Objective To explore the effectiveness of changeable cross-leg style sural neurovascular flap in repairing contralateral fairly large soft tissue defects on dorsum of forefoot. Methods Between June 2006 and June 2015, 12 patients with fairly large soft tissue defect on dorsum of forefoot were treated. There were 8 males and 4 females, with an average age of 35.6 years (range, 18-57 years). Defects were caused by traffic accident injury in 4 cases, machine crush injury in 3 cases, and heavy object crush injury in 3 cases, with a median disease duration of 11 days (range, 5 hours to 28 days) in the 10 cases; the defect cause was atrophic scar in 2 cases, with disease duration of 2 years and 3 years respectively. The wound size of soft tissue ranged from 6.2 cm×4.1 cm to 11.5 cm×7.4 cm; combined injuries included tendon exposure in all cases and bone exposure in 6 cases. The changeable cross-leg style sural neurovascular flaps were used to repair defects. The width and length of flap pedicle were increased. The cross-leg position was maintained with the elastic net bandage. The size of flaps was 16 cm×7 cm to 21 cm×11 cm, with a pedicle of 8-16 cm in length and 5-6 cm in width. Results After operation, 10 flaps survived, and wound healed by first intention. Extravasated blood occurred at the flap edge in 2 cases and was cured after symptomatic treatment. No pressure sore occurred. All patients were followed up 3-24 months (mean, 7 months). The appearance and function of the affected legs were good, and the flaps had soft texture and normal color. Conclusion Changeable cross-leg style sural neurovascular flap can achieve good effectiveness in repairing fairly large soft tissue defect on dorsum of forefoot. Some drawbacks of single cross-leg style can be avoided.
Objective To explore the feasibility and technical points of soft tissue defect reconstruction of the lower extremity using the distally based anterolateral thigh (dALT) flap based on perforating vessels from the lateral circumflex femoral artery (LCFA) oblique branch. Methods Between July 2010 and July 2016, 7 patients underwent defect reconstruction of the lower extremities using the dALT flap based on perforating vessels from the LCFA oblique branch. There were 4 males and 3 females with an average age of 26.7 years (range, 3-58 years). The etiologies included angiofibrolipoma in 1 case, malignant fibrous sarcoma in 1 case, soft tissue sarcoma in 1 case, and post-burn scar contracture in 4 cases. The disease duration was 13 years, 1 year, and 8 months in 3 patients with tumors respectively, and was from 6 months to 35 years in 4 patients with post-burn scar contracture. After resection of lesion tissues, the defect size ranged from 8 cm×6 cm to 24 cm×8 cm. The flap size ranged from 9 cm×7 cm to 24 cm×8 cm. The length of the pedicle ranged from 12 to 22 cm (mean, 16.6 cm). The distance from the flap pivot point to the superolateral border of the patella ranged from 9.5 to 14.0 cm (mean, 11.8 cm). The donor sites were directly closed in 6 cases and covered with the split-thickness skin graft in 1 case. Results All flaps survived after surgery without any major complications. All wounds at the donor and the recipient sites healed primarily. The patients were followed up from 5 to 54 months (mean, 30.7 months). The color, texture, and thickness of the flaps were similar to those of the surrounding skin. No tumor recurrence was observed. The range of motion of flexion and extension of the knee joint were greatly improved in the patients with post-burn scar contracture. Conclusion For patients who have the oblique branch from the LCFA descending branch which sends out perforating vessels to the skin of the anterolateral thigh region, a dALT flap could be used to reconstruct soft tissue defects of the lower extremities.
ObjectiveTo investigate the efficacy of anterolateral thigh (myocutaneous) flap designed with computed tomography angiography (CTA) to reconstruct oral and maxillofacial soft tissue defects.MethodsBetween January 2011 and December 2015, 23 cases of oral and maxillofacial tumors were treated. There were 14 males and 9 females with the age range from 45 to 72 years (mean, 56.8 years). There were 12 cases of tongue carcinoma, 5 cases of buccal mucosa carcinoma, 4 cases of mouth floor carcinoma, and 2 cases of oropharynx carcinoma; all were squamous cell carcinoma. According to standard TNM staging of the Union for International Cancer Control (UICC), 8 cases were rated as T2N0M0, 3 cases as T2N1M0, 1 case as T2N2M0, 4 cases as T3N0M0, 2 cases as T3N1M0, 2 cases as T3N2M0, 2 cases as T4N1M0, and 1 case as T4N2M0. The course of disease was 1-6 months (mean, 2.4 months). CTA was performed before operation to locate the perforator vessel and its surface projection of emerging point and to design anterolateral thigh (myocutaneous) flap by computer. The defects of soft tissue ranged from 6 cm×4 cm to 11 cm×7 cm after resection of tumor. The flap was used to repair defects, including 14 thinned anterolateral thigh flaps, 7 anterolateral thigh myocutaneous flaps, and 2 anterolateral bilobed flaps; and the flap area ranged from 7 cm× 5 cm to 12 cm×8 cm. The donor sites were sutured directly.ResultsCTA showed that myocutaneous perforators penetrated at the fascias of the vastus lateralis muscles in 22 cases with a location rate of 95.7% (22/23). Submandibular fistula occurred in 1 case at 5 days after operation and fistula healed after changed dressings. Other wounds at recipient site and donor site healed at primary stage. Anastomose with 2 vein was performed because of poor venous return in 1 case, and the flap survived. The other flaps survived well. All the patients were followed up 6-36 months (mean, 16.4 months). At 3 months after operation, the simplified recovery standard of speech function and swallow function was established according to the University of Washington Quality of Life Scale (UW-QOL). The speech and swallow function recovered satisfactorily in 22 cases, and not very satisfactorily in 1 case of well differentiated squamous cell carcinoma of the right mouth floor (T 4N1M0). No obvious tissue atrophy was observed in 23 cases. No dysfunction was found at the donor site. There was no tumor recurrence in 21 patients; 1 patient accepted the second operation due to lymphonodi metastasis of contralateral neck at 6 months after first operation, who died after 23 months; 1 patient died of distant metastasis at 10 months after first operation.ConclusionThe anterolateral thigh (myocutaneous) flap designed with CTA could well recover the morphology and function of the recipient site.
