Orthoplastic approach in lower leg and foot reconstruction / 中华显微外科杂志

The reconstruction of lower leg and foot is very challenging due to their anatomical characteristics. In the last half century, we assisted to a dramatical change in thinking and approaching the lower leg and foot complex tissue defects. This became possible due to the new knowledge in vascular anatomy and advances in microsurgical techniques and instrumentation. The main way to well treat this kind of lesions is to ensure a multidisciplinary approach by collaboration between the specialists involved in approaching them. That’s why, in the later part of the last millennium, a new specialty appeared: Orthoplastic Surgery. Orthoplastic extremity reconstructive surgery may be addressed to the treatment of traumatic, oncologic, and septic conditions. This paper will discuss the timing of tissue transfer and the armamentarium of tissue reconstructive techniques for surgery of the lower leg and foot, from traditional flaps to the modern perforator flaps.

Clinical application of a thoracodorsal artery chimeric perforator flap to repair extremity soft tissue defects complicated with a deep dead cavity / 中华创伤骨科杂志

Objective:To explore the curative effects of thoracodorsal artery chimeric perforator flap used to repair extremity soft tissue defects complicated with a deep dead cavity.Methods:From July 2014 to July 2019, 17 patients with extremity soft tissue defects complicated with a deep dead cavity were repaired by a thoracodorsal artery chimeric perforator flap at Department of Orthopaedics, Xiangya Hospital. They were 10 males and 7 females, aged from 2 to 39 years (mean, 20.2 years). There were 7 cases of traffic accident trauma, 5 ones of chronic osteomyelitis, 2 ones of crushing injury and 3 ones of radical resection of tumor. The defects were located at the lower extremity in 15 cases and at the upper extremity in 2. The wound sizes ranged from 5 cm × 3 cm to 24 cm × 9 cm. All the wounds were complicated somewhat with a dead cavity or exposure of deep tissues after debridement. The muscular component of thoracodorsal artery chimeric perforator flap was used to fill the dead cavity while the skin component to cover the superficial wounds. The flap donor sites were closed directly. The flap survival and donor site recovery were followed up regularly after operation. The curative effects were assessed according to the comprehensive evaluation criteria of hand surgery for flaps.Results:Necrosis of the distal flap occurred in only one case which responded to dressing change; the flaps survived uneventfully in the other 16 cases. The recipient and donor sites of flaps healed primarily in all patients. Venous crisis developed in one case which survived uneventfully after vascular crisis exploration. The 17 patients were followed up for 6 to 24 months (mean, 15.8 months). In all patients the flap presented with good color, texture and elasticity but without obvious swelling. At the last follow-up, the curative effects by the comprehensive evaluation criteria of hand surgery for flaps were excellent in 10 cases, good in 6 and fair in one. Only linear scar remained at the flap donor site and abduction of the shoulder was not affected.Conclusion:The thoracodorsal artery chimeric perforator flap is an ideal means for repair of extremity soft tissue defects complicated with a deep dead cavity because it can repair the deep dead cavity and body surface wounds at the same time only after anastomosis of a bundle of vascular pedicles.

Clinical effects of expanded super-thin perforator flaps in the shoulder, neck, and chest in reconstruction of extensive burn scars in the face / 中华烧伤杂志

