【Abstract】 Objective To research the method and effectiveness of V-Y advancement of skin flap pedicled with the upper limb lateral branch in the treatment of small skin defect in the dorsal elbow. Methods Between March 2008 and August 2010, 6 cases of skin defect in the dorsal elbow were treated by V-Y advancement of skin flap pedicled with the upper limb lateral branch, including 4 males and 2 females with a mean age of 53 years (range, 16-76 years). Defects were caused by crushing in 3 cases, by punching in 2 cases, and the disease duration was 4 hours 30 minutes to 7 days (mean, 29.5 hours); and by chronic infection in 1 case, and the disease duration was 12 months. The defect size ranged from 4.0 cm × 2.5 cm to 9.5 cm × 3.5 cm, all complicating by bone or tendon exposure. The flap size ranged from 6.0 cm × 4.0 cm to 12.5 cm × 9.5 cm; the donor sites were sutured directly. Results All flaps survived completely, wounds and incisions at donor sites healed by first intention. Six cases were followed up 6-12 months after operation. The flaps had good texture and color. Two-point discrimination of the skin flap was 12-16 mm. The function of limb was normal, and elbow flexion and extension activity averaged 105° (range, 95-125°). Conclusion It is ideal to treat small skin defect in the dorsal elbow with V-Y advancement of skin flap pedicled with the upper limb lateral branch because of easier operation and less injury at donor site.
Objective To explore the method and effectiveness of abdominal expanded subdermal vascular plexus skin flaps in repairing dorsal hand scar. Methods Between May 2005 and October 2010, 16 cases of dorsal hand scars weretreated with the abdominal expanded flaps. There were 13 males and 3 females, aged 22.5 years on average (range, 10-35 years). Defect was caused by burn in 10 cases, hot crush injury in 4 cases, and scald injury in 2 cases. The average scar formation was 21 months (range, 1 year and 6 months to 2 years). The patients had flexion restriction of metacarpophalangeal joint and interphalangeal joint. The scar size ranged from 11 cm × 7 cm to 18 cm × 10 cm. The expander was implanted in abdominal skin and inflated with water regularly at the first stage. After 2 weeks, the expanded pedicled flap was trasferred to repair wounds in which scars were excised. The flap size ranged from 12 cm × 9 cm to 19 cm × 12 cm. After being cut off the pedicle at 14 days, the fingers were divided, and the digital web was formed. The abdominal donor site was directly sutured. Results All flaps survived. The wound and donor site achieved primary heal ing. Sixteen cases were followed up 1 year and 2 months to 3 years with an average of 2 years and 3 months. The flaps had soft texture and good flexibil ity. At last follow-up, hand function was graded as excellent in 13 cases, good in 2 cases, and poor in 1 case with an excellent and good rate of 93.7% according to the total active motion evaluation system. Conclusion Abdominal expanded subdermal vascular plexus skin flap is an effective method to repair large scar of the dorsal hand because it has satisfactory texture, fast rebuilding of blood supply, and large area of survival.
