A prospective study of super-thin anterolateral thigh flap harvesting assisted by high-frequency color Doppler ultrasound in detecting perforators in deep adipose layers / 中国修复重建外科杂志

OBJECTIVE@#To investigate the clinical application of high-frequency color Doppler ultrasound (HFCDU) in detecting perforators in the deep adipose layers for harvesting super-thin anterolateral thigh flap (ALTF).@*METHODS@#Between August 2019 and January 2023, 45 patients (46 sides) with skin and soft tissue defects in the foot and ankle were treated, including 29 males and 16 females, aged from 22 to 62 years, with an average of 46.7 years. The body mass index ranged from 19.6 to 36.2 kg/m 2, with an average of 23.62 kg/m 2. The causes of injury included traffic accident injury in 15 cases, heavy object crush injury in 20 cases, mechanical injury in 8 cases, heat crush injury in 1 case, and chronic infection in 1 case. There were 20 cases on the left side, 24 cases on the right side, and 1 case on both sides. After thorough debridement, the wound size ranged from 5 cm×4 cm to 17 cm×11 cm. All patients underwent free super-thin ALTF transplantation repair. HFCDU was used to detect the location of the perforators piercing the deep and superficial fascia, as well as the direction and branches of the perforators within the deep adipose layers before operation. According to the preoperative HFCDU findings, the dimensions of the super-thin ALTF ranged from 6 cm×4 cm to 18 cm×12 cm. The donor sites of the flaps were directly sutured.@*RESULTS@#A total of 55 perforators were detected by HFCDU before operation, but 1 was not found during operation. During operation, a total of 56 perforators were found, and 2 perforators were not detected by HFCDU. The positive predictive value of HFCDU for identifying perforator vessels was 98.2%, and the sensitivity was 96.4%. Among the 54 perforators accurately located by HFCDU, the orientation of the perforators in the deep adipose layers was confirmed during operation. There were 21 perforators (38.9%) traveled laterally and inferiorly, 12 (22.2%) traveled medially and inferiorly, 14 (25.9%) traveled laterally and superiorly, 5 (9.3%) traveled medially and superiorly, and 2 (3.7%) ran almost vertically to the body surface. Among the 54 perforators accurately located by HFCDU, 35 were identified as type 1 perforators and 12 as type 2 perforators (HFCDU misidentified 7 type 2 perforators as type 1 perforators). The sensitivity of HFCDU in identifying type 1 perforators was 100%, with a positive predictive value of 83.3%. For type 2 perforators, the sensitivity was 63.2%, and the positive predictive value was 100%. The surgeries were successfully completed. The super-thin ALTF had a thickness ranging from 2 to 6 mm, with an average of 3.56 mm. All super-thin ALTF survived, however, 1 flap experienced a venous crisis at 1 day after operation, but it survived after emergency exploration and re-anastomosis of the veins; 1 flap developed venous crisis at 3 days after operation but survived after bleeding with several small incisions; 3 flaps had necrosis at the distal edge of the epidermis, which healed after undergoing dressing changes. All 45 patients were followed up 6-18 months (mean, 13.6 months). Three flaps required secondary defatting procedures, while the rest had the appropriate thickness, and the overall appearance was satisfactory.@*CONCLUSION@#Preoperative application of HFCDU to detect the perforator in the deep adipose layers can improve the success and safety of the procedure by facilitating the harvest of super-thin ALTF.

Using dorsal digital flap to repair donor site of the digital artery perforator flap / 中华整形外科杂志

