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Objective:To introduce a new surgical procedure for harvesting an iliac bone flap with deep iliac circumflex vessels—"retrograde anatomical method", and report the effect of preliminary application with this procedure.Methods:From June 2018 to May 2021, 15 patients who admitted in the Department of Hand and Microsurgery, Xiangya Hospital of Central South University received surgeries of iliac bone flap with deep iliac circumflex artery by "retrograde anatomical method". During the surgery, appropriate cutaneous perforators or muscular branches were found near the medial side of the iliac bone of iliac tubercle. The branches were dissected from surface inwards to the starting point of deep circumflex iliac blood vessel with microsurgery and micro Schlieren forceps. The iliac bone flap was chiselled out, inserted into femoral head, and then anastomosed with the transverse branches of deep circumflex iliac blood vessel and lateral circumflex femoral blood vessel. All patients were included in the postoperative follow-up at the outpatient clinic to evaluate the preliminary effect of this procedure. Harris scores before and after surgery were assessed with paired t test. P<0.05 was considered statistically significant. Results:The length of iliac bone flap was at 3.0-5.0(4.0±0.5) cm, and the length of vascular pedicle was at 4.0-7.0(5.3±1.0) cm. The time of iliac bone flap harvest was 35-55(45.0±6.1) minutes. During the operation, the success rate of harvesting iliac bone flap with deep iliac circumflex artery was 100%, and blood had oozed out of bone surface before the pedicle of all iliac bone flaps was cut-off. The volume of intraoperative autologous blood transfusion was 100-400(226.7±78.2) ml. One patient suffered from traction injury of lateral femoral cutaneous nerve in the operation. The numbness of anterolateral thigh area occurred on the 1st day after the surgery, and relieved 4 months later. Other 14 patients did not suffer from postoperative numbness in the area of anterolateral thigh. The amount of drainage from donor site for the iliac bone flap was 50-70 ml[(62.7±7.5) ml in average] after surgery. Incisions at the donor sites of iliac bone flap healed in stage I. Postoperative follow-up lasted between 3 months and 3 years. There was no incision hernia and other complication in the donor sites of the iliac bone flap. There was a significant difference in Harris scores between at 9, 12 and 18 months after surgery and that before the surgery, respectively( P<0.05). After 18 months, Harris score were at a better level. Conclusion:The "retrograde anatomical method" can quickly determine the nutrient vessels of an iliac bone flap with deep circumflex iliac vessels. The surgical procedure is relatively simple with safe and reliable anatomy. Donor site damage and postoperative complications are greatly minimised. This surgical technique can be considered to be applied clinically.
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Objective:To explore the feasibility and clinical effect of modified tibial transverse transport (TTT) technique in treatment of severe diabetic foot.Methods:The research was carried out from November 2015 to November 2017 at the Department of Hand Microsurgery, Xiangya Hospital of Central South University. Red latex was used to perfuse 10 adult lower limb specimens through femoral artery. The study observed the occurrence rate of osteofascial cutaneous branches from the inner and posterior edge of tibia within 6.0 to 10.0 cm distal from the tibial tubercle, as well as the number, distribution, outer diameter and other indicators of the perforating cutaneous branches and periosteal branches. Combined with findings in the anatomical observation, a chimeric flap with a vessel of posterior medial tibial osteofascial cutaneous branch was designed to improve TTT in the treatment of diabetic foot. From February 2016 to November 2018, 12 patients with Wagner’s Grades Ⅲ and Ⅳ diabetic feet were treated. All the patients were treated with a modified TTT, with a piece of designed tibial bone flap at 10.0 cm × 2.5 cm in size. After surgery, 5 patients with gangrenous toes received various toe stump reconstruction surgery for removal of the external fixator for bone transport. Two patients had arch stone flap reconstructions for the wounds of heel and sole, 3 patients had the wounds self-healed, and 2 patients with Wagner’s Grade IV diabetic feet had proximal calf amputations. Postoperative follow-ups were run through visits of outpatient clinic, and meanwhile the preliminary effects of the surgical procedure were observed and summarised.Results:Among the 10 specimens, it was found that a total of 11 osteofascial cutaneous branches(2 branches in 1 case and 1 branch in 9 cases) branched out from the posterior edge of tibia within 6-10 cm distal to the tibial tubercle. The distance to the tibial tubercle was 9.23 cm± 0.62 cm, with an outer diameter at 1.10 mm ± 0.10 mm. After penetrating the deep fascia, the osteofascial cutaneous branch further branched out a skin branch with an outer diameter of 0.59 mm± 0.09 mm, and delivered blood supply to the medial skin of calf. Meanwhile, it also branched out a periosteal branch with an outer diameter of 0.85 mm ± 0.10 mm, and supplied blood to the medial periosteum of tibia. All surgery went smoothly. A significant increase of temperature in foot skin and a significant decrease in postoperative Visual Analogue Scale(VAS) score were found in comparison with what before the surgery( P<0.05). The follow-up time of 12 patients was 24-36(29.33 months ± 4.36 months). After surgery, the symptoms of pain and numbness in the affected limbs were significantly improved or even disappeared and the wounds in foot were completely healed in 10 patients. The wounds of TTT in the calf were all healed in stage-I. The segments of tibial bone transport were all completely healed with healing time of 6.17 months ± 0.83 months. The wounds of the 2 amputees healed well. Conclusion:Modified TTT bone graft can effectively promote wound healing and reduce complications by covering the wound with a posterior tibial medial fascia flap in the treatment of severe diabetic foot. Further studies are required to confirm the benefits to the patients from this modified surgical procedure.
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Objective:To investigate the feasibility and clinical effect of the computer assisted design of the lobulated perforator flap based on the descending branch of lateral circumflex femoral artery(d-LCFA) to reconstruct the soft tissue defects of heel.Methods:From October 2014 to November 2016, a computer assisted virtual technology was used to simulate the process of pre-operative design, isolation, and harvest of d-LCFA perforating flaps. This method was used to guide the design and harvest of the flap of d-LCFA in the repair of large-area soft tissue defects of the heel in all of the 5 patients. One patient received a combine flap of the d-LCFA flap and the perforating branch of the inferior abdominal artery flap(DIEPF). Heel appearance and function were reconstructed in phase I together with the repair of the defect. Donor site was directly sutured. The recovery effect was followed-up in the clinic.Results:The 3D visualised model of the vessels in the donor area for quadriceps artery was successfully established in all 5 patients, and the design and removal of the perforating flap were successfully guided. All the 10 flaps survived successfully in 5 patients, except 1 patient had a backflow disorder at the distal end of the inferior epigastric artery perforator flap, with partial necrosis and II grafting. After 6 to 12 months of follow-up(mean, 8.7 months), the flap showed good in colour and texture, with satisfactory heel appearance. The donor site was left with a linear scar.Conclusion:Computer assisted design technology can effectively help in the design of the polyfoliate perforator flap pedicled with d-LCFA, using this technique to assist the design and repair of large area soft tissue defect of heel could reconstruct the shape of heel in phase I and restore the function of the heel to the maximum extent.
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Objective:To explore the effects of specially formed radial collateral artery perforator flaps in reconstruction of the complex digit defects.Methods:From April, 2014 to March, 2020, 20 patients with multiple digit injuries combined with bone defects were treated by digit reconstruction with radial collateral artery chimeric and polyfoliate perforator flaps. Of the 20 patients, 7 patients were treated by chimeric perforator flaps, 12 by polyfoliate perforator flaps and 1 by chimeric polyfoliate perforator flap. Altogether 28 perforator flaps and 13 bone flaps were taken. The size of perforator flaps were 9.5 cm×4.0 cm to 4.0 cm×2.0 cm, and bone flap were 1.5 cm×0.6 cm×0.6 cm to 2.5 cm×1.0 cm×0.6 cm. All the donor sites were closed directly. Regular follow-up was performed. Function and clinical effect evaluation of repaired digits were made according to the Standard for Upper Limb Function Assessment of Hand Surgery Society of Chinese Medical Association and Sensory Function Assessment Criteria of British Medical Research Council (BMRC).Results:Twenty-seven flaps survived without any event. Venous congestion occurred in 1 flap with partial skin necrosis. Postoperative follow-up lasted from 3 months to 3.5 years (average 17.5 months). The appearance and texture of all flaps were good. All bone flaps properly healed. Sensory recovery achieved S 4 in 8 flaps, S 3 in 16 flaps and S 2 in 4 flaps. Hand function evaluation showed excellent in 12 patients and good in 8 patients. Conclusion:The specially formed radial collateral artery perforator flaps have the features of various designs with reliable blood supply, and are effective in repair of multiple digit injuries combined with soft tissue and bone defects.
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Objective:To investigate the feasibility and clinical efficacy of anterolateral thigh chimeric perforator flap in repair of large area soft tissue defects around the knee joint.Methods:From January, 2015 to October, 2019, 9 patients with large area soft tissue defects around the knee joint were treated. All patients had different degrees of defect in knee joint capsule and joint opening. Before operation, the width of the flap was determined by "skin lifting and kneading test", and the location of perforators in anterolateral femoral region was confirmed and marked with the assistance of HHD detector. According to the size and shape of the wound surface, single leaf or lobulated perforator flap was designed based on the principle that the donor site should be closed directly. The minimum size of the flap was 14.0 cm×5.0 cm, there was 1 case of lobulated flap with the largest area, respectively was 17.0 cm×9.0 cm and 18.0 cm×8.5 cm. The chimeric tissue flap(muscle flap or fascia lata flap) was taken according to the location and severity of joint opening. The grafted tissue flap was used to fill the articular cavity, the flap was used to repair the wound of knee joint, the blood supply of the flap was reconstructed, and a drainage catheter was placed in the cavity of knee joint. The recovery follow-up conducted in outpatient department.Results:All flaps survived without vascular incident. The recipient site of flap in 1 patient was not thoroughly washed and drained, and there was more exudation. After dressing change and drainage, the rest recipient areas of the flap were healed in stage I. All patients entered 3 to 36(average 12) months of follow-up. The appearance and function of recipient area recovery were satisfactorily. Only a linear scar remained in donor site.Conclusion:Anterolateral thigh chemeric perforator flap is ideal for repairing large soft tissue defects around the knee joint.
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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.
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Objective:To evaluate the feasibility and clinical results of micro-dissected chimeric (II-MCh) perforator flap based on the descending branch of lateral circumflex femoral artery(d-LCFA) for repairing composite soft tissue defects of limbs.Methods:From April, 2011 to December, 2019, a total of 19 cases of composite soft tissue defects of limbs combined with deep cavity were repaired with II-MCh perforator flap or micro-dissected thin lobulated (III-MPCh) perforator flap based on d-LCFA. The flap was micro-dissected before cut off the perforator. The deep dead cavity was filled with muscle flap, and the superficial wound was repaired with micro-dissected thin perforator flap. The sizes of flaps were 6.0 cm×3.0 cm-33.0 cm×8.0 cm. The muscle flaps were cut with volumes of 5.0 cm×3.0 cm×1.0 cm-13.0 cm×10.0 cm×1.5 cm. Donor sites of the flap were closed directly. Postoperative reviews were assigned at 1, 3, 6, 9 and 12 months. The appearance, colour, texture and recurrence of infection of the flap were checked and recorded.Results:Sixteen flaps survived successfully without necrosis and with primary healing at the donor sites. Two flaps had venous occlusion within 24 hours after surgery and healed after surgical exploration and venous anastomosis. One flap had arterial crisis within 24 hours after surgery and healed after surgical exploration and arterial anastomosis. All patients entered follow-up for 8-36 months with an average of 16 months. All recipient sites achieved satisfactory appearance and function, and only linear scars left at the donor sites.Conclusion:The II-MCh perforator flap based on d-LCFA is a special modality of anterolateral thigh perforator flap, which achieves a satisfying appearance at the recipient site by micro-dissecting the flap within one procedure. This emerging technique can effectively fill the dead cavity, and is an effective method to repair complex soft tissue defects of limbs combined with deep cavity.
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Perforator flaps became popular in past 30 years due to the minimum donor site morbidity and good aesthetically contour. Limitations are found in the use of traditional perforator flap, such as limited surface area, unsuitable for repairing super-long wounds, extensive wound and wounds accompanying with dead space, etc. Special form of perforator flap is derived from the perforator flap. It overcomes the shortcomings of traditional perforator flaps, such as less donor-site morbidity, thinner flap, better patient satisfaction and without severe complications in the recipient area. In addition it further improves the clinical curative effect and enhances the value and the applications of perforator flaps. In this article, the historical development and evolution of special form perforator flaps are reviewed, and the clinical applications of the special form perforator flap in recent years are summarised, for the purpose to promote the application and development of special form perforator flap in the reconstruction of complex soft tissue defects.
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Objective:To introduce a novel surgical technique for dissecting perforator vessels (orderly retrograde four-side dissection) in anterolateral thigh perforator flap (ALTPF) and explore its clinical outcome.Methods:Respective analysis of 94 patients who underwent reconstruction of soft tissue defects with ALTPF which were dissected by orderly retrograde four-side dissection between June, 2013 and December, 2016. After surgery, the survival of flaps, recovery in shape and function of the recipient sites, and the effect on shape and function of the donor sites were observed.Results:The size of ALTPF ranged from 7 cm×5 cm to 32 cm×10 cm. Ninety-four perforators were included in 94 ALTPF, which were 89 perforators of the descending branch of circumflex femoral lateral artery, 4 perforators of the transverse branch of circumflex femoral lateral artery and 1 perforator of femoral medial artery. The time for flap harvesting was 35-95(54.39±16.39) min. Success rate of perforator harvesting was 98.9%, only 1 perforator was injured and another encountered vasospasm during surgery. Three cases had vascular crisis after flap transfer with 2 venous crises and 1 artery crisis. All of the flaps completely survived except 1 that had a partial necrosis. The follow-up time was (12.91±9.17) months. No muscular weakness on donor sites was shown in all cases.Conclusion:Orderly retrograde four-side dissection of perforator vessels in the ALTPF has achieved less donor site morbidity, shorter surgical time and is safer than the traditional techniques. It is a reliable technique to harvest perforator flaps.
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A child who suffered a complex and exceptionally large soft tissue defects of both lower extremities and feet was referred in January, 2017. A debulking deep inferior epigastric perforator (DIEPF) was used to cover the defect in right shank. The defects in left shank and foot were reconstructed by latissimus dorsi flap and bilateral debulking anterolateral thigh perforator flap (ALTPF) . Two years after operation, the appearance and texture of both lower limbs were good, and the child could walk and run almost normally. There were slightly noticeable scars left in both thighs and the back.