Application of flow-through flaps for replantation after traumatic limb amputation according to the angiosome concept.

OBJECTIVE: This study was performed to explore the treatment of the injury caused by traumatic limb amputation. METHODS: From October 2002 to October 2021, 30 cases were enrolled in the present study. The reasons for injury were as follows: 8 cases with single hydraulic column crush injury, 12 cases with gear and wire rope stranding, 6 cases with belt avulsion injury, and 4 cases with carbon block smash injury. The present study application of a free or small saphenous vein bypass to reconstruct the injured artery and vein according to the concept of the angiosome model. The defective vessels were bridged with the axial vessels of a flow-through flap, such as a medial calf flap or anterolateral femoral flap, to construct an additional blood supply and drainage vein for the severed limb. The clinical data of 30 cases with traumatic limb amputation of the lower leg and ankle were retrospectively analyzed. RESULTS: In all 30 cases of traumatic limb amputation, the replantation via the adoption of a flow-through flap was successful, and 85.6% of the patients remained in good postoperative condition. There were no symptoms of ischemia in the marginal segment after blood supply reconstruction of the transected limb by axial vascular bridging within the flap. CONCLUSION: Via the adoption of microsurgical techniques, the blood supply to the transected limb can be reconstructed by bridging the defective vessels with the adoption of the axial vessels of the flow-through flap is a feasible and advanced treatment option.

Management of Complex Upper Extremity Trauma with Associated Vascular Injury.

Introduction Combined soft tissue and vascular injuries of the upper extremity pose several challenges at once to the plastic surgeon. Many decisions have to be taken urgently that will influence the salvage or amputation of the affected extremity. The aim of this article was to provide an evidence-based outline for the management of such injuries. Learning objectives of this article are as follows: (1) approach to a patient with upper extremity composite tissue and vascular injury presenting to the emergency, (2) decision-making as to when to salvage and when to go for amputation of the traumatized upper extremity, (3) role of imaging in emergency situation, (4) role of fasciotomy, (5) intraoperative sequencing of steps, and (6) options for vascular reconstruction and the flaps used for coverage. After reading this article, the reader should have a clear understanding of the management of vascular injury in a patient with composite defects of upper extremity.

Our experience with the anterior interosseous artery fasciocutaneous flap for local and distant soft tissue reconstructions.

BACKGROUND: Martin and his colleagues in 1989 described for the first time a fasciocutaneous flap based on a posterior branch of the anterior interosseous artery (AIA). Despite its promising characteristics, this flap never achieved popularity and the literature about it is limited. The aim of the present study is to share our experience with the AIA flap both as a local and free flap in reconstructing defects of various body regions. PATIENTS AND METHODS: A retrospective review of 26 consecutive patients operated between January2001 and August 2020 was conducted. Seventeen male and nine female patients, mean age 52 years, underwent reconstruction of local and distant soft tissue defects using the AIA flap. Fourteen flaps were raised as free flap and 12 as local flaps for a total of 26 flaps. The locations of the defects included the face, the lower limb, the hand dorsum, and fingers. RESULTS: Twenty-four out of 26 flaps survived completely, and two pedicled flaps presented partial necrosis, with one requiring a new free flap procedure. One free anterior interosseous flap required revision of the venous anastomosis. Two donor site dehiscence were observed, and they both healed by secondary intention healing. Follow-ups were conducted for a mean of 18 months. All patients showed good contour restoration of the affected body part. CONCLUSIONS: The AIA flap, either free or pedicled, represents a reliable tool to perform "like-with-like" reconstructions of hand defects. In some occasions, it is well suited for shallow defects in other body parts.

Lymphatic Complications Prevention and Soft Tissue Reconstruction after Soft Tissue Sarcoma Resection in the Limbs.

Background and Objectives: The definitive treatment of soft tissue sarcomas (STS) requires a radical surgical removal of the tumor, which often leads to large soft tissue defects. When they are located in the limbs, significant damage to the lymphatic pathways is not uncommon. In the present article, we present different techniques aimed at both reconstructing the defect and restoring sufficient lymph drainage, thus preventing short- and long-term lymphatic complications. Materials and Methods: Between 2018 and 2020, 10 patients presenting a soft tissue defect with lymphatic impairment received a locoregional reconstruction by means of either pedicled or free SCIP flap. Seven patients required a second flap to reach a good dead space obliteration. In six cases, we performed an interpositional flap, namely a soft tissue transfer with lymphatic tissue preservation, and in four cases a lymphatic flow-through flap. In all cases, the cause of the defect was STS surgical excision. The average age was 60.5 years old (ranging 39-84), seven patients were females and six were males. Results: All the patients were successfully treated. In two cases, minor post-operative complications were encountered (infected seroma), which were conservatively managed. No secondary procedures were required. The average follow-up was 8.9 months (ranging 7-12 months). No signs of lymphedema were reported during this time. In all cases, complete range of motion (ROM) and a good cosmetic result were achieved. Conclusions: A reconstructive procedure that aims not only to restore the missing volume, but also the lymphatic drainage might successfully reduce the rate of postoperative complications. Both lymphatic interpositional flaps and lymphatic flow-through flaps could be effective, and the right choice must be done according to each patient's needs.

Flow-through anterolateral thigh perforator flap or medial sural artery perforator flap in repair of Gustilo Ⅲ C wound of foot / 中华显微外科杂志

Objective:To investigate the therapeutic effect of Flow-through anterolateral thigh perforator flap (ALTPF) or medial sural artery perforator flap (MSAPF) in repair of Gustilo III C wound of foot.Methods:From July 2015 to June 2021, 8 patients with Gustilo III C wound of foot were treated in the Department of Foot and Ankle Surgery of Wuxi No.9 People’s Hospital. The patients were 7 males and 1 female, aged 25-62 years old, and (45.88±12.96) years old in average. Flow-through ALTPF or Flow-through MSAPF were used to repair the defect according to the size of the wound and the length and diameter of the defect vascular. Among the patients, 6 were repaired with free Flow-through ALTPF, and 2 with free Flow-through MSAPF. The size of flap was 9 cm×5 cm-22 cm×8 cm with (115.00±46.16) cm 2 in average, and the vascular bridging was 6-12 cm in length, with (8.75±2.50) cm in average. All patients received outpatient follow-up. The appearance of the flap, blood supply of affected limb, healing of fracture and dislocation and the recovery of limb function were recorded. Maryland score was used to evaluate functional recovery. Results:The flaps survived uneventfully in all 8 patients, and the wounds in donor site healed primarily. All patients were followed-up for 6-22 months with (12.25±5.39 ) months in average. At the last follow-up, all the flaps had satisfactory contour in soft texture and blood supply without occlusion in the bridging vessels. The fractures and dislocation were healed, and the appearance and function of the foot recovered satisfactorily. The Maryland score showed excellent in 3 patients, good in 4 patients and fair in 1 patient.Conclusion:Flow-through ALTPF or MSAPF can selectively used to reconstruct the Gustilo III C wound of foot in one stage. The functional recovery of the affected limb was satisfactory and the clinical effect was good.

Revascularization of the tongue by radial forearm flow-through flap.

The concept of a flow-through flap refers to a free flap in which both the proximal and distal ends of the vascular pedicle are anastomosed to provide blood flow to the distal tissues. The purpose of this paper is to highlight the use of this technique, which may be useful in selected cases of head and neck reconstruction. In certain situations, like bilateral resection of the base of the tongue involving both lingual arteries, the application of a flow-through forearm free flap can provide an anatomical and functional restoration of the defect while revascularizing the anterior two-thirds of the tongue. We review this technique, which was used in a case of adenoid cystic carcinoma of the base of the tongue with excellent results.

Lower Extremity Marjolin's Ulcer Reconstruction With Free Anterolateral Thigh Flap: A Case Series of 11 Patients.