Objective@#To investigate the application and clinical efficacy of dorsal finger flap on repairing donor site of the digital artery perforator flap.@*Methods@#From July 2015 to February 2017, the reversed digital artery perforator flaps were used to repair soft tissue defects at distal part of the fingers. Donor site defects were reconstructed with the dorsal finger flaps in 21 fingers of 18 cases.Male 11 cases, female 7 cases. The defect areas of donor sites were about 1.4 cm×2.0 cm-1.8 cm×2.5 cm.@*Results@#Primary wound healing were achieved in 21 finger of 18 cases. All the flaps survived.19 fingers of 16 cases were follow-up for 6 to 18 months(average 9.2 months), while 2 cases were lost to follow-up.The results of hand function were excellent 14 fingers, good 4 fingers, bad 1 finger. The sensory evaluation of the digital artery perforator flap were 3 fingers S3, 14 fingers S4 and 2 fingers S5, and the distance between two points of flap was 5-9 mm.@*Conclusions@#Using proximal dorsal transverse flaps to reconstruct the defects of digital artery perforator flap can avoid skin graft.It is an effective method for the treatment of the skin and soft tissue defects of the dorsal fingers.

Free anterolateral thigh perforator flap without carrying the source of blood vessels and fascia lata for the coverage of the hand defects / 中华显微外科杂志

Objective To study the surgical method of repairing the defects of the hand with the free antero-lateral thigh perforator flap without carrying the source of blood vessels and the fascia. Methods From February, 2013 to October, 2016, 8 cases of hand defects with tendon and bone exposure.Looking for the thickest perforator in the anterolateral thigh region by using the Multidetector computed tomography angiography(MDCTA)and color Doppler Sonography(CDS). Find the perforator in the superficial fascia,cut a small part of the fascia lata and vastus lateralis,cut off the pedicle at the musculocutaneous perforator.Cover the defects with flap after debridement. Regular follow-up include:the healing of the wound,the texture,shape and sensation of the skin flap, the scar and complica-tions of the donor area. Results All flaps survived in 8 cases, in one case,there are 1.0 cm necrosis in the distal flap, after debridement, direct suture. All patients were followed up for 6-12 months. The flaps were soft and normal color, restore the protective touch. The donor site healed well, linear scar, no itching and dysfunction. Conclusion Free anterolateral thigh perforator flap without source blood vessels and fascia lata is a good method for the repair of hand defects.

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.

A comparative study of two kinds of reverse radial flap for thumb soft tissue reconstruction / 中华显微外科杂志

Objective To evaluate the clinical results of the thumb dorsoradial flap and the greater thenar flap for coverage of thumb soft tissue defect,and to provide guidance on clinical selection of flaps.Methods From January,2013 to June,2014,23 thumb dorsoradial flaps and 20 greater thenar flaps were used to repair the soft tissues defects in thumbs and were followed up to compare the results.Patient satisfaction,cold intolerance scores,TAM of the reconstructed thumb,sensation (pain and temperature sensation,Semmes-Weinstein monofilament test,static two-point discrimination) and blood perfusion of the flaps were recorded and analyzed statistically.Results Thumb dorsoradial flaps group:patient satisfaction was (36.97 ± 7.70)％,cold intolerance score was 58.96 ± 12.47,TAM of the thumb was (87.57 ± 12.83)°,median Semmes-Weinstein monofilament test was 3.61mm,static two-point discrimination was (14.22 ± 2.84)mm,and blood perfusion was (98.41 ± 15.66) PU.Greater thenar flaps group:patient satisfaction was (50.00 ± 10.80)％,cold intolerance score was 60.45 ± 14.10,TAM of the thumb was (95.00 ± 14.58)°,median Semmes-Weinstein monofilament test was 4.31mm,static twopoint discrimination was (20.70 ± 2.56)mm,and blood perfusion was (104.74 ± 14.12)PU.The greater thenar flap had a larger degree of satisfaction than the dorsoradial flap (P ＜ 0.05).Both pain and temperature sensation of the flap were regained in all cases,but the dorsoradial flap presented better Semmes-Weinstein monofilament score and static two-point discrimination(P ＜ 0.05).No differences were found regarding TAM of the thumb,cold intolerance score and blood perfusion of the flap (P ＞ 0.05).Conclusion The dorsoradial flap is suitable for repairing the thumb pulp defect due to its good sensation.For the small defect of non-functional dorsal area,the greater thenar flap will be a satisfactory method.