Objective To investigate the cl inical results of cross-finger flap combined with laterodigital pedicled skin flap for repair of severe flexion contracture of the proximal interphalangeal joint. Methods Between October 2008 and February 2011, 11 patients (11 fingers) with severe flexion contracture of the proximal interphalangeal joint were treated with cross-finger flap combined with laterodigital pedicled skin flap. There were 7 males and 4 females, aged 20-63 years (mean, 32.6years). The causes of injury were crush or electric-saw injury in 7 cases, burn or explosive injury in 3 cases, and electrical injury in 1 case. The locations were the index finger in 4 cases, the middle finger in 2 cases, the ring finger in 2 cases, and the l ittle finger in 3 cases. The mean disease duration was 12.4 months (range, 6-24 months). All cases were rated as type III according to Stern classification standard. The volar tissue defect ranged from 3.0 cm × 1.5 cm to 5.0 cm × 2.5 cm, with exposed tendons, nerves, vessels, or bone after scar relaxation. The defects were repaired with cross-finger flaps (2.2 cm × 1.8 cm to 3.8 cm × 2.5 cm) combined with laterodigital pedicled skin flaps (1.5 cm × 1.2 cm to 2.5 cm × 2.0 cm). Double laterodigital pedicled skin flaps were used in 3 cases. The flap donor site was sutured directly or repaired with the skin graft. Results All flaps survived completely and wound healed by first intention. The donor skin graft survived. All the patients were followed up 6-18 months (mean, 11.3 months). The finger appearance was satisfactory. The flaps had soft texture and good color in all cases. No obvious pigmentation or contraction was observed. The contracted fingers could extend completely with good active flexion and extension motion. At last follow-up, the extension of the proximal interphalangeal joint was 10-15°. Based on proximal interphalangeal joint motion standard of Chinese Medical Association for hand surgery, the results were excellent in 6 cases, good in 4 cases, and fair in 1 case; the excellent and good rate was 90.9%. Conclusion It is an easy and simple therapy to cover wound area of severe flexioncontracture of the proximal interphalangeal joint after scar relaxation using cross-finger flap combined with laterodigital pedicled skin flap, which can repair large defect and achieve good results in finger appearance and function.
Objective Dexamethasone (DXM) can regulate the balance of neutrophil and cytokine and enhance the ischemia-reperfusion tolerance of the skin flap; amlodipine besylate (AB) can selectively expand the peripheral blood vesselsand rel ieve the vascular smooth muscle spasm. To investigate the percutaneous penetration abil ity of DXM/AB compound gel and evaluate its effect on survival of ischemic skin flap. Methods Sodium carboxymethylcellulose was used to make blank gel, which was mixed in DXM, AB, azone (AZ), and progylene glycol (PG) respectively to make the compound gel containing 0.3%DXM/0.5%AB only (group D), the compound gel containing 3%AZ/2%PG, 3%AZ, and 2%PG (groups A, B, and C), the 0.3%DXM gel containing 3%AZ/2%PG (group E), the 0.5%AB gel containing 3%AZ/2%PG (group F). The accumulative penetration of DXM and AB in compound gel, 0.3%DXM gel, 0.5%AB gel through excised rat skin and its penetration within flap tissue were investigated by ultraviolet spectrophotometry. Fifty SD rats were selected to make 100 mm × 10 mm random flap at the back, and were randomly divided into 5 groups according to different gels which were used to treat flaps (n=10): compound gel group (group A1), 0.3%DXM gel group (group B1), 0.5%AB gel group (group C1), blank gel group (group D1), and peritoneal injection of DXM (5 mg/kg) and AB (2 mg/kg) (group E1). The survival area of ischemic random skin flap was measured on the 7th day by planimetry. Twenty-four SD rats were selected to make 100 mm × 10 mm random flap at the back, and were randomly divided into 2 groups (n=12). The accumulative penetration of DXM and AB within skin flap were also detected at 2 and 6 hours after appl ication of 2 g of compound gel containing 3%AZ/2%PG (group A2) and peritoneal injection AB (2 mg/kg) / DXM (5 mg/kg) (group B2). Results The accumulative penetration of DXM and AB in compound gel were increased in time-dependent manner (P lt; 0.05), and it was the highest in group A, and was significantly higher than that in group B and group C (P lt; 0.01), but there was no significant difference when compared with group E or group F (P gt; 0.05). The accumulative penetration of DXM and AB in groups A, B, and C were significant higher than that in group D (P lt; 0.05). After 7 days, the survival area of flaps in groups A1, B1, C1, D1, and E1 were (695.0 ± 4.6), (439.3 ± 7.1), (477.5 ± 14.5), (215.2 ± 3.8), and (569.4 ± 9.7) mm2, respectively; group A1 was significantly higher than other groups (P lt; 0.05). After 2 and 6 hours, the quantities of DXM and AB in skin flap of group A2 were significantly higher than that of group B2 (P lt; 0.05). Conclusion In 0.3%DXM/0.5%AB compound gel, DXM and AB might penetrate into skin tissue, which could significantly increase the survivalarea of ischemic skin flap.
Objective To investigate the effects of ecdysterone on the survival of the dorsal random-pattern skin flap with large length-to-width ratio in rats and its possible mechanisms. Methods Twenty-four healthy adult SD rats (male and/or female) weighing 200-250 g were randomly divided into the experimental group and the control group (n=12 per group).A caudally based dorsal random pattern skin flap, measuring 8 cm × 2 cm, was symmetrically raised. Ecdysterone (5 mg/kg) and normal sal ine (5 mg/kg) were injected into the abdominal cavity of rats in the experimental group and the control group at 10 minutes before operation and from the first to the fifth day after operation, respectively. The general condition of the rats was observed after operation. At 7 days after operation, the survival rate of the flap was detected, the superoxide dismutase (SOD) activity and the malonyldialdehyde (MDA) level were tested, HE and immunohistochemistry staining observation of the flap were performed. VIII factor dried microvessels in the middle part of the flap (4 cm far away from pedicle) were counted. Results All the rats survived until the end of the experiment. At 7 days after operation, the survival rate of the flap was 62.323% ± 7.046% in the experimental group and 47.753% ± 2.952% in the control group (P lt; 0.001); SOD activity was (54.560 ± 4.535) U/mgprot in the experimental group and (23.962 ± 3.985) U/mgprot in the control group (P lt; 0.001); MDA level was (8.445 ± 0.992) nmol/mgprot in the experimental group and (14.983 ± 0.929) nmol/mgprot in the control group (P lt; 0.001). Histology observation: compared with the control group, the inflammatory cells infiltration was less and the hyperplasia of fibers was more obvious in the experimental group. The microvessel counting in the middle part of the flap was 17.817 ± 2.420 in the experimental group and 8.967 ± 2.000 in the control group (P lt; 0.001). Conclusion Perioperative intraperitoneal injection of ecdysterone can promote the survival of the random-pattern skin flaps with large length-to-width ratio. Its mechanism may be related to its effects of improving SOD activity, decreasing l ipid peroxidation, and promoting angiogenesis of skin flaps.
【Abstract】 Objective To investigate the blood supply of the expanded skin flap from the medial upper arm andits appl ication for the repair of facial and cervical scar. Methods From May 2000 to February 2007, 20 cases (12 males and 8 females; aging from 7 to 42 years) of facial and cervical scar were treated with the expender flap from medial upper arm. The disease course was 9 months to 20 years. The size of the scar was 8 cm × 6 cm - 22 cm × 18 cm. The operation was carried out for three steps: ① The expander was embed under the superior proper fascia. ② The scar in the face and cervix was loosed and dissected. Combined the expanded skin flap from the medial upper arm(the size of the flap was 9 cm × 7 cm - 24 cm × 18 cm) in which the blood supply to the flap was the superior collateral artery and the attributive branches of the basil ica with auxil iary veins for blood collection with partial scar flap (3.5 cm × 2.5 cm - 8.0 cm × 6.0 cm) was harvested and transferred onto the facial and cervical defect. ③ After being cut off the pedicle, the scar was dissected. The expanded flap was employed to coverthe defect. Results After 3-24 months follow-up with 16 cases, all the grafted skin flaps survived at least with nearly normal skin color, texture and contour. The scars at the donor sites were acceptable. The function and appearance of the face and cervix was improved significantly. No surgery-related significant compl ications were observed. Conclusion Repair of facial and cervical scar with the medial upper arm expanded skin flap is a plausible reconstructive option for head and face reconstructions. However, a longer surgery time and some restrictive motion of the harvested upper l imbs might be a disadvantage.
Objective To research the effects of vascular endothelial growth factor (VEGF) on the survival of reverse flow axial skin flaps. Methods A 8 cm×2 cm full thickness transverse dorsal flap based on right deep circumflex iliacartery was elevated in 20 SpragueDawley rats, which length crossing midline was 4.0 cm. The rats were randomized into two groups:experimental group (n=10), subcutaneous VEGF injections into the flap (200 ng, 200 μl) after flap elevation; controlgroup (n=10), subcutaneous saline injections into the flap (200 μl) after flap elevation. The flap was immediately sutured to its recipient beds then the injection was executed. Seven days after operation, the survival area of flaps and density of vessels were observed and measured, meanwhile its histological representation of the flaps was examined. Results After 7 days of recovery, the mean survival area of flaps was 15.55±0.27 cm2 in experimental group and 13.42±0.57 cm2 in control group. The difference was significant between experimental group and control group (P＜0.01). The mean vessel density of flaps was 21.00±3.16 in control group and 34.40±3.75 in experimental group. The difference was significant between experimental group and control group (P＜0.01). Histological analysis demonstrated that a qualitatively greater amount of granulation tissue, regular collagen fiber and a lot of fibrillated cells were observed in experimental group. Erythrocytes were leaked outfrom vessels, and inflammatory cells were observed around in control group. Conclusion In early survival of flaps, the VEGF can improve the survival of areverse flow axial skin flap through improving angiogenesis and increasing the perfusion of vessel. It is an effective method of improving the survival of reverse flow axial skin flaps that VEGF is fully injected in subcutaneous flaps by single, when flaps are elevated.
Objectives To investigate the clinical therapeutic effect of tibial boneskin flaps in the repair of infective boneskin defects of the leg. Methods Between February 2000 and March 2005, 68 cases of leg infective wounds with tibial bone and skin defects were treated: 4 cases using free grafting, 64 cases using crossleg or ipsilateral transposition grafting of tibial boneskin flaps so that the tibial support continuity of the affected leg could be reconstructed and the wound could be covered at one stage. The skin flap area ranged from 9 cm×4 cm to 25 cm×12 cm and the bone flap length ranged from 6 cm to 21 cm. Results The flaps were completely survived in 67 of the 68 cases except 1 case which was repaired by fibular boneskin flaps because of the failed blood-vessel anastomosis; the bone flaps were healed in 66 cases,except 1 case which had delayed union of the proximal end through 6month follow-up because tibial bone flap was lengthened, leading to long soft tissue stripping of the proximal end. All the 68 patients were followed up 6 months to 5 years. The leg function and contour weresatisfactory 2 years after operation. Those patients followed up more than 2 years showed normal weight loading walking without obviously abnormal gait, and can engaged in original work. Conclusion On the basis of sufficient antiinfection, the onestage reconstruction of tibial support continuity and the covering of wound by the three methods are suitable for many types of leg bone and skin defects, have a great application value and high successful rate and can retain the affected limb and create the conditions for the functional recovery.
Objective To investigate the effect of natural hirudin which is appl ied locally on vein congestion of random pattern skin flap in porcine models. Methods Three Guangxi Bama miniature pigs, including male and female aged 6-8 months and weighing 10-15 kg, were employed to establ ish animal model of vein congestive. Six dorsal random pattern skin flaps (three on each side) were prepared on each animal, 14 cm × 4 cm in size. According to the pharmacologic manipulations which were administered immediately and at 1, 2, and 3 days after operation respectively, the eighteen flaps were divided randomly into 3 groups (six in each group). In group A, isotonic Na chloride was locally appl ied as control group. In group B, 3 mL of 20 ATU natural hirudin was locally appl ied at each flap. In group C, 3 mL of 40 ATU natural hirudin was locally appl ied at each flap. Macroscopic observation (at 1 and 10 days postoperatively) and histological observation (at 1 and 7 days postoperatively) were made, the ratio of wet weight to dry weight of the congestive tissue (at 3 and 7 days postoperatively), the temperature of the surface of congestive flap (at 5 days postoperatively) and local blood flow of the flap (by Color Doppler Ultrasound at 7 days postoperatively) were measured. The survival rate of skin flaps was determined at 12 days postoperatively. Results Macroscopic observation showed that congestion of the flaps had no significance among three groups immediately after operation (P gt; 0.05); at 1 day postoperatively, the length of the congestion of the flap in group A (9.68 ± 0.43) cm was significantly longer than that in group B (6.81 ± 0.53) cm and group C (8.51 ± 0.64) cm (P lt; 0.05), while there was no significant difference between group B and group C (P gt; 0.05); at 10 days postoperatively, the necrosis at the distal end of flap in group A and group C were significantly longer than that in group B (P lt; 0.05), while there was no significant difference between group A and group C (P gt; 0.05). The histological observation revealed that the degree of erythrocyte agglutination in dermis capillary and veinule in group A was more serious than that of group B at 1 day postoperatively, and there was l ittle collagen and granulation tissue in group A when compared with group B at 7 days postoperatively. The ratio of wet weight to dry weight: at 3 days postoperatively, the value in group A (3.94 ± 0.14) was significantly higher than that of group B (3.43 ± 0.14) and group C (3.60 ± 0.19) (P lt; 0.05), and there was no significant difference between group B and group C (P gt; 0.05); at 7 days postoperatively, the value in group A (3.61 ± 0.11) was significantly higher than that of group B (3.08 ± 0.13) and group C (3.34 ± 0.21) (P lt; 0.05), and there was no significant difference between group B and group C (P gt; 0.05). The surface temperature of the congestive flap was (36.64 ± 0.70)℃ in group A, (38.61 ± 0.42)℃ in group B and (37.50 ± 0.46)℃ in group C at 5 days postoperatively; showing significant difference between group A and groups B, C (P lt; 0.05), and no significant difference between group B and group C (P gt; 0.05). The Color Doppler Ultrasound showed that the image of blood flow was very l ittle in group A, the image of venous return and perforator artery could be seen in group B and the image of arterial blood flow could be detected in group C. The survival rate of skin flaps was 45% ± 7% in group A, 67% ± 4% in group B and 52% ± 4% in group C at 12 days postoperatively; showing statistically significant difference between groups B, C and group A (P lt; 0.05), but no statistically significant difference between group B and group C (P gt; 0.05). Conclusion Local appl ication of natural hirudin can significantly improve the congestion of random pattern skin flap in a porcine model.
Objective To investigate the microanatomic basis of thepudendalthigh flap and provide the anatomic basis for clinical application. Methods Skin microdissection of the pudendal regions was performed on 11 adult cadavers (22 sides). Then, the clinical way was simulated to obtain the flaps, and the vessels and nerves contained in them were surveyed. After that, the tissues in the deep part were dissected, and the vessels and nerves were traced back to their origins. The notes were taken. Results The blood supply to the pudenal regions was plentiful and constant. The initiation point of the superficial external pudendal artery was 2.14+ 0.23 mm in diameter; one branch of it was the inguinal branch and the other branch was the perineal branch. Their diameters were 1.38+0.34mm and 1.21+0.24 mm. The initiation point of the posterior labial or scrotum arteries was 1.13+0.24 mm in diameter, and the lateral branch was 0.67+0.33 mm in diameter. The anterior cutaneous branch of the obturator artery was 1.68+ 0.11 mm in diameter. The position of all the blood vessels was relatively constant, especially the external pudendal artery and the lateral branch of the posterior scrotal artery. Many of the blood vessels passed through the areas of the pudendum and the thigh, anastomosed with each other. Three groups of the vascular net passed through the upper, middle and lower parts of the flap. Three main groups of the innervation were as the following: the ramus femoralis nervi genitofemoralis, the cutaneous branches of the ilioinguinal nerve, and the postnerve of the scrotum or the labia vulvae. Conclusion The pudendalthigh flaphas an abundant blood supply, and its dissection is convenient with an easy incision; the donor site is covert. The pudendalthigh skin flap has the following advantages for the sexual organ reconstruction: the skin flap can have a good sensation and a good shape, and the operative procedure is easy to perform.