Background Marjolin's ulcer (MU) of lower extremities usually presents with scar contracture and functional disability. They often follow an aggressive course and poor outcome, and require early radical removal. Split-thickness skin grafts, local flaps, or amputation are commonly practiced surgical options for MU. Though free flaps are gaining popularity for various oncoplastic reconstruction, they are not frequently used for MU. A free anterolateral thigh (ALT) flap may have a beneficial role as it provides simultaneous coverage for a large defect after radical tumor and scar excision. Methods Between January 2015 and December 2018, 11 patients with lower limb MU reconstructed with free ALT flap were reviewed retrospectively for the surgical procedure, recurrences, and functional outcomes. Results Mean dimensions of the defect and flaps were 8 cm × 6 cm and 18.91 cm × 11 cm, respectively, and total flap coverage was obtained in nine cases. Marginal flap loss was noted in one and residual contracture in two cases. Functional improvement of the limb was achieved in all cases. Recurrence or disease-related mortality was not seen in any patient after a mean follow-up of 35.82 months. Conclusions Free ALT flap reconstruction of MU of extremity facilitates most radical tumor and scar-contracture removal and thus reduces the chances of re-ulceration. It facilitates local radiotherapy protocol with the provision of immediate durable coverage. Thus, it has a beneficial role other than a secondary reconstructive procedure. Moreover, an added benefit may be obtained with a "flow-through' flap" to avoid amputation and improve functional outcomes.

Microsurgical Tissue Transfer in Complex Upper Extremity Trauma.

Microsurgical tissue transfer may provide reconstructive option for extensive loss of tissues due to upper extremity trauma or tumor resection. This article reviews the authors' experience in using microsurgical tissue transfers for reconstruction of upper extremity trauma.

Treatment of chronictibial osteomyelitis with irrigation sequential Flow-through type anterolateral thigh chimeric myocutaneous flap / 中华显微外科杂志

Objective To investigate the clinical effects of irrigation sequential Flow-through type anterolat eral thigh chimeric myocutaneous flap in the treatment of chronic tibial osteomyelitis.Methods From January,2012 to December,2017,trench grooved sequential Flow-through anterolateral femoral chimeric flaps were u sed to treat chronic tibial osteomyelitis.On the basis of sensitive antibiotics,bone grooving and VSD grooved sequential Flow-through anterolateral thigh chimeric flaps were used to fill the bone cavity and cover the wound.The patients received the follow-up care in outpatient office and telephone regularly after hospital discharge.Results Among the 18 cases in this group,2 cases were positive and 16 cases were negative in secondary bacteriological detection.The flaps and donor sites survived in one stage.Fifteen cases healed in one stage,and extravasate occurred in 3 cases after operation.After dressing change,the wounds healed in 25 days,32 days and 43 days after flap operation,respectively.All the patients were followed-up for 12 to 30 months,with an average of 25 months.Local low toxicity infection symptom occurred again in 1 case with delayed healing 6 months after operation.After 1 week of antibiotic treatment,the symptom subsided.After 1 more week of antibiotic use,the patient was discharged from hospital.And followed-up for 1 year,no recurrence occurred.During the follow-up period,no recurrence of infection and no fracture occurred after primary fracture healing in other 17 cases.One year after the second operation,there was no obvi ous stenosis in the bridged vessels examined by Doppler ultrasonography and the blood flow velocity was the same as that of the contralateral limbs.Conclusion The application of irrigation and sequential Flow-through type anterolateral thigh chimeric myocutaneous flap for treatment of chronic tibial osteomyelitis can achieve good therapeutic effect and is worth popularizing.

The Deep Circumflex Iliac Artery Perforator Flap for Breast Reconstruction: Un lambeau perforateur de l'artère iliaque circonflexe profonde pour la reconstruction mammaire.

Autologous breast reconstruction using abdominal-based perforator flaps produces excellent aesthetic results with minimal donor site morbidity. The superficial inferior epigastric artery and deep inferior epigastric perforator (DIEP) flaps reliably perfuse a hemi-abdomen, up to the anterior axillary line. Beyond this line laterally, the flank or "love handle" tissue is primarily perfused by the deep circumflex iliac artery (DCIA) or secondarily by the superficial circumflex iliac artery. The flank tissue is a valuable addition to increase flap size when harvested with a DIEP flap or to provide vascularized tissue when the abdomen has been previously harvested. Harvesting the flank tissue in combination with the anterior abdominal tissue improves the contour of the trunk, accentuates the waist, and minimizes secondary revisions to excise prominent "dogears." The DCIA flap is a novel technique for breast reconstruction. In this article, we describe our technique, pearls and pitfalls, and early results.

La reconstruction mammaire autologue à l'aide de lambeaux perforateurs abdominaux produit d'excellents résultats esthétiques et une morbidité minimale au siège du donneur. Les lambeaux de l'artère épigastrique inférieure superficielle et du perforateur épigastrique inférieur profond (PÉIF) perfusent en toute fiabilité un hémi-abdomen, jusqu'à la ligne axillaire antérieure. Au-delà de cette ligne latérale, la perfusion primaire des tissus du flanc, ou de la « poignée d'amour ¼, est d'abord assurée par l'artère iliaque circonflexe profonde (AICP) ou secondairement par l'artère iliaque circonflexe superficielle. Les tissus du flanc sont un ajout précieux à l'accroissement de la dimension du lambeau lorsqu'il est prélevé avec un lambeau du PÉIF ou qu'il vise à fournir des tissus vascularisés après avoir été prélevé dans l'abdomen. Le prélèvement des tissus du flanc en combinaison avec les tissus abdominaux antérieurs améliore le contour du tronc, accentue la taille et réduit les révisions secondaires pour exciser les « oreilles de chien ¼ proéminentes. Le lambeau de l'AICP est une nouvelle technique de reconstruction mammaire. Dans le présent article, les auteurs décrivent leur technique, leurs perles et leurs écueils de même que leurs résultats préliminaires.

Application of MDCTA in free Flow-through anterolateral thigh flap for reconstructing the combined limb soft tissue with main vascular defect / 中华显微外科杂志

Objective To evaluate the clinical value of MDCTA (Multi-detector computed tomographic angiography) in reconstruction of the soft tissue defect of the limbs combined with the main vascular defects by using Flow-through anterolateral thigh flap.Methods From September,2013 to May,2016,12 cases of limb soft tissue with main vascular defects were examined by MDCTA.The length of vascular defect was measured.The length of bridging vessel needed to design a Flow-through anterolateral thigh flap was measured.The points of anterolateral thigh flap perforator were positioned.The relationship between the perforation and the trunk vascular pedicle was defined.The outcomes were evaluated based on Berton scores for upper extremities and John-Wruh scores for lower extremities.Results The length of the main vascular defects,the positions of flap perforators and the configuration of vascular pedicles were successfully imaged through MDCTA.The length of the main vascular defects were 5-12 cm,which was consistent with the intraoperative findings.The length of bridging vessel for the defects were 7-14 cm,which was enough for the vascular defects.There were not vessel grafts.Twenty perforators were imaged by MDCTA preoperatively,and 22 perforators were found during the operations,which means 2 perforators were not imaged.All flaps survived completely.All patients were followed-up from 6 to 21 months (average,11 months).According to the Berton scores for upper extremities and John-Wruh scores for lower extremities,the excellent/good were 6 in 8 cases and 4 in 4 cases,respectively.Conclusion MDCTA can be used to evaluate the pedicle conditions of the free Flow-through anterolateral thigh flap for the reconstructions.It is worthy to be popularized in clinical application.

Flow-through anterolateral thigh flap transfer combined with bone transport technique for repairing the segamental mutilating injury in lower extremity / 中华显微外科杂志

Objective To explore the clinical application and effect of Flow-through anterolateral thigh flap transfer combined with bone transport technique for repairing the segamental mutilating injury in lower extremity.Methods From June,2010 to June,2016,Flow-through anterolateral thigh flap transfer combined with Ilizarov technique were applied to repair the segamental mutilating injury in lower extremity in 10 cases.Of the 10 cases,there were 8 males and 2 females (their ages ranged from 26 to 55,36 on average).Four caused by road accident,4 caused by crush injury,2 cases caused by squeeze injury.First stage,Flow-through anterolateral thigh flap transfer were applied to revascularize the lower limb and repair the soft tissue defect in emergency.Second stage,bone transfort with external fixator were applied to repair bone defect in second stage.The area of the flap ranged from 12.0 cm×15.5 cm to 20.0 cm×25.0 cm.The repair of bone defect ranged from 4.0 cm to 10.0 cm.Time interval between two stages ranged from 2 to 4 months,3 months on average.Followed-up method was regular outpatientcare after discharge.The main contents include:the presence of red swollen with pus,the condition of infection in the pin,if the fixed pin was loosening,and adjust the speed of bone transport according to the mineralization of new bone.Results All cases were successfully repaired in 10 cases.Ten cases were followed-up with a mean followed-up time of 42 months.All flaps survived,in with 6 cases were healed in first stage,4 case were healed in second stage (healing time ranged from 14 to 30 days),and bone transfort time ranged from 6 to 16 months.The docking site union occurred in 6 cases and were healed by use of bone debridement,bone graft and compression.Deformity in foot and ankle occurred during the bone transport in 2 cases and were cured by draft therapy with adding ring fixator.The functions of donor sites were not found malfunctional.Conclusion Flow-through anterolateral thigh flap transfer combined with bone transport have high success rate of limb salvage,good quality of os teogenesis,and satisfactory function recovery.It is an optimal method to repair the segamental mutilating injury of the lower extremity.

The Vilkki Procedure as an emergency treatment in an apocalyptical hand injury - a case report and first description.

We describe a young man who suffered a severe mutilating injury of the hand and forearm while working as a cheesemaker. He underwent a complex reconstruction of his right adominant hand including a heterotopic thumb replantation into the distal radius and combined with an emergency flow-through anterolateral thigh flap.

Functional salvage of a hand after unsuccessfull attempt of replantation.

Amputation by crush injuries generally represents a contraindication for replantation, and especially when the lesion is caused by the summation of multiple concomitant traumatic mechanisms. We present the case of a 22 year- old female who arrived in our service with a crush/torsion amputation of all long fingers at the metacarpo-phalangeal level of the right hand. After the unsuccessful attempt of replantation, the functional reconstruction of the hand was achieved by using a double free flap transfer: anterolateral thigh perforator flap (ALT) and digital block transfer of second and third toes.

A case series of flow-through free anterolateral thigh flap to augment the vascularity of ischaemic limbs with soft tissue defect.

INTRODUCTION: In a world of fast moving vehicles, heavy machinery and industries crush injury to limbs with vascular compromise and soft tissue defect is common. The traditional treatment is a 2 step one dealing with vascular repair and soft tissue cover separately, in the same operation. We report a series of single step vascular repair and soft tissue cover with flow through anterolateral thigh flap (ALT) flap for limb salvage. MATERIALS AND METHODS: Ten patients with soft tissue defect and vascular injury were included in this study. A two team approach was used to minimise operative time, team one prepared the vessels and team 2 harvested the flap. OBSERVATIONS AND RESULTS: Of the ten patients operated (8 males), eight flaps were done for upper limb and two for lower limb salvage. Six anastomosis were done with ulnar vessels, two with radial and two with posterior tibial vessels. Nine extremities could be salvaged while one patient developed progressive thrombosis leading to amputation. CONCLUSION: The ALT flow-through flap is a versatile single step procedure that can be used to salvage an ischemic limb with soft tissue loss avoiding the need for interpositional vein graft.

Effects of preserving different veins on flow-through flap survival: An experimental study.

Flow-through skin flap grafting is becoming widely used for the reconstruction of skin and soft tissue defects, particularly for patients with poor blood supply around the defect. However, the treatment of the veins remains controversial. In the present study, 5×2-cm skin flaps were created on the left inner thighs of rabbits in order to investigate the effects of various treatments of the veins on the survival of a flow-through skin flap. A femoral artery perforator running through the flap was preserved. Five groups were established in which no veins, one superficial vein (SV), one accompanying vein (AV), one SV plus one AV, or all trunk veins (control) were retained. The percentage of flap area survival was determined on day 10. On days 3, 5, 7 and 9, tissues were harvested from the skin flaps and immunohistochemical analysis was performed in order to count the number of microvessels. Western blot analysis was subsequently completed in order to determine the expression levels of vascular endothelial growth factor (VEGF). The flap areas in which no veins were retained demonstrated significantly reduced survival rates on day 10, as compared with those in the other four groups (P<0.01). Furthermore, flaps with the retention of a SV also demonstrated reduced survival rates, as compared with the AV, AV plus SV and all veins groups (P<0.01); however, there no significant differences were detected between the latter three groups (P>0.05). Immunohistochemical analysis on day 3 detected a greater number of microvessels in the flaps of the control group, as compared with the flaps of the other groups. Furthermore, the AV and AV plus SV groups demonstrated a greater number of microvessels, as compared with the SV and no vein groups, and he no vein group demonstrated the fewest microvessels. No significant differences were found between the AV, AV plus SV and control groups on day 5, 7 and 9. Western blot analysis on day 5 demonstrated that the expression levles of VEGF were significantly increased in the flaps of the AV, AV plus SV and control groups, as compared with those in the SV and no vein groups. No significant differences were detected between the former three groups, and increased VEGF expression levels were detected in the flaps of the SV group, as compared with the no vein group. The flow-through flap grafts with no retained veins barely survived. Anastomosing one AV was adequate for flap survival; however, further studies are required in order to investigate the survival of flow-through flaps in more detail.

Application of venous flow-through flap in complex finger replantation / 中华显微外科杂志

Objective To analyze the outcome of applying venous flow-through flap in replantation of complex severed finger.Methods From March,2011 to August,2012,15 cases of complex severed fingers were repaired by flow-through flap with two sets of venous system of forearm vein and one stage repair of wound.The time from injury to operation was 1.5-5.5 h (mean 2.5 h).Vascular defect length ranged from 1.5 to 11.0 cm (mean 3.6 cm);and soft tissue defect of 1.5 cm × 3.0 cm to 11.0 cm × 11.0 cm.All digits had severe soft tissue defect and segmental defect of blood vessels.All the finger blood circulation was disorder.Results All flaps and replanted fingers survived completely,except 1 case of postoperative venous crisis occurred which was remission after the vascular transplantation,and 1 case of skin flap necrosis at the distal part which was healed after skin grafting; Fourteen cases were followed-up from 7 to 20 months.At the final followed-up the flaps were of good consistency and appearance.Function of the finger was graded excellent in 7 cases,good in 5 cases,and poor in 2 cases.All flaps and replanted fingers survived completely over a period of 12 to 30 months follow-up.The flaps were of good consistency and appearance.Function of the finger was graded excellent in 7 cases and good in 5 cases.Conclusion With less injury at donor site,and good repair results,venous flow-through flap is well indicated in complex finger replantation with soft tissue defect and vascule defect.

Reconstruction of lateral forefoot using reversed medial plantar flap with free anterolateral thigh flap.

Skin defects of the heel have frequently been reconstructed using the medial plantar flap; however, forefoot coverage has remained a challenge, because the alternatives for flap coverage have been very limited. We describe a case of malignant melanoma on the lateral forefoot that was radically removed and reconstructed successfully with a distally based medial plantar flap, together with a free anterolateral thigh flap. The advantages of this flap include that it does not reduce the vascular supply to the foot owing to reconstruction of the medial plantar vascular systems, reduces the risk of flap congestion, minimizes donor site morbidity, and enables the transport of structurally similar tissues to the plantar forefoot. We believe this technique is a reasonable reconstructive option for large lateral plantar forefoot defects.