Abstract The narrow pedicled intercostal cutaneous perforater (np-ICP) thin flaps were successfully used for reconstruction of hand deformity from scar contraction. This flap was designed with a narrow pedicle (3～5cm in width) which included ICPs of 4th～9th intercostal spaces, and with awide distal part (the maximum is 15cm×15cm) which covered the lower chest and upper abdomen. The thickness of flap was cut until the subdermal vascular networkwas observed. The pedicle was divided between the 7th～14th days after operation. Sixteen flaps in 15 cases were transferred for covering of the skin defects at the dorsum of the hand. The perforators which were included in the narrow pediclewere mostly from the 7th intercostal spaces in 9 flaps. Fifteen of the 16 flapswere survived almost completely, except in one case there was necrosis of the distal portion of the flap. It seemed that this flap was more useful than the conventional methods, not only functionally but also aesthetically. Moreover, the operative techinque was more simple and safer than the island or free intercostalflap due to without the necessity to dissect the main trunk of the intercostalneurovascular bundle. Gentle pressure on the thinning portion of the flap for a short time after operation was important.
Objective To explore the application value of infrared thermography in the design and harvesting of ultrathin anterolateral thigh perforator flaps. Methods Between June 2024 and December 2024, 9 cases of ultrathin anterolateral thigh perforator flaps were designed and harvested with the assistance of infrared thermography. There were 7 males and 2 females, aged 21-61 years (mean, 39.8 years). The body mass index ranged from 19.49 to 26.45 kg/m² (mean, 23.85 kg/m²). Causes of injury included 5 cases of traffic accident injuries and 4 cases of machine crush injuries. There were 3 cases of leg wounds, 2 cases of foot wounds, and 4 cases of hand wounds. After debridement, the size of wound ranged from 7 cm×4 cm to 13 cm×11 cm. The time from admission to flap repair surgery was 5-12 days (mean, 7 days). Preoperatively, perforator localization was performed using a traditional Doppler flow detector and infrared thermography, respectively. The results were compared with the actual intraoperative locations; a discrepancy ≤10 mm was considered as consistent localization (positive), and the positive predictive value was calculated. All 9 cases were repaired with ultrathin anterolateral thigh perforator flaps designed and harvested based on thermographic images. The size of flap ranged from 8 cm×5 cm to 14 cm×8 cm, with a thickness of 3-6 mm (mean, 5.2 mm). One donor site was repaired with a full-thickness skin graft, and the others were sutured directly. Postoperatively, anti-inflammatory, anticoagulant, and anti-vascular spasm treatments were administered, and follow-up was conducted. ResultsThe Doppler flow detector identified 22 perforating vessels within the set range, among which 16 were confirmed as superficial fascia layer perforators intraoperatively, with a positive predictive value of 72.7%. The infrared thermograph detected 23 superficial fascia layer perforating vessels, and 21 were verified intraoperatively, with a positive predictive value of 91.3%. There was no significant difference between the two methods [OR (95%CI)=3.93 (0.70, 22.15), P=0.100]. The perforator localization time of the infrared thermograph was (5.1±1.3) minutes, which was significantly shorter than that of the Doppler flow detector [(10.1±2.6) minutes; MD (95%CI)=–5.00 (–7.08, –2.91), P<0.001]. Postoperatively, 1 case of distal flap necrosis healed after dressing change; all other flaps survived successfully. The skin grafts at donor site survived, and all incisions healed by first intention. All patients were followed up 3-6 months (mean, 4.7 months). No pain or other discomfort occurred at the donor or recipient sites. All patients with foot wounds could walk with shoes, and no secondary flap revision was required. Flaps in 3 hand wound cases, 2 foot wound cases, and 3 leg wound cases recovered light touch and pressure sensation, but not pain or temperature sensation; the remaining 2 cases had no sensory recovery.ConclusionPreoperative localization using infrared thermography for repairing ultrathin anterolateral thigh perforator flaps can help evaluate the blood supply status of perforators, reduce complications, and improve surgical safety and flap survival rate.
