital, 2 cases were parietal occipital, 4 cases were parietal temporal, and 1 case was frontotemporal. After debridement, the defect area was 10 cm×9 cm-16 cm×14 cm. The incision area of the free anterolateral thigh perforator lobulated flap was 22 cm×6 cm-30 cm×9 cm. The artery and vein of flap were anastomosed with superficial temporal artery and vein or facial artery and vein, and the other vein of skin flap was anastomosed with superficial vein of recipient area. The donor site of skin flap was closed by layer interrupted tension-reducing suture. After the operation, the survival of flop, donor site wound healing and complications were observed. The flap appearance, wound healing of donor sites, long-term complications and functional recovery of donor sites were observed on follow-up. Results: After the operation, the flaps of 8 patients survived completely without vascular crisis. The donor sites of flaps in all the patients healed well with no osteofascial compartment syndrome. Seven patients were followed up for 3 to 12 months, and 1 case was lost to follow up. During follow-up, the flaps of the patients' heads were in good appearance but with alopecia. The donor sites showed linear scars, which were well hidden. There were no significant differences in sensory and motor functions between the two sides, and no complications were found such as muscle hernia. Conclusions: Free anterolateral thigh perforator lobulated flap has a good clinical effect in the early repair of electrical burn wounds with huge scalp defect and skull exposure on head, and the donor wounds can be directly closed and sutured, greatly reducing the damage to the donor area.

Transplantation of bilateral superficial inferior epigastric artery perforator flap for breast reconstruction in a patient with unilateral breast cancer / 中华烧伤杂志

On May 14, 2020, a 37 year old female patient with unilateral breast cancer was admitted to Hunan Cancer Hospital. She underwent modified radical mastectomy for right breast cancer and free transplantation of bilateral superficial inferior epigastric artery perforator flap (weighed 305 g) for breast reconstruction. During the operation, the right inferior epigastric vascular pedicle was anastomosed with the proximal end of the right internal mammary vessel, and the left inferior epigastric vascular pedicle was anastomosed with the distal end of the right internal mammary vessel; the blood flow of the flap was good; the wound in the donor site of the abdominal flap was closed directly. The operation lasted for 9 hours. In the first 48 hours post operation, the flap showed mild elevation in perfusion over drainage, but no obvious edema or blister was observed, flap temperature was consistent with the surrounding skin, and the drainage volume out of drainage tube was only 40 mL. The blood supply of the flap was completely restored to normal 3 days post operation, the flap survived well, the donor site incision had no obvious tension, and the healing was smooth. After 2 months of follow-up, the donor site incision of abdomen healed completely, only linear scar was left, and the reconstructed breast had a natural appearance; the patient planned to perform further nipple reconstruction and contralateral breast mastopexy. This case suggests that autologous breast reconstruction can be performed using bilateral superficial inferior epigastric artery perforator flaps under certain circumstances to minimize donor site injury to the greatest extent.

Clinical effects of proximal ulnar artery perforator flap combined with iliac bone graft in the reconstruction of subtotal thumb or finger defects / 中华烧伤杂志

Objective: To explore the clinical effects of proximal ulnar artery perforator flap combined with iliac bone graft in the reconstruction of subtotal thumb or finger defects. Methods: A retrospective observational study was conducted. From August 2016 to August 2019, 7 patients with thumb or finger defects caused by mechanical damage who met the inclusion criteria were admitted to Ruihua Affiliated Hospital of Soochow University, including 6 males and 1 female, aged 46 to 58 years. Their length of fingers was repaired with iliac bone, with length of 2.0 to 3.0 cm. After the bone graft, the skin defect area of the affected finger ranged from 2.8 cm×2.2 cm to 6.0 cm×3.2 cm. Then the free proximal ulnar artery perforator flap with area of 3.0 cm×2.4 cm to 6.5 cm×3.5 cm was used to cover the wounds. The wounds in donor sites of iliac crest and flap were directly sutured. The survival of flap in one week post surgery and the donor site wound healing in 2 weeks post surgery were observed, respectively. During the follow-up, the appearance and sensory function of the affected finger, bone healing, and scar hypertrophy of wound in the donor site were observed and evaluated. At the last follow-up, the functional recovery of the affected finger was evaluated with trial standard for the evaluation of functions of the upper limbs of the Hand Surgery Society of Chinese Medical Association. Results: In one week post surgery, all the flaps survived. In 2 weeks post surgery, the iliac bone and the wounds in forearm donor site healed. During the follow-up of 5 to 13 months, the flap was good in appearance, without obvious pigmentation; the sensory recovery reached level S2 in 5 patients and S0 in 2 patients; all the grafted iliac bones were bony union without obvious resorption; the wounds in donor site healed well, with only mild scar formation. At the last follow-up, the shape of the reconstructed finger was close to the healthy finger, and the functional evaluation results were excellent in 3 cases and good in 4 cases. Conclusions: The use of proximal ulnar artery perforator flap combined with iliac bone graft to reconstruct subtotal thumb or finger can partially restore part of the appearance and function, with less damage to the donor site. It is a good choice for patients who have low expectations of appearance and function for the reconstructed finger.

Comparative study of the effects between second toe tibial dorsal artery flap and second toe tibial plantar proper artery flap in repairing finger skin and soft tissue defects / 中华烧伤杂志

Objective: To compare the effects between second toe tibial dorsal artery flap (2-TDAF) and second toe tibial plantar proper artery flap (2-TPPAF) in repairing finger skin and soft tissue defects. Methods: A retrospective cohort study was conducted. From January 2019 to June 2020, 27 patients with skin and soft tissue defects at the fingertips with area of 1.5 cm×1.2 cm-2.6 cm×1.8 cm after debridement who met the inclusion criteria were admitted to Suzhou Ruihua Orthopaedic Hospital, including 21 males and 6 females, aged 19-59 (37±10) years. According to flap repair methods used in the defective fingers, the patients were divided into 2-TDAF group (12 cases) and 2-TPPAF group (15 cases). The area of 2-TDAF ranged from 1.5 cm×1.2 cm to 2.5 cm×1.6 cm, and the area of 2-TPPAF ranged from 1.7 cm×1.3 cm to 2.6 cm×1.8 cm. Full-thickness skin grafts from the medial side of the ipsilateral leg were grafted to the wounds in donor sites, and the wounds in donor sites of skin grafts were directly sutured. Flap arterial diameter, flap excision time, flap survival situation of patients in 2 weeks after operation, and follow-up time were recorded. At the last follow-up, the two-point discrimination distance of flap graft site, total action motion (TAM) of the finger joints, and wound healing of the flap donor site were recorded; the Vancouver scar scale (VSS) was used to score the scar in donor area of the second toe and the recipient area of fingers; the appearance and self-satisfaction subscales of the Michigan hand outcomes questionnaire (MHQ) were used to evaluate the affected finger. Data were statistically analyzed with independent sample t test or Fisher's exact probability test. Results: The flap artery diameter of patients in 2-TDAF group was 0.35-0.80 (0.56±0.14) mm and the flap cutting time was (14.0±2.7) min, which were significantly shorter than 0.80-1.35 (1.02±0.16) mm and (19.7±3.4) min in 2-TPPAF group (with t values of 7.81 and 4.79, respectively, P<0.01). The flaps of patients in the 2 groups in recipient areas survived well in 2 weeks after operation, and the wounds in donor areas of flaps of patients in the 2 groups healed well at the last follow-up. There was no statistically significant difference in the postoperative follow-up time, and two-point discrimination distance of flap graft site, TAM of the finger joints, VSS score of scar in the second toe donor site and the finger recipient site, and the appearance and self-satisfaction of MHQ scores of the affected finger at the last follow-up (P>0.05). Conclusions: Compared with 2-TPPAF, 2-TDAF has a shallower anatomical layer and shorter time for surgical flap removal, which can preserve the proper arteries and nerves at the base of the toes and reduce the damage to the donor site.

Clinical effects of lateral supramalleolar perforator island flaps with low rotation points in repairing foot skin and soft tissue defect wounds / 中华烧伤杂志

Objective: To investigate the clinical effects of lateral supramalleolar perforator island flaps with low rotation points in repairing foot skin and soft tissue defect wounds. Methods: The retrospective observational study was conducted. From October 2017 to August 2020, 14 patients (6 males and 8 females, aged 14-77 years) with foot skin and soft tissue defect wounds were admitted to Lanzhou University Second Hospital, including 4 cases of plantar skin tumor, 4 cases of chronic plantar ulcer, 4 cases of foot traffic injury, and 2 cases of residual wounds after deep foot burns. The wound size was 2.0 cm×2.0 cm to 7.0 cm×5.0 cm after tumor resection or debridement, which was repaired with island flap pedicled with the descending branch of the lateral supramalleolar perforator and the rotation point located at the lower front edge of the lateral ankle. The size of the flap ranged from 3.0 cm×2.0 cm to 8.0 cm×6.0 cm, and the length of vascular pedicle ranged from 8.0 to 14.0 cm. The flap was transferred by subcutaneous tunnel to repair the wound. The donor site wound of the flap was repaired with medium thickness skin graft from the lateral thigh. The survival of flaps, wound healing of the donor and recipient sites, and the occurrence of complications after operation were observed. The appearances of flaps and donor sites, and foot function were observed during follow-up. Results: The flaps of 14 patients survived successfully after operation, and the wounds in the donor and recipient sites healed well, without vascular crisis, venous congestion, or other complications. Follow-up for 2 to 24 months showed that the flaps had good appearance without bloating and were wear-resistant, the functions of wearing shoes and walking were not affected, and there was no obvious scar hyperplasia or hyperpigmentation at the donor site. Conclusions: With the descending branch of the lateral supramalleolar perforator as the pedicle and the rotation point located at the lower front edge of the lateral ankle, the island flap has a good effect in repairing the skin and soft tissue defect wound of the foot because of its reliable blood supply, simple design and operation, no need for vascular anastomosis, low rotation point, long vascular pedicle, and large radius of rotation.

Clinical effects of free superficial peroneal artery perforator flaps in repairing skin and soft tissue defects of the hallux / 中华烧伤杂志

Objective: To explore the clinical effects of free superficial peroneal artery perforator flaps in repairing skin and soft tissue defects of the hallux. Methods: A retrospective observational study was conducted. From January 2020 to January 2021, 13 patients with skin and soft tissue defects of the hallux who met the inclusion criteria were admitted to Department of Foot and Ankle Surgery of Ruihua Affiliated Hospital of Soochow University, including 12 males and 1 female, aged 26 to 53 years. Before operation, the perforating point of the superficial peroneal artery perforator was located by color Doppler ultrasound on the calf on the same side of the affected hallux and marked on the body surface. The operation was performed under spinal anesthesia combined with continuous epidural anesthesia. The area of skin and soft tissue defect after debridement was 4.5 cm×2.5 cm to 12.0 cm×3.0 cm. According to the size and shape of the wound, the superficial peroneal artery perforator flap was designed with the line between the fibular head and the lateral malleolus tip parallel shifting 2 cm to the tibial side as the flap axis line, and the perforating point of the perforator near the midpoint of the axis line as the center. The cut area of the flap was 5.0 cm×3.0 cm to 13.0 cm×4.0 cm, and part of the deep fascia was cut when the pedicle was freed. The donor site wound was sutured directly. During the operation, the number and type of the perforator and the cutting time of the flap were recorded, and the length of the perforator pedicle and diameter of the perforator were measured. The survival of the flap, the healing time and the healing condition of the donor and recipient areas were recorded after operation. The color, texture, elasticity of the flap, standing and walking functions of patients, the recovery of the donor area, and the patients' satisfaction with the recovery of the donor and recipient areas were recorded during the follow-up. At the last follow-up, the sensation of the flap was evaluated by the British Medical Association sensory function evaluation standard, the function of the affected limb was evaluated by the American Society of Foot and Ankle Surgery scoring system, and the excellent and good rate of the function of the affected limb was calculated. Results: A total of 13 perforators of the superficial peroneal artery were detected during the operation, all of which were septocutaneous perforators, and the perforator diameter was 0.3 to 0.5 mm. The vascular pedicle length was 2 to 5 cm. Flap cutting time was 11 to 26 minutes. The flaps of 13 patients all survived completely. The wounds at the donor and recipient sites healed well 9 to 18 days after operation. During follow-up of 6 to 14 months, the flaps had good color, texture, and elasticity; 11 patients had no obvious bloated appearance, and the other 2 patients underwent flap thinning and plastic surgery in the second stage because of their bloated appearance; all the patients returned to normal walking and standing functions. There was only one linear scar left in the donor site, with no obvious scar hyperplasia or hyperpigmentation. All the patients were satisfied with the recovery of the donor and recipient areas. At the last follow-up, the sensation of the flap was evaluated as grade S3 in 2 cases, grade S2 in 9 cases, and grade S1 in 2 cases; the function of the affected limb was evaluated as excellent in 7 cases and good in 6 cases, with an excellent and good rate of 100%. Conclusions: The free superficial peroneal artery perforator flap has relatively constant vascular anatomy, which is thin and wear-resistant, with less damage to the donor site after flap excision, and can preserve the shape and function of the hallux to the greatest extent. It is an effective method for repairing skin and soft tissue defect of the hallux.

Clinical effects of free peroneal artery perforator flaps in repairing forefoot skin and soft tissue defect wounds assisted with three-dimensional computed tomography angiography / 中华烧伤杂志

Objective: To investigate the clinical effects of free peroneal artery perforator flaps in repairing forefoot skin and soft tissue defect wounds assisted with three-dimensional computed tomography angiography (3D-CTA). Methods: A retrospective observational study was conducted. From March 2017 to September 2019, 15 patients with skin and soft tissue defect wounds in the forefoot were treated in the Department of Burn and Plastic Surgery of Yidu Central Hospital of Weifang, including 12 males and 3 females, with age of 18-60 years. The wound area on admission was 3.0 cm×3.0 cm-9.0 cm×8.0 cm. The 3D-CTA examination before operation was performed to select the peroneal artery perforating vessels with appropriate length of vascular pedicle and good blood perfusion. According to the wound area and the perforating vessels of the peroneal artery located by 3D-CTA, the peroneal artery perforator flaps of 3.5 cm×3.5 cm-9.5 cm×8.5 cm carried with lateral sural cutaneous nerve was designed and cut, and the nerve was anastomosed with the nerve of the wound. The wound in the donor site of the flap was directly sutured or covered with medium-thickness skin graft from the thigh. The consistencies of type, diameter, and perforating position of perforating vessel of the peroneal artery detected by 3D-CTA before the operation with those of the actual measurement during operation were observed. The length of time for flap cutting and the survival of the flap after operation were recorded. During follow-up of 12 months after the operation, the patients were instructed to evaluate the foot function according to the Maryland foot function score standard, and the wound healing in the donor area and the occurrence of complications affecting the motor function of limb were observed. Data were statistically analyzed with paired sample t test. Results: The types of peroneal artery perforating vessels in patients measured during the operation were septocutaneous perforator of 12 cases, musculocutaneous perforator of 2 cases, and musculomuscular septal perforator of 1 case, which were consistent with those measured by preoperative 3D-CTA. The diameter of the peroneal artery perforating vessel measured by preoperative 3D-CTA was (1.38±0.17) mm, which was close to (1.40±0.19) mm measured during the operation (t=0.30, P>0.05). The horizontal distance from the starting point of the perforating vessel to the outer edge of the shank was (42±6) mm, and the vertical distance from the starting point of the perforating vessel to the level of the lateral ankle tip was (219±14) mm measured by preoperative 3D-CTA, which were respectively close to (43±6) and (221±15) mm of intraoperative measurement (with t values of 0.46 and 0.38, respectively, P>0.05). The length of time for cutting flap was (31±6) min. All flaps survived post operation without vascular crisis. During follow-up of 12 months after the operation, the foot function was evaluated as excellent in 11 cases, good in 3 cases, and fair in 1 case, the donor site wound healed well, the scar was not noticeable with no contracture, and the motor function of joints was not affected. Conclusions: Free peroneal artery perforator flap is one of the effective methods to reconstruct skin and soft tissue defect wounds in the forefoot, and the risk of surgery can be reduced when the anatomical location of the perforating vessels is confirmed by 3D-CTA.

Use of Propeller Flap in the Coverage of Soft-Tissue Injury in the Lower Limb / Utilização de retalho em hélice para cobertura de lesões de partes moles em membro inferior

Abstract Objective To evaluate the use of a propeller flap to cover soft-tissue injuries in the lower limb. Materials and Methods A retrospective study, with review of medical records, and a convenience sample of 14 patients operated between July 2018 and June 2019. The following clinical aspects were evaluated: sex; age group; type of injury; cause of the injury; initial diagnosis; affected location; techniques for incision and identification; surgical planning; flap design; postoperative period; result of the propeller flap; and complications. Results The sample was composed of male patients (100%), with a mean age of 36.4 years, and 92.7% of the injuries resulted from motorcycle accidents, mostly on the right side (71.4%). The surgical planning of the propeller flap followed the same procedure in all cases. Immediate postsurgical complications were present in 35.7% of the cases, and they included excessive bleeding (14.3%), partial necrosis (14.3%), and flap dehiscence (7.1%). In total, 13 patients had excellent coverage, and only 1 had flap loss. Conclusion The propeller-flap technique to cover lesions in the lower limb proved to be a good alternative in most cases evaluated, with a good surgical result, although complications were observed in some cases.

Resumo Objetivo Avaliar o uso de retalho em hélice para cobertura de lesões de partes moles em membro inferior. Métodos Estudo retrospectivo, de revisão de prontuários e amostra de conveniência, com 14 pacientes operados entre julho de 2018 e junho de 2019. Foram avaliados os seguintes aspectos clínicos: sexo; faixa etária; tipo de lesão; causa da lesão; diagnóstico inicial; local acometido; técnica de incisão e identificação; planejamento cirúrgico; desenho do retalho; pós-operatório; resultado do retalho em hélice; e complicações. Resultados A amostra era composta por pacientes do sexo masculino (100%), com idade média de 36,4 anos, e 92,7% das lesões eram decorrentes de acidente motociclístico, a maioria do lado direito (71,4%). O planejamento cirúrgico do retalho em hélice seguiu o mesmo procedimento em todos os casos. As complicações pós-cirúrgicas imediatas estavam presentes em 35,7%, e incluíram sangramento excessivo (14,3%), necroses parciais (14,3%), e deiscência do retalho (7,1%). No total, 13 pacientes apresentaram ótima cobertura, e em apenas 1 houve perda do retalho. Conclusão A técnica do retalho em hélice para a cobertura de lesões em membro inferior mostrou-se uma boa alternativa na maioria dos casos avaliados, com um bom resultado cirúrgico, embora tenham sido observadas complicações em alguns casos.