Repair of multi-fingers soft tissue defects with flaps based on cutaneous branches of dorsal metacarpal artery / 中华显微外科杂志

Objective To investigate the method and result of repairing multi-fingers soft tissue defects using the dorsal metacarpal flaps with cutaneous branches as pedicle.Methods From February,2010 to January,2013,9 patients with multi-fingers tissue defects were treated with the 2nd,3rd,4th dorsal metacarpal flaps with cutaneous branches as pedicles.The area of flaps ranged from 1.2 cm × 2.5 cm to 2.5 cm × 5.0 cm.The donor sites were sutured with full thick skin graft.Results All flaps survived.After a followed-up of 8 months to 24 months(average 12 months),the texture and shape of the flaps were good and non-bloated.The flap sensibility as sessment were S3-S3+.The two-point discrimination testing were 10 to 13 mm (average 11.6 mm).The TAM score of range of motion was 60％ to 75％ of the healthy side.The skin graft of donor site were soft.Conclusion Procedure of dorsal metacarpal flaps with cutaneous branches as pedicles easy is a good method to repaire the soft tissue defects of muhi-fingers.

Clinical application of reverse island flap of the adjacent digit pedicled with the Y-V vascular of digital artery by anastomosis of superficial veins / 中华显微外科杂志

Objective To investigate the methods and results of reverse island flap of the adjacent digit pedicled with the Y-V vascular of digital artery by anastomosis of superficial veins for repairing soft tissue defects of the fingers.Methods From March 2009 to June 2011,twenty cases with soft tissue defect distal to the proximal interphalangeal join of fingers were treated by reverse island flap of the adjacent digit pedicled with the Y-V vascular of digital artery by anastomosis of superficial veins.There were 12 cases of the index finger,eight of middle finger,the largest area of the flaps was 4.5 cm × 3.5 cm,and the smallest area was 3.5 cm × 2.5 cm,an average of the pedical length was 4.0 cm.All cases anastomosis one superficial vein,fourteen cases suture dorsal digital nerve,and the donor area covered with full-thickness skin graft.Results All flaps survived.Postoperative follow-up time ranged from 8 to 16 months,the appearance and texture of the flaps were excellent,the flaps with suture nerves,the two-point discrimination was 7 mm to 9 mm,the other flaps that the nerves were disconnected.The sensation of the flaps recovered to S2-S3,no morbidity of the donor fingers occurred.Conclusion Reverse island flap of the adjacent digit pedicled with the Y-V vascular of digital artery by anastomosis of superficial veins can form a longer vascular pedicle,to repair the soft tissue defect distal to the proximal interphalangeal joint,through anastomoses superficial venous can reduce the flap venous pressure obviously,improve the survival quality of the flap,the effect is satisfacted.

Using modified great toe wrap-around flap to reconstruct degloved thumb and fingers / 中华显微外科杂志

Objective To explore the clinical outcome of using modified great toe wrap-around flap to reconstruct degloved thumb and fingers.Methods Eighteen patients were involved.Based on different types of injury,four procedures were carried on for reconstructing degloved thumb and fingers:①Unilateral modified great toe wrap-around flap to reconstruct 9 degloved thumbs of distal proximal level and 3 degloved fingers of proximal interphalangeal joint level.②Unilateral modified great toe wrap-around flap with second toe medial flap to reconstruct 2 total degloved fingers.③Bilateral modified great toe wrap-around flap to reconstruct 2 thumbs.④Bilateral modified great toe wrap-around flap and second toe medial flap with neurolized super thin anterolateral thigh flap to reconstruct 12 degloved fingers.This wrap-around flap carried with entire nail.A triangle flap was reserved at medial plantar of great toe.Results All free flaps were survived in one stage.Fifteen patients were followed up for 8 to 25 months.The contour of reconstructed digit was as same as contralateral digit with satisfactory motion arc and sensation.There was no extensive scar in donor toe.The width of medial plantar triangle flap increased significantly.All patients could walking,running,jumping without restricted.Conclusions With reconstructed by modified great toe wrap-around flap,degloved thumb or finger can be promised with excellent contour and function outcome.In the meantime,the loss of donor foot can be expected to minimal.This procedure is one of the best ways for reconstructing degloved thumb and finger.

G7nerve double-neurotization in the treatment of total brachial plexus avulsion: An experimental study / 中华显微外科杂志

Objective To test the feasibility of rescuing 2 impaired nerves by C7 nerve transfer (C7 nerve double-neurotization). Methods Using adult male Sprague-Dawley rats(200 - 250 g),a C7 nerve double-neurotization model was established. At postoperative 2, 4, 6, 8, 12th weeks the recovery underwent muscle-nerve morpholosical, histological examinations and was compared with C7 single neurotization, Results Most of the parameters in double neurotization group approximated to those in the single neurotization groups and normal control group at the end of observation period, thus indicating C7 nerve contains enough nerve fibers to provide sufficient regeneration for 2 recipient nerves. Conclusion Compared to single neurotization, C7 nerve double-neurotization has the advantage of restoring 2 nerve function at same time. This implicates its future clinical application in the treatment of severe brachial plexus avulsion injuries.

Reconstruction of many fingers with bilateral multiple toe transplantation / 中华显微外科杂志

@#Objective To evaluate the treatment effect of hand reconstruction with bilateral multiple toe transplantation. Methods There are four schedules as follow applied in 102 cases: (1) bilateral second toes to thumb and index finger transplantation in 86 cases; (2) wrap-around flap to thumb and second toe on opposite side to index or middle finger transplantation in 11 cases; (3) wrap-around flap to thumb and bilateral second toes to index and middle fingers transplantation in 8 cases; (4) bilateral wrap-around flap to bilateral thumb and second toe to index finger transplantation in 1 case. Results All reconstructed finger survived in 102 cases except for partial wrap-around flap necrosis in one case and second toe in two cases. Sixty-two patients got more than one-year following up. Two points discrimination in reconstructed finger was between 8 to 14 mm in all cases. The reconstructed finger grew synchronously with toe among children. Thumb opposition function recovered in all cases except for one case. Donor site: no limp or hallux eversion observed in all cases. Conclusion There is less damage on foot and most hand function recovery using bilateral multiple toe transplantation to repair hand or multiple fingers defect.

An experimental study on early active mobilization to promote regeneration of flexor tendon sheath / 中华创伤骨科杂志

Objective To study the different effects of early active mobilization on flexor ten don sheath regeneration when the sheath has bee n partially removed and when the inju red sheath has been sutured.Methods In 192Leghorns involved in this study,the zone II flexor digital profoun d tendons were partially ruptured at their bilateral 3rd digits.Their te ndon sheathes were partially removed or sutured.All the Leghorns were di vided into four groups randomly:active mo bilization-sheath removed(A 1 ),active mobilization-sheath sutur ed(A 2 ),immobilization-sheath removed(C 1 ),and immobilization-sheath suture d(C 2 ).Their toes were harvested in the1st,2nd,3rd,4th,8th and 12thweeks postoperatively.Then morphologic al observations and biomechanical tests were performed.All data were s tatistically analyzed.Results In the 1st week postoperatively,the tendon sheath structure disappeared in the injured areas in both groups of A 2 and C 2 ,while in groups of A 1 and A 2 ,neogenetic tendon sheath formed in t he operation areas.In groups of C 1 and C 2 dense scar tissues developed around the tendon without neogenesis of tendon sheath or sheath-like str ucture.There was no significant dif ference either morphologically or biomechanically between A 1 and A 2 as well as C 1 and C 2 while significant differences were found between A 1 and C 1 as well as A 2 and C 2 .Conclusions The pathologic transformation afte r sheath repair during active mobilization c an be divided into three stages:The s heath decomposed and degenerated in the1st week postoperatively.Early neogenetic sheath formed in 2weeks.The neogenetic sheath matured in 4to 8weeks.Active mobilization to promo te neogenesis of sheath is a key facto r to prevent adhesion.Only tendon sheath repair cannot prevent adhesion effectively.