Objective To review the research progress of adipose-derived stem cells (ADSCs) in skin wound healing. Methods The recent experiments and clinical studies on the role of ADSCs in skin wound healing were extensively retrieved and analyzed. Additionally, possible mechanisms and novel application strategies were proposed. Results As confirmed by in vitro and in vivo experiments and clinical studies, ADSCs promote skin wound healing mainly by two mechanisms: differentiation to target cells that participate in skin wound healing and cytokines paracrine to promote proliferation and migration of various cell lines that are mandatory to promote skin wound healing. Moreover, scaffold materials and cell sheet technology may further add to the potency of ADSCs in promoting skin wound healing. Conclusion Remarkable progress has been made in the application of ADSCs in skin wound healing. Further studies are needed to explore the application methods of ADSCs.
Objective To explore the feasibility of harvesting free thinned innervated anterolateral thigh (ALT) perforator flap for repairing the donor defect after wrap-around flap transfer. Methods Between May 2011 and December 2013, free thinned innervated ALT perforator flap was used to repair the donor defects after wrap-around flap transfer in 9 patients. There were 8 males and 1 female, with a mean age of 31.2 years (range, 19-42 years). The interval time between injury and admission was 3-12 hours (mean, 6.5 hours). Injury causes included machine crush injury (4 cases), traffic accident injury (3 cases), and twisting injury (2 cases). The wrap-around flaps were transferred to reconstruct thumb defects. And the size of donor site defect ranged from 3 cm×2 cm to 8 cm×5 cm. A branch of the lateral femoral cutaneous nerve was carried to make innervated ALT perforator flap for donor site repair. The size of innervated ALT perforator flap ranged from 3.0 cm×2.0 cm to 8.5 cm×5.0 cm. The thickness of innervated ALT perforator flap before defatting ranged from 2.0 to 4.5 cm (mean, 3.2 cm); the thickness after defatting ranged from 0.4 to 0.6 cm (mean, 0.5 cm). The defect at the anterolateral thigh was primarily closed in all cases. Results All reconstructed thumbs and ALT perforator flaps survived. All patients were followed up 6-30 months (mean, 15.8 months). The ALT perforator flaps had good appearance and color, with no further flap revision or defatting procedures. The static two-point discrimination was 8-15 mm (mean, 10.5 mm). All patients could walk and run normally without postoperative skin erosions or ulcerations. Conclusion The free thinned innervated ALT perforator flap is pliable and thin. It is suitable for repairing the donor site defects after wrap-around flap transfer for thumb reconstruction.
Objective To investigate the effectiveness of latissimus dorsi Kiss flap for repairing composite tissue defects and functional reconstruction of upper arm. Methods Between March 2010 and November 2016, 12 cases of composite tissue defects of upper arm were repaired by latissimus dorsi Kiss flap with blood vessel and nerve bunch. There were 8 males and 4 females with a median age of 34 years (range, 21-50 years). The reason of injury included plowing mechanical injury in 4 cases, traffic accident injury in 5 cases, electrical injury in 2 cases, and resecting upper arm soft tissue sarcoma in 1 case. There were deltoid defect in 5 cases, triceps brachii and brachialis defect in 4 cases, and deltoid, triceps brachii, and brachialis damaged in varying degrees in 3 cases. The defect area ranged from 13 cm×7 cm to 20 cm×8 cm. Among them, there were 6 cases of fracture combined with partial bone exposure, one of them with bone defect. The disease duration was 3 hours to 6 months. The flap size ranged from 10 cm×6 cm to 15 cm×7 cm, and the donor sites were directly sutured. Results Twelve flaps survived with primary healing of wounds. Ten patients were followed up 6-26 months (mean, 14 months). At last follow-up, the flaps were soft and the skin color was similar to the surrounding skin. No obvious scar was found at donor sites. The abduction range of motion of shoulder was 30-90°. The muscle strength of brachialis were all at grade 4 or above. The superficial sensation and tactile sensation recovered partialy (S1 in 2 cases, S2 in 6 cases, S3 in 2 cases). According to Society of Hand Surgery standard for the evaluation of upper part of the function, the shoulder joint function was excellent in 2 cases, good in 4 cases, and fair in 4 cases. Conclusion The design of the latissimus dorsi Kiss flaps are flexible, and the donor site can be directly sutured, with the nerves of the latissimus dorsi muscle can partialy reconstruct abduction function of upper arm. In general, the Kiss flap repairing upper arm defect can obtain satisfactory effectiveness.