Objective@#To explore the clinical effects and key techniques of expanded super-thin perforator flaps in the shoulder, neck, and chest in reconstruction of extensive burn scars in the face.@*Methods@#From January 2008 to November 2018, 22 patients with extensive burn scars in the face were admitted to the Department of Plastic Surgery of Dongguan Kanghua Hospital and the Department of Plastic Surgery of Dermatology Hospital of Southern Medical University, with 3 males and 19 females, aged from 4 to 48 years. There were 16 cases of type Ⅱ and 6 cases of type Ⅲ in facial scars. Before the first stage of expansion surgery, Doppler blood flow survey meter or multi-slice CT was used to locate the perforator vessels. One to four expanders with rated capacity ranged from 100 to 600 mL were placed in the patients. We gave 20% to 30% of the rated capacity of expander intro-operation and common injection with 10% to 15% of the rated capacity of expander per week post-operation until the volume reached 1.5 to 2.5 times of the rated capacity of expander during the past 3 to 4 months. At the second stage of surgery, the perforators were located again before surgery with the same method. The size of defects after the excision of facial scars ranged from 6 cm×4 cm to 18 cm×16 cm. With perforators used as nutrient vessels, narrow pedicle flaps or random flaps ranging from 6 cm×6 cm to 22 cm×18 cm were elevated as rotating or advancing to reconstruct the defects. The donor sites were sutured directly. Some of the flaps needed stage Ⅲ operation for cutting the pedicle. The survival of flaps, post-operation complications, and follow-up were assessed.@*Results@#All flaps of 22 patients survived. All the donor sites were closed simultaneously. One patient underwent an additional surgery for 5 cm×4 cm necrosis on distal part of flap caused by subcutaneous hematoma. Two patients with epidermis blister on the flaps were healed by themselves after dressing change. Due to rapid expansion, blood capillary proliferation appeared on the central part of the flap in 3 cases, after slowing down the expansion speed properly, which had no impact on flap transfer. No ischemia or venous congestion phenomenon were observed in the other flaps. During follow-up of 5 to 48 months, the flaps of patients showed no significant bloated appearance, with good complexion and texture, and even could reproduce facial fine-grained expressions naturally.@*Conclusions@#For the reconstruction of extensive burn scars in the face, expanded super-thin perforator flaps can not only acquire large and thin flaps with high matching degree surface skin defect, but also reproduce facial fine-grained expressions. It is a simple and safe method which conforms to the facial aesthetic standard.

Clinical effects of extra-long lateral femoral supercharged perforator flaps in repair of foot and ankle wounds / 中华烧伤杂志

Objective@#To investigate the clinical effects of extra-long lateral femoral supercharged perforator flaps in repair of ankle and foot wounds.@*Methods@#From March 2014 to October 2018, 16 patients with foot and ankle injuries were admitted to our hospital and left large area of wounds on foot and ankle after emergency treatment. There were 13 males and 3 females, with age of 27 to 60 years. The area of the wounds ranged from 14 cm×10 cm to 40 cm×17 cm. The wounds were repaired with extra-long lateral femoral supercharged perforator flaps. The widths of flaps in 8 patients were longer than 8 cm, and the bilobed flaps were designed to repair the wounds. The area of the flaps ranged from 12 cm×5 cm to 40 cm×9 cm. During the operation, 54 perforators were detected, with an average of 3.2 perforators in each flap, and 36 source arteries of perforators were detected. The blood vessel trunk of 15 patients was descending branch of the lateral femoral circumflex artery, and their supercharged mode was anastomosis of the bulky perforator of descending branch of the lateral femoral circumflex artery with the oblique branch of the lateral femoral circumflex artery and/or medial femoral circumflex artery or the descending branch of superficial illiac circumflex artery. The blood vessel trunk of 1 patient was oblique branch of the lateral femoral circumflex artery, and the supercharged mode of the patient was anastomosis of the oblique branch of the lateral femoral circumflex artery with the bulky perforator of the descending branch of the lateral femoral circumflex artery. The wounds were covered with the flaps after supercharged blood vessel anastomosis, and blood vessels in the donor sites were anastomosed with those in the recipient sites. The donor site was sutured directly. The survival of the flap after the operation and healing time of the wound, and the flap condition, the two-point discrimination distance of flap in patients who were reconstructed with sensation, the recovery of the ankle function, and the appearance of the donor site during follow-up were recorded.@*Results@#A total of 17 flaps in 16 patients were designed, including 8 bilobed flaps and 9 non-lobulated flaps. Sixteen flaps in 15 patients survived. Vascular crisis occurred in the flap of one patient, and the flap survived when the vascular crisis was relieved by the second operation. The healing time of foot and ankle wounds ranged from 12 to 90 days. All the lateral femoral donor sites healed completely. During follow-up of 8 to 48 months, flaps in 2 patients were slightly bloated and were trimmed in 6 months after the operation. The other flaps were with good appearance, soft texture, good elasticity, and no rupture or ulceration. The two-point discrimination distances of flaps ranged from 7 to 16 mm in 8 patients who were reconstructed with sensation, and the other flaps recovered protective sensation. The flexion and extension function of ankle joint recovered well, and the walking function was not affected significantly. All donor sites formed linear scar, with no deep tissue infection such as osteomyelitis.@*Conclusions@#The application of extra-long lateral femoral supercharged perforator flaps to repair the large area of wounds in foot and ankle can significantly reduce damage to donor sites and has advantages of rich blood supply and good safety, thus it has satisfactory clinical effects.

Effects of perforator flaps in the reconstruction of hypertrophic scar contracture deformities in the large joints of extremities of patients after severe burns / 中华烧伤杂志

Objective@#To explore the clinical effects of perforator flaps in the reconstruction of hypertrophic scar contracture deformities in the large joints of extremities after severe burns.@*Methods@#From January 2008 to January 2018, 72 patients (53 males and 19 females, aged 5 to 63 years) with hypertrophic scar contracture deformities and functional disorder in the large joints of extremities after severe burns were admitted to the Department of Burns of Beijing Jishuitan Hospital. Scar hyperplasia and contracture deformity were located at shoulder joints of 28 patients, elbow joints of 15 patients, hip joints of 7 patients, knee joints of 17 patients, and ankle joints of 5 patients. The wound area of patients after the scars were excised and released ranged from 7 cm×6 cm to 34 cm×12 cm. The wounds were repaired with corresponding unexpanded perforator flaps or expanded perforator flaps according to the joint location and existing soft tissue conditions. The size of flaps ranged from 7 cm×6 cm to 35 cm×14 cm. The donor sites of 51 patients were sutured directly; the donor sites of 21 patients were repaired by segmented grafts or mesh grafts. The adopted surgeries, the survival of flaps after surgery, and the functional recovery of the joints during follow-up were recorded.@*Results@#Among the 72 patients, 53 patients had perforator flap repairing surgery only; 19 patients had perforator flap repairing surgery and skin grafting. Among them, 12 patients had expanded perforator flaps, 60 patients had unexpanded perforator flaps. The perforator flaps were performed free transplantation in 9 patients, pedicled transplantation in 61 patients, and groin transplantation in 2 patients. At last, 67 flaps survived completely, while 5 flaps had distal-end necrosis which were healed after dressing change or skin grafting after debridement. During follow-up of 6 months to 3 years, the joint function of all the patients was obviously improved. The abduction angles of shoulder joints were over 110°; the hip, knee, and elbow joints could reach the straight position, and the flexion was normal; the foot drop deformity was corrected, and the appearance of flaps was good with obvious extension compared with the original state.@*Conclusions@#Perforator flaps are suitable for reconstruction of hypertrophic scar contracture deformities in the large joints of extremities of patients after severe burns. They can restore the joint function to the greatest extent as well as repair the wounds.

The application of multiple end-to-side anastomosis in free anterolateral thigh perforator flap transplantation / 中华显微外科杂志

Objective To explore the clinical application effect of multiple end-to-side anastomosis in free anterolateral thigh perforator flap transplantation.Methods From January,2013 to October,2017,29 cases were applied the technology of multiple end-to-side anastomosis to the same recipient vessel in anterolateral thigh perforator flap transplantation for wound repair.Fifteen cases treated with multiple end-to-side anastomosis on flap arteries,and 2-3 arteries were anastomosed,with the average of 2.13.Nine cases were treated with venous multiple end-to-side anastomosis,and 2-4 veins were anastomosed,with the average of 3.11.Five cases treated with arterial and venous multiple end-to-side anastomosis,and 4-6 vessels were anastomosed,with the average of 5.20.Distribution of wounds:10 cases with hands and wrists wounded,15 cases with forearms and elbow joints wounded,and 4 cases with lower legs and feet wounded.The soft tissue defect size was 5 cm×13 cm-11 cm×27 cm,and the flap area was 6 cm× 15 cm-12 cm×29 cm.Postoperative followed-up was performed every 3-6 months to review flap survival.Results All flaps of 29 cases survived.Venous congestion occurred in 2 flaps within 48 h after the operation,among which,1 was overcomed after released the dressing and sutures,and the other underwent surgical exploration.The venous end-to-side anastomotic stomas were unobstructed,and hematoma was formed.After the hematoma compression was removed,circulation was recovered and the flap survived.With followed-up for 6 months to 2.5 years,both donor site and recipient site of the flaps healed well and the injured distal limbs had no hemodynamic disorder.Conclusion The application of multiple end-to-side anastomosis to the same recipient vessel for free transplantation of anterolateral thigh perforator flaps is safe and reliable.

The flip-flap puzzle flap: Another recycling option

Post-traumatic soft tissue defects sometimes require sequential flap coverage to achieve complete healing. In the era of propeller flaps, which were developed to reduce donor site morbidity, Feng et al. introduced the concept of the free-style puzzle flap, in which a previously harvested flap becomes its own donor site by recycling the perforator. However, when a perforator cannot be found with a Doppler device, we suggest performing a new type of flap, the flip-flap puzzle flap, which combines two concepts: the free-style puzzle flap and the flip-flap flap described by Voche et al. in the 1990s. We present the cases of three patients who achieved complete healing through this procedure.

Repair of soft tissue defects at middle or distal part of 2nd ～ 5th finger and donor site with relaying reversed perforator flaps / 中华显微外科杂志

Objective To investigate the clinical effectiveness of the reversed flaps pedicled with lateral vas-cular chain of dorsal branch of digital artery and perforating branch of the dorsal metacarpal artery for relaying repair of soft tissue defects at middle-distal part of the 2nd ～ 5th finger and donor site. Methods From June, 2014 to May, 2016, a total of 18 cases (11 male and 7 female) with soft tissue defects at middle-distal part of 2nd～5th fin-ger were treated with the reversed flap pedicled with lateral vascular chain of dorsal branch of digital artery. The donor site was repaired with the reversed flap pedicled with the perforating branch of the dorsal metacarpal artery. The aver-age age at the time of reconstruction was 41 years. The right hand was involved in 12 cases and the left in 6 cases. The etiologies of injury were avulsion (n=5) , crush (n=6), and saw-cut injury (n=7). There were 15 cases with soft tissue defect at the distal phalanx and 3 cases with loss of distal and middle phalanx. All these cases were exposed with bone or tendon. The defect size ranged from 1.0 cm × 1.8 cm to 2.0 cm × 3.0 cm. And the dimension of the re-versed flaps pedicled with lateral vascular chain of dorsal branch of digital artery and perforating branch of the dorsal metacarpal artery ranged from 1.2 cm × 2.0 cm to 2.3 cm × 3.3 cm, and 1.4 cm × 2.3 cm to 2.6 cm × 3.6 cm, respec-tively. Postoperative follow-up was done termly. Results All flaps survived uneventfully with primary healing at donor site. The mean of followed-up time was 11 months (ranged from 6 to 15 months). The appearance and texture of the flaps were satisfactory and similar to the surrounding tissue. There was only some linear scar left at the dorsum of the palm. On the basis of the MHQ, 16 patients were strongly satisfied (score 5) with the appearance of the flap, and the remaining 2 patients was satisfied (score 4) with the appearance. The static 2-point discrimination of the flaps at the middle-distal part of 2nd～5th finger was 5-9 mm. Based on TAM assessment, the function of the injured finger was graded as excellent in 15 cases, good in 3 cases. Conclusion The relaying reversed flaps pedicled with lat-eral vascular chain of dorsal branch of digital artery and perforating branch of the dorsal metacarpal artery can be applied for repair of soft tissue defects at middle-distal part of 2nd～5th finger and donor site with easy procedure, reliable blood supply, satisfactory results, good appearance as well as less complications at donor sites.

Two flaps based on the proximal and distal perforator from ulnar artery in the repair of defect of two fin-gers / 中华显微外科杂志

Objective To study the clinical application of the 2 flaps based on the proximal and distal perfo-rator from ulnar artery in the repair of defect of 2 fingers and evaluate the outcome of the procedures. Methods From January,2014 to January,2015, 8 cases with skin and soft tissue defects of 2 fingers were treated simultaneous-ly with the distal and proximal perforator flap of ulnar artery in ipsilateral limb. The area of the distal flaps ranged from 2.5 cm×4.5 cm to 4.0 cm×6.5 cm. The area of the proximal flaps ranged from 3.5 cm×4.5 cm to 4.5 cm×6.5 cm. The followed-up were performed at 3rd, 6th and 12th months post-operation. The patients' satisfaction of the appear-ance and function of repaired finger and working situation were investigated. The postoperatively pain prick , touch and temperature sensation of the flaps were examined. Total active range of motion (TAM) of the finger points were measured. Results All flaps survived. Two flaps got plastic surgery at 5 months post-operation. The pain , tempera-ture and light touch sensation were restored 12 months after the surgery. Five patients returned to work again 12 months after the operation. Conclusion The distal and proximal perforator flap has their own characteristics, can be used simultaneously to repair skin and soft tissue defects of the two fingers.

Application of digital technique in repair wounds of the lower leg and foot with perforator pedicled propeller flap / 中华显微外科杂志

Objective To investigate the effectiveness of digital technology in repairing wounds of the lower leg and foot with perforator pedicled propeller flaps.Methods Eighteen patients with wounds of the lower leg and foot were returned to the hospital for review and evaluated retrospectively.The wounds were repaired by using the perforator pedicled propeller flaps from January,2013 to February,2014.There were 11 males and 7 females,with an average age of 27 years (range,6-48 years).Including 6 cases of injuries caused by the spokes and the Achilles heel of soft tissue defects.Five cases of infection after internal fixation of calcaneal fractures induced skin necrosis,2 cases of dorsal skin defects caused by heavy injured,5 cases of foot and ankle soft tissue defects caused by car accidents.All wounds were associated with exposure of tendon.The wounds area were ranged from 2.5 cm×5.0 cmn to 4.0 cm× 15.0 cm.The course of disease was from 3 hour to 35 days.Computed tomography angiography (CTA) was performed preoperatively,the appropriate perforator was selected and the CTA data were imported into the Mimics 15.0 software for the location of the perforator vessel and the design of the propeller flap,and simulate flap cut and transfer.The flap was obtained according to preoperative plan during operation.The flap size ranged from 4.0 cm×7.0 cm to 5.0 cm ×20.5 cm.These flaps included terminal branch of the peroneal artery perforator in 14 cases,posterior tibia artery perforator in 4 cases.All patients were followed up at regular intervals.Results The reconstruction of Mimics 15.0 software could confirm the perforator vessels origin,vascular distribution,diameter,and the cutting length.The rotation direction of the flap could be simulated preoperatively,which was consistent with the actual observation intraoperative.The donor sites were sutured directly.One case suffered from vascular crisis in 1 day was cured by the removal of part of the suture,massage and bloodletting.All cases were followed-up for 1 month to 16 months,and all flaps survived well and pediele were smooth with a satisfied appearance.The patient were extremely satisfied with the results for repair.Conclusion The preoperative individualization design of the perforator pedicled propeller flaps can be realized through CTA combined with Mimics 15.0 software.It can reduce the risk of operation.

The application of pedicled anterolateral thigh propeller flaps in reconstruction of inguinal skin and soft tissue defects / 中华显微外科杂志

Objective To discuss the effectiveness of anterolateral thigh propeller flaps for treatment of inguinal skin and soft tissue defects.Methods From June,2009 to October,2014,12 patients with inguinal skin and soft tissue defects were treated with anterolateral thigh propeller flaps pedicled with perforator of descending branch of lateral circumflex femoral artery.Of them there were 8 males and 4 females,aged from 22 to 51 years.The left side was involved in 3 cases and right side 9 cases.Defects were caused by traffic accident injury in 5 cases,crash injury of heavy object in 7 cases.There were mere skin and soft tissue in 2 cases,combined with bone fractures,nerves,vessels and muscles injury in 10 cases.The area of defects ranged from 9.0 cm×5.0 cm to 22.0 cm×9.0 cm.During operation,anterolateral thigh propeller flaps ranging from 11.0 cm×7.0 cm to 24.0 cm×1 1.0 cm were used to repair the wounds.Results All flaps and skingrafts survived after operation and the wounds obtained primary healing.After 8-24 months follow-up,all flaps were characterized by soft texture,good color,and satisfactory appearance.According to the Britain's Medical Research Council at 8 months after operation,the sensation of the flaps were recovered to S2 ～ S3+,No obvious scar contracture and chromatosis were observed at donor site.Conclusion Anterolateral thigh propeller flaps pedicled with artery descending branch of lateral circumflex femoral perforator is an ideal choice for the reconstruction for inguinal skin and soft tissue defects.

Repairing ankle and foot injuries with perforator-based propeller flaps / 中国骨伤

<p><b>OBJECTIVE</b>To evaluate clinical effects of repairing ankle and foot injuries with perforator-based propeller flaps.</p><p><b>METHODS</b>From June 2012 to April 2014, 20 patients with soft tissue defects on the foot and ankle were treated by perforator-based propeller flaps, including 14 males and 6 females with an average age of (36.2±4.6) years old ranging from 8 to 64 years. Area of soft tissue defect varied from 5 cm×2 cm to 22 cm×7 cm. The time from injury to operation ranged from 8 to 90 days, with an average of(38.2±6.2) days. AOFAS scoring were applied to evaluate therapeutic effects.</p><p><b>RESULTS</b>All patients were followed up from 6 to 24 months with an average of(13.5±2.2) months. Appearance and quality of flap were good. Operation time was 90 to 210 min, with an average of(120±32) min. Nineteen flaps were survived successfully, the flap edge of 1 case was necrosis and healed after free skin grafting. A good contour was confirmed on the recipient area. The total AOFAS score was(93.1±10.0) at the final following-up, 14 cases obtained excellent results and 6 cases were good.</p><p><b>CONCLUSIONS</b>Perforator-based propeller flaps for ankle and foot injuries has advantages of safe, effectivity and could receive good results.</p>

Three-Directional Reconstruction of a Massive Perineal Defect after Wide Local Excision of Extramammary Paget's Disease

Extramammary Paget's disease (EMPD) is a rare, slow-growing intraepithelial malignancy that mainly involves the genital region, including the vulva, penis, scrotum, perianal, and periurethral areas. Although several treatment options exist, wide local excision with a safe margin is considered the treatment of choice. After resection of the lesion, it is often challenging to reconstruct the defect because defects in the perineal region require adequate volume for protection and are susceptible to infections, which is a particularly significant risk for large defects. We report a case of perivulvar EMPD that was reconstructed with three-directional local flaps after wide excision of the tumor. We covered the defect sequentially using the following 3 flaps: a gracilis myocutaneous flap from the left thigh, a bipedicled V-Y advancement flap from the lower abdomen, and an internal pudendal artery perforator-based island flap from the right buttock. To the best of our knowledge, this report is the first to describe a three-directional approach to extensive perivulvar reconstruction.

Clinical application of lateral leg multi-perforators pedicled propeller flaps for reconstructing the foot and ankle defects / 中华显微外科杂志

Objective To investigate the methods and results of lateral leg propeller pedicled flaps based on multi-perforators for coverage of soft-tissue defects on the foot and ankle.Methods From May,2012 to June,2013,8 patients with soft-tissue defects were treated,including 5 cases by trauma,2 cases by chronic unlcers,1 case by infection on the foot and ankle with exposed osseous and tendinous.Lateral leg propeller pedicled flaps based on multi-perforators were elevated and rotated with the angle from 150° to 180° for coverage of soft-tissue de-fects.Flap size ranged from 15.0 cm × 7.0 cm to 23.0 cm × 9.0 cm.Skin graft was applied to cover the donor sites.After the operation,the blood supplies of flaps were observed severely over 10 days.Questionnaire of the flap aesthetic satisfactory and AOFAS evaluation were performed in 7 patients during fellowed-up periods.Results Seven flaps were all survived well,1 flap had partial marginal skin necrosis on the distal,which was managed with surgical debridement,and wound healed in 1 month.Seven patients had a mean of 10.7 months' fellowed-up periods.The flaps had like-like appearance,good contour,and high aesthetic satisfactor (100％).The mean AOFAS score was 90.5.Conclusion Lateral leg propeller pedicled flaps based on multi-perforators can supply the blood of the larger volume of tissue,which can be safely sustained to repair distal and larger defects on the foot and ankle.

Reconstrução da mama utilizando retalhos perfurantes: uso do DIEAP flap no Serviço de Cirurgia Plástica e Microcirurgia da Universidade Federal de Ciências da Saúde de Porto Alegre e da Irmandade Santa Casa de Misericórdia de Porto Alegre / Breast reconstruction with perforator flaps: use of the DIEAP flap at the Plastic Surgery and Microsurgery Service of Universidade Federal de Ciências da Saúde de Porto Alegre and Santa Casa de Misericórdia de Porto Alegre

INTRODUÇÃO: Uma grande evolução ocorreu desde o primeiro registro de transferência de tecido abdominal para reconstrução de mama pós-mastectomia. O retalho baseado em vasos perfurantes da artéria epigástrica inferior (DIEAP flap) apresenta-se com um dos mais recentes desenvolvimentos da área. MÉTODOS: Este artigo analisa fatos importantes na área de reconstrução autóloga da mama utilizando retalhos baseados no abdome, com ênfase nos retalhos microcirúrgicos vascularizados por pedículos perfurantes. RESULTADOS: Na experiência inicial do serviço, pudemos verificar que o retalho se comportou de acordo com a experiência relatada na literatura. CONCLUSÃO: O DIEAP flap apresenta uma possibilidade maior de escultura e ganho volumétrico na mama reconstruída, além de evolução pós-operatória muito positiva.

INTRODUCTION: Great advances have been reported since the first abdominal tissue transfer carried out for breast reconstruction after a mastectomy. The deep inferior epigastric artery perforator (DIEAP) flap is one of the most recent advances in this area. METHODS: In this article, we evaluate the important aspects in the field of autologous breast reconstruction with abdominal-based flaps, with emphasis on microsurgical flaps vascularized by perforating pedicles. RESULTS: During the initial experience of this procedure, we were able to verify that the flap behaved according to what was reported in the literature. CONCLUSION: The DIEAP flap provides a great degree of sculpting and volumetric gain to the reconstructed breast besides allowing a positive postoperative course for the patient.

Using lower leg perforator flaps to repair soft tissue defect on ankle / 中华显微外科杂志

Objective To explore the application value of the lower leg perforator flaps in repairing soft tissue defect on ankle.Methods From January 2007 to December 2012,62 cases of soft tissue defect on ankles have been repaired.The defects were combined with tendon and/or bone exposure for all the cases,among them 7 cases were exposure or sinus tract after achilles tendon rupture surgery,8 cases with ankle or intertarsal joint defect and exposure,24 cases with distal tibia fracture,or medial malleolus fracture,or lateral malleolus fracture,or calcaneus fracture,11 cases with different level of infection.Fifteen cases were primarily repair,and 47 cases were secondly repair or extended phase.The cases were repaired by applying different types retrograde transferred perforator pedicle flaps of lower legs,with 10 cases of posterior tibial artery perforator flaps on the medial malleolus,12 cases of front top flaps of com peroneal artery on external ankle,40 cases of back top flaps of peroneal artery on external ankle.The sizes of the flap ranged from 4.0 cm ×5.5 cm to 9.0 cm × 15.0 cm.Ten cases were applied direct suturing in donor site,and other cases were applied skin grafts to repair the defect.Results Flaps in 56 cases completely survived.Partial necrosis appeared in 3 cases of front top flaps of peroneal artery on external ankle,one perforator flap of posterior tibial artery on the medial malleolus and 2 cases of back top flaps of peroneal artery on external ankle.All these cases recovered after careful dressing changes.Sixty two cases were followed up for 3-12 months.Texture of flaps was soft with good elasticity.All of the donor skin grafts in patients survived.Conclusion Perforator flaps have the advantage of easy operation,little damage to the main blood vessels,high reliability in flap survival,less destroy to donor site.It is important that individualized flap is selected given different position of defect.

Regional Analysis of Soft Tissue Thickness on Korean Buttocks and Application to Fasciocutaneous Flap Design

BACKGROUND: Various shapes and designs of the gluteal artery perforator flap have been used for treating sacral pressure sores and reconstructing breasts. To establish the ideal fasciocutaneous flap design for use in the gluteal area, the soft tissue thickness distribution was measured. METHODS: Twenty-one buttocks of adult Korean cadavers were analyzed through rectangular subfascial dissection. Each buttock was divided horizontally into 10 sections and vertically into 10 sections, and then, the thickness at the corners of the sections was measured. For the sake of comparison and statistical verification with living bodies, computed tomography (CT) images of 120 buttocks of patients were randomly selected. Five horizontal sections and 4 vertical sections were made, and the thickness at each corner was recorded. RESULTS: According to the dissection and the CT images, the area with the thinnest soft tissues in the buttock was around the posterior superior iliac spine, close to the sacral area. The thickest area was the superolateral area of the buttock, which was 3.24 times and 2.15 times thicker than the thinnest area in the studies on cadaver anatomy and the CT images, respectively. CONCLUSIONS: The thickness of the soft tissues in the buttocks differed by area. The superolateral area had the thickest soft tissues, and the superomedial area had the thinnest. This study includes information on the distribution of the thickness of the gluteal soft tissues of Koreans. The outcome of this study may contribute to the design of effective local flaps for pressure sore reconstruction and free flaps for breast reconstruction.

A Preoperative Marking Template for Deep Inferior Epigastric Artery Perforator Flap Perforators in Breast Reconstruction

Preoperative perforator marking for deep inferior epigastric artery perforator flaps is vital to the success of the procedure in breast reconstruction. Advances in imaging have facilitated accurate identification and preselection of potentially useful perforators. However, the reported imaging accuracy may be lost when preoperatively marking the patient, due to 'mapping errors', as this relies on the use of 2 reported vectors from a landmark such as the umbilicus. Observation errors have been encountered where inaccurate perforator vector measurements have been reported in relation to the umbilicus. Transcription errors have been noted where confusing and wordy reports have been typed or where incorrect units have been given (millimetres vs. centimetres). Interpretation errors have also occurred when using the report for preoperative marking. Furthermore, the marking process may be unnecessarily time-consuming. We describe a bespoke template, created using an individual computed tomography angiography image, that increases the efficiency and accuracy of preoperative marking. The template is created to scale, is individually tailored to the patient, and is particularly useful in cases where multiple potential suitable perforators exist.

Application of lateral femoral circumflex artery perforator flaps and fit together for limbs complex wound surface / 中华显微外科杂志

Objective To evaluate the feasibility and clinical efficacy of lateral femoral circumflex artery perforator flaps and fit together in the treatment of limbs complex wound surface.Methods From January 2010 to March 2012,use the characteristics that the descending branch of lateral femoral circumflex artery extend its branches over the flap,fascia and skin,to form lenticulostriate arteries,which contain 2 to 3 different species tissues fits together,flaps cover the important tissues such as vessel,nerves and bones.Fascia covers the tendinous tissues etc.Muscle can not only cover the tissues,but also fill in the space,and followed by skin grafting.This research was to perform the treatment for 4 cases of lacking limbs ring tissue,three cases of multiple wound surface,six cases of hand avulsion injury of skin and 9 cases of Gustilo grade-Ⅲ C.Results As for the 22 cases in the research,nineteen cases of flaps survived,the other 3 cases were necrosis with length of 1cm to 2 cm at distal and self-healed later.During 6 months to 2 years followed-up of 18 cases,external flaps were satisfactory,skin grafting over the fascia layers develops very well,smooth with great elasticity,no recoil,and no color change.Conclusion Lateral femoral circumflex artery is one of effective restoration methods for limbs with complex wound surface.

Colgajos de peroorantes principios básicos y aplicaciones clínicas / Perforator flps basic principles and clinical applications / Realhos perfuranntes princípios básicos e aplicações cínnicas

Los colgajos de perforantes se han constituido en el escalón reconstructivo de mayor refinamiento quirúrgico por sus beneficios al dejar mínima morbilidad en las áreas donantes y permitir el tallado de los tejidos más precisos a los defectos a reconstruir, permitiendo al mismo tiempo la transferencia de varios tipos de tejidos, constituyéndose así en una herramienta versátil para casos complejos, con defectos tridimensionales y necesidades tisulares específicas. El presente artículo realiza una revisión de los aspectos clínicos, así como la presentación de pacientes manejados con esta opción que dentro del campo de la microcirugía reconstructiva se posiciona como la primera elección al contemplar las diferentes posibilidades de tratamiento.

Perforator flaps have turned into the reconstructive step with the highest surgical refinement because of its benefits by limiting the donor site morbidity and allowing more accurate tissue graving in the defects to be reconstructed while allowing the transference of several types of tissues, thus becoming a versatile tool for complex cases with tridimensional defects and specific tissue needs. This article reviews the clinical features as well as the presentation of patients managed through this option, which, in the field of reconstructive microsurgery, has been positioned as the leading election when the different possibilities of treatment are considered.

Os retalhos de perfurantes constituemse no degrau reconstrutivo de maior refinamento cirúrgico por seus benefícios ao deixar mínima morbilidade nas áreas doadoras e permitir esculpir os tecidos de forma mais precisa no momento de corrigir defeitos e reconstruir, permitindo ao mesmo tempo a transferência de vários tipos de tecidos, constituindose assim em uma ferramenta versátil para casos complexos, com defeitos tridimensionais e necessidades tissulares específicas. O presente artigo faz uma revisão dos aspectos clínicos, bem como a apresentação de pacientes tratados com esta opção que dentro do campo da microcirurgia reconstrutiva se posiciona como a primeira escolha ao considerar as diferentes possibilidades de tratamento.