Objective To investigate the effectiveness of free peroneal artery chimeric perforator flap in repairing the defect after advanced local lesions resection in parotid gland carcinoma (PGC). Methods Between June 2010 and June 2020, 32 patients with advanced local lesions of PGC were treated with extended radical resection. After that, 17 patients were repaired with the free peroneal artery chimeric perforator flaps (trial group) and another 15 patients were repaired with the pedicled pectoralis major myocutaneous flaps (control group). There was no significant difference in gender, age, disease type, histopathological classification, clinical stage, and pathological stage between groups (P>0.05). The size of skin flap in trial group ranged from 7 cm×6 cm to 12 cm×8 cm and the size of soleus muscle flap ranged from 5 cm×3 cm to 6 cm×4 cm. The donor sites were repaired with skin grafting. The size of the pedicled pectoralis major myocutaneous flaps in control group ranged from 9 cm×6 cm to 14 cm×7 cm. The donor sites were sutured directly. The operation time, survival rate of flap, and postoperative survival of patients were recorded and compared between groups. At 1 year after operation, the University of Washington quality of life (UW-QOL) questionnaire was used to evaluate the quality of life of patients in the two groups, including appearance, shoulder movement, sociability, masticatory function, speech function, and mood. Results The operations completed successfully. The operation time was (6.19±0.72) hours in trial group and (6.41±0.71) hours in control group, showing no significant difference between groups (t=–0.863, P=0.395). The survival rate of flap in trial group was 94.1% (16/17); and 1 patient suffered from vascular crisis after operation and was replaced with the pedicled pectoralis major myocutaneous flap. The survival rate of flap in control group was 100%. All grafts survived and the incisions healed by first intention in the two groups. All patients were followed up. The follow-up time was 6-60 months (median, 60 months) in trial group and 7-60 months (median, 60 months) in control group. Cumulative survival rates of patients at 1, 3, and 5 years after operation were 94.1%, 64.7%, and 58.8% in trial group, respectively; 86.7%, 66.7%, and 53.3% in control group, respectively. There was no significant difference in the cumulative survival rate between groups (χ2=0.090, P=0.762). According to the UW-QOL questionnaire at 1 year after operation, the scores of appearance, shoulder movement, sociability, and mood in trial group were significantly higher than those in control group (P<0.05); and there was no significant difference in masticatory function and speech function scores between groups (P>0.05). Conclusion The peroneal artery perforator has an invariable anatomical relationship. Each perforator emits the muscular branch that nourishes the soleus muscle. Therefore, personalized free peroneal artery chimeric perforator flap can be designed according to the tissue defect, and used to repair the defect after advanced local lesions resection in PGC.
Objective To investigate the feasibility and effectiveness of thoracodorsal artery perforator (TDAP) flap for repairing serious scar contracture of the opisthenar. Methods Between March 2015 and June 2017, 7 cases of serious scar contracture of opisthenar were repaired with TDAP flaps. There were 5 males and 2 females with an average age of 31 years (range, 11-48 years). The time from injury to operation was 8-67 months, with an average of 42 months. After the relocation of the joint and release of the scar, the size of soft tissue defect ranged from 5 cm×4 cm to 10 cm×8 cm. The size of TDAP flap ranged from 5.5 cm×5.0 cm to 10.5 cm×9.0 cm. Results All flaps survived completely with primary healing at both donor site and recipient site. The flaps of 3 patients were bulky and underwent second-stage skin flap thinning at 3 months after operation. All 7 patients were followed up 6-32 months, with an average of 15 months. The skin flaps were soft and elastic. According to the upper limb function evaluation system recommended by Chinese Society of Hand Surgery, sensory function was classified as \begin{document}$\small{{\rm{S}}_{{{\scriptsize 3}^ + }}}$\end{document} in 2 cases, \begin{document}$\small{{\rm{S}}_{{{\scriptsize 3} }}}$\end{document} in 1 case, \begin{document}$\small{{\rm{S}}_{{{\scriptsize 2} }}}$\end{document} in 3 cases, and \begin{document}$\small{{\rm{S}}_{{{\scriptsize 1} }}}$\end{document} in 1 case. The hand function was excellent in 2 cases, good in 4 cases, and fair in 1 case. There was no significant effect on shoulder movement. Conclusion The TDAP flap is an ideal method for serious scar contracture of opisthenar.
Objective To explore the feasibility and effectiveness of perforator propeller flap sequential transfer technique in repair of soft tissue defect of distal lower extremity. Methods Between July 2015 and July 2021, 10 patients with soft tissue defect of distal lower extremity were treated with perforator propeller flap sequential transfer technique. There were 8 males and 2 females, with a median age of 47 years (range, 6-71 years). The etiologies included malignant tumor in 5 cases, trauma in 3 cases, postburn scar contracture in 1 case, and diabetic foot ulcer in 1 case. The defects were located at the pretibial area in 1 case, the distal lower extremity and Achilles tendon in 3 cases, the dorsum of foot and lateral malleolar area in 4 cases, the heel in 1 case, and the plantar foot in 1 case. The size of the defect ranged from 5 cm×3 cm to 8 cm×8 cm. Peroneal artery perforator propellor flaps (the 1st flap) in size of 14 cm×4 cm to 29 cm×8 cm were used to repair the defects of distal lower extremity. The donor site defects were repaired with the other perforator propeller flaps (the 2nd flap) in size of 7 cm×3 cm to 19 cm×7 cm. The donor site of the 2nd flap was directly closed. ResultsAll the operations were successfully completed and all of the 2nd flaps were elevated within 1 hour. Eight the 1st flaps survived completely; 2 had venous congestion. Among the 2 patients with venous congestion, 1 had necrosis of the distal end of the flap, and the secondary wound was repaired by skin grafting; 1 recovered spontaneously after 7 days. The 2nd flaps totally survived. No complication such as hematoma or infection occurred. Primary closure was achieved in all the recipient and donor sites. All patients were followed up 2-39 months, with a median of 15.5 months. The color, texture, and thickness of the flaps matched well with those of recipient sites. The normal contour of the leg was preserved. During follow-up, no recurrence of malignance or ulcer was observed. The scar contracture was completely released. All patients were satisfied with the reconstructive outcomes. Conclusion The application of the perforator propeller flap sequential transfer technique can improve the repair ability of the lower extremity perforator propeller flap while ensuring the first-stage closure of the donor site, thereby improving the effectiveness.
Objective To evaluate the effectiveness of anterolateral thigh polyfoliate perforator flap plus pedicle with one foliate flap for repairing extremities soft tissue defect. Methods Between January 2014 and January 2017, 24 patients with extremities soft tissue defects were treated by anterolateral thigh polyfoliate perforator flap plus pedicle with one foliate flap. There were 15 males and 9 females, with a median age of 33.5 years (range, 5-64 years). Wounds located in upper limb in 8 cases, complicated with radial styloid fracture in 1 case, extensor tendon exposure in 3 cases, and brachioradialis muscle tendon exposed in 1 case. Wounds located in lower extremity in 16 cases, complicated with calcaneal or metatarsal, phalangeal fractures in 4 cases, Achilles tendon departure in 1 case, toe long extensor tendon and flexor digitorum longus tendon exposed in 8 cases. The wound area ranged from 8 cm×5 cm to 18 cm×12 cm. According to wound size, anterolateral thigh perforators were detected by conventional ultrasound Doppler (2-5 perforators). The irregular wounds were decomposed into multiple parts and the leaf number (2-4 leaves) of polyfoliate flap depended on the part number of the wound. The flap area ranged from 9 cm×6 cm to 20 cm×14 cm, and the largest area of single leaf was 24 cm×6 cm. The vascular pedicle length ranged from 7 cm to 12 cm. The foliate flap area with protecting pedicle ranged from 5 cm×3 cm to 7 cm×5 cm. Results All the flaps survived, and no vascular crisis occurred. All the patients were followed up 2-28 months (mean, 9 months). Sinus occurred in 1 case of calcaneal fracture after flap repair, and the sinus was healed after 3 months by conventional dressing. All the flaps were thin and had a good texture. Healing of soft tissue was found in 5 patients with fracture. The wrist and ankle plantar flexion and dorsiflexion function of recipient site were normal in all patients. Conclusion It is safe and reliable to repair the extremities soft tissue defect with anterolateral thigh polyfoliate perforator flap plus pedicle with one foliate flap. And it is one of the ways to reduce the vascular crisis of the anterolateral thigh free perforator flap.
Objective To investigate the clinical application of relaying anteromedial thigh (AMT) perforator flap in resurfacing of the donor defect after anterolateral thigh (ALT) flap transfer. Methods Between February 2012 and December 2015, 23 cases of oral carcinoma underwent radical resection; after resection of lesions, the tongue or mouth floor defects were reconstructed by ALT perforator flaps, and the donor sites were repaired with relaying AMT perforator flap at the same stage. There were 21 males and 2 females,with a mean age of 52.6 years (range, 29-74 years). Sixteen patients had tongue squamous cell carcinoma and 7 patients had buccal cancer. According to TNM tumor stage, 3 cases were classified as T4N0M0, 5 cases as T4N1M0, 7 cases as T3N1M0, 5 cases as T3N2M0, and 3 cases as T3N0M0. The disease duration ranged from 6 to 18 months (mean, 8.8 months). Results The AMT perforators existed consistently in all patients. All flaps survived, and primary healing of wounds was obtained at recipient sites and donor sites. No vascular crisis, wound dehiscence, or obvious swelling occurred. All patients were followed up 6-20 months (mean, 9.4 months). There was only linear scar at the donor sites, and the function of thighs was normal. The color and contour of the flaps were satisfactory. Conclusion The relaying AMT perforator flap is an ideal choice to reconstruct the donor site of ALT flap.
ObjectiveTo investigate the feasibility and effectiveness of the latissimus dorsi myocutaneous flap in repair of large complex tissue defects of limb and the relaying posterior intercostal artery perforator flap in repair of donor defect after latissimus dorsi myocutaneous flap transfer.MethodsBetween January 2016 and May 2017, 9 patients with large complex tissue defects were treated. There were 8 males and 1 female with a median age of 33 years (range, 21-56 years). The injury caused by traffic accident in 8 cases, and the time from post-traumatic admission to flap repair was 1-3 weeks (mean, 13 days). The defect in 1 case was caused by the resection of medial vastus muscle fibrosarcoma. There were 5 cases of upper arm defects and 4 cases of thigh defects. The size of wounds ranged from 20 cm×12 cm to 36 cm×27 cm. There were biceps brachii defect in 2 cases, triceps brachii defect in 3 cases, biceps femoris defect in 2 cases, quadriceps femoris defect in 2 cases, humerus fracture in 2 cases, brachial artery injury in 2 cases, and arteria femoralis split defect combined with nervus peroneus communis and tibia nerve split defect in 1 case. The latissimus dorsi myocutaneous flaps were used to repair the wounds and reconstruct the muscle function. The size of the skin flaps ranged from 22 cm×13 cm to 39 cm×28 cm; the size of the muscle flaps ranged from 12 cm×3 cm to 18 cm×5 cm. The wounds were repaired with pedicle flaps and free flaps in upper limbs and lower limbs, respectively. The donor sites were repaired with posterior intercostal artery perforator flaps. The size of flaps ranged from 10 cm×5 cm to 17 cm×8 cm. The second donor sites were sutured directly.ResultsAll the flaps survived smoothly and the wounds and donor sites healed by first intention. All patients were followed up 10-19 months (mean, 13 months). At last follow-up, the flaps had good appearances and textures. The muscle strength recovered to grade 4 in 5 cases and to grade 3 in 4 cases. After latissimus dorsi myocutaneous flap transfer, the range of motion of shoulder joint was 40-90°, with an average of 70°. The two-point discrimination of latissimus dorsi myocutaneous flap was 9-15 mm (mean, 12.5 mm), and that of posterior intercostal artery perforator flap was 8-10 mm (mean, 9.2 mm). There were only residual linear scars at the second donor sites.ConclusionThe latissimus dorsi myocutaneous flap combined with posterior intercostal artery perforator flap for the large complex tissue defects and donor site can not only improve the appearance of donor and recipient sites, but also reconstruct muscle function, and reduce the incidence of donor complications.
Objective To study the effect of dimethyloxalylglycine (DMOG) on angiogenesis in Choke Ⅱ zone of rats cross-zone perforator flaps and its mechanism. Methods One hundred and twenty-six adult male Sprague Dawley rats were randomly divided into DMOG group, YC-1 group, and control group, with 42 rats in each group. Cross-zone perforator flap model with size of 12 cm×3 cm was made on the back of rats in the three groups. DMOG group was intraperitoneally injected with DMOG (40 mg/kg) at 1 day before operation, 2 hours before operation, and 1, 2, and 3 days after operation; YC-1 group and control group were intraperitoneally injected with YC-1 (10 mg/kg) and the same amount of normal saline at the same time points, respectively. The survival of flap was observed after operation. At 7 days after operation, the survival area of flap in each group was measured and the survival rate of flap was calculated. Flap transmittance test, gelatin-lead oxide angiography, and HE staining were used to observed the angiogenesis in the Choke Ⅱ zone of flaps in each group. Immunohistochemical staining and Western blot were used to detect the expressions of vascular endothelial growth factor (VEGF) and hypoxia-inducible factor 1α (HIF-1α) in Choke Ⅱ zone of flaps in each group. The expressions of VEGF and HIF-1α were also determined by ELISA at 3, 5, and 7 days. Results At 7 days after operation, there was no obvious necrosis at the distal end of the flap in DMOG group, while necrosis occurred in both the control group and YC-1 group, mainly located at the distal end. The flap survival rate of DMOG group was 90.28%±1.37%, which was significantly higher than that of YC-1 group (84.28%±1.45%) and control group (85.83%±1.60%) (P<0.05). DMOG group had more angiogenesis in Choke Ⅱ zone and the vascular structure was clear and complete. In YC-1 group and control group, the vessels in Choke Ⅱ zone was less and the vascular structure was disordered. The number of vessels was (25.56±1.29)/field in the DMOG group, which was significantly higher than that in the YC-1 group [(7.38±0.54)/field] and the control group [(14.48±0.91)/field] (P<0.05). At 3, 5, and 7 days after operation, HIF-1α and VEGF expressions in ChokeⅡzone of DMOG group were significantly higher than those in YC-1 group and control group (P<0.05). ConclusionDMOG can promote angiogenesis in Choke Ⅱ zone, accelerate the early angiogenesis of the flap, improve the microcirculation and blood supply in the potential zone of the flap, reduce the injury of flap ischemia and hypoxia, and increase the survival rate of the flap.
ObjectiveTo investigate the feasibility and effectiveness of the superior lateral genicular artery perforator flap for repairing of soft tissue defects in extremities.MethodsBetween September 2010 and October 2017, 11 cases of skin and soft tissue in extremities were repaired with the superior lateral genicular artery perforator flap. There were 10 males and 1 female, with an average age of 37.6 years (range, 6-72 years). The causes of injury were traffic accident in 6 cases, machine injury in 1 case, falling down injury in 1 case, falling from height in 1 case, crushing injury in 1 case, and electric injury in 1 case. The defects located at the forearm in 1 case, knee in 5 cases, popliteal fossa in 2 cases, shank in 1 case, and foot and ankle in 2 cases. The area of the wound ranged from 8.0 cm×4.5 cm to 27.0 cm×8.0 cm. The interval from injury to admission was 6 days on average (range, 3-12 days). The area of perforator flap ranged from 9.0 cm×5.5 cm to 28.0 cm×9.0 cm. There were 8 cases of pedicle flap and 3 cases of free flap. All the donor sites were closed directly.ResultsEight flaps survived without any complications and the donor sites healed by first intention. Two flaps had arterial crisis and 1 flap had venous crisis after operation, and the wounds healed after symptomatic treatment. There was no hematoma and secondary infections in all patients after operation. Ten patients were followed up 2-48 months (mean, 13.1 months). All flaps had satisfied appearance and texture. There was no motion limitations in the hip and knee joints of the operated legs.ConclusionThe superior lateral genicular artery perforator flap not only can be used to repair the soft tissue defect around the knee joint as pedicle flap, but also can be used to repair the forearm and foot skin and soft tissue defects as free flap, which is a feasible way to repair soft tissue defects in extremities.