Objective To investigate the feasibility and effectiveness of designing wide pedicle of abdominal pedicled flap and repairing large skin defect of upper limb with improved suture method. Methods Between March 2014 and August 2016, 11 cases with hand and forearm skin soft tissue defect were repaired with abdominal pedicled flaps. Among them, 8 cases were male and 3 were female; aged 18-65 years (mean, 38 years). The causes of injury were machinery injury in 7 cases and traffic accident in 4 cases. The wound located at left upper limb in 6 cases and right upper limb in 5 cases. The size of wound ranged from 12 cm×7 cm to 20 cm×10 cm. The interval from injury to operation was 2-5 days (mean, 4 days). Four cases were repaired with lower abdominal flap and 7 with umbilical flap. The size of flap ranged from 10 cm×9 cm to 22 cm×10 cm. And the flap was designed with wide pedicle at width of 8 to 18 cm (mean, 15 cm); then the wound was sutured with improved method. The pedicle was cut after 3 weeks. Results All the flaps survived without congestion, necrosis, and tension blisters. The wound and the incision were both healed at stage Ⅰ. All patients were followed up 4-12 months (mean, 8 months). The skin color, texture, and shape were satisfying, and no ulcer formed. Only line-like scar left at the donor site. Conclusion Abdominal pedicled flap with wide pedicle and improved suture method can reduce the abdominal skin waste, avoid postoperative infection, and be feasible to repair large skin defect of upper limb with advantages of simple operation and reliable fixation.
Objective To explore the effectiveness of modified anterolateral thigh perforator flap pedicled by cross-bridge microvascular anastomosis in treatment of soft tissue defects in the middle and lower segments of the leg. Methods Between March 2011 and June 2015, 15 cases with skin and soft tissue defects in the middle and lower segments of the legs were treated. There were 9 males and 6 females, aged 22-48 years (mean, 32.6 years). Of whom, 8 patients caused by traffic accidents, 5 by machine twist, and 2 by crash injury of heavy object. The mean interval from injury to admission was 82.6 hours (range, 2 hours to 1 week). The area of defect ranged from 13 cm×9 cm to 23 cm×16 cm. After primary debridement and vaccum sealing drainage treatment, the defects were repaired with modified anterolateral thigh perforator flap pedicled by cross-bridge microvascular anastomosis. The size of flap ranged from 15 cm×10 cm to 25 cm×15 cm. The donor sites were sutured directly or repaired with the skin grafts. The pedicle division was done at 4 weeks after operation. Results After operation, venous crisis occurred in 1 case and distal skin necrosis in 2 cases which was healed by dressing change. The other tissue flaps survived successfully and wounds healed by first intention. All skin grafts at donor site survived after operation, and primary healing of wound was obtained. All patients were followed up 6-24 months (mean, 13 months). All flaps were characterized by soft texture, satisfactory appearance, and restoring the protective sensation. Moreover, the two-point discrimination ranged from 15 to 28 mm (mean, 19.5 mm) at 6 months after operation. The function of both lower extremities were normal without obvious contracture of scar at donor site. Conclusion Modified free anterolateral thigh perforator flap, with little damage in donor site, a reliable blood supply by making a cross-bridge microvascular anastomosis with pretibial or posterior tibial blood vessel on normal leg, is a reliable alternative method for repairing soft tissue defects with the main vessels of serious injury in the middle and lower segments of the leg.
Objective To investigate the clinical application of relaying lateral gastrocnemius artery perforator flap in reconstruction of the donor defect after distally sural flap transferring. Methods Between January 2014 and January 2016, 12 cases with foot and ankle defects were treated. There were 10 males and 2 females with an average age of 23.4 years (mean, 14-52 years). The injury was caused by motorcycle accident in 7 cases and traffic accident in 5 cases. The injury located at left limb in 7 cases and right limb in 5 cases. The size of soft tissue ranged from 10 cm×4 cm to 12 cm×6 cm. The disease duration was 2-84 hours (mean, 26.2 hours). The foot and ankle defects were reconstructed by distally sural flaps, then the flap donor sites were reconstructed with relaying lateral gastrocnemius artery perforator flap at the same stage. The size of distally sural flap ranged from 11 cm×5 cm to 13 cm×7 cm. The size of relaying flap ranged from 7 cm×4 cm to 10 cm×6 cm. Results All flaps survived uneventfully. All recipient sites and donor sites healed smoothly. No vascular crisis, wound dehiscence, or evident swelling occurred. All patients were followed up 6-14 months (mean, 12.4 months) with satisfied esthetic and functional results in recipient and donor sites. There were only linear scar on the donor sites. The color and contour was satisfying, the function of calf and foot were not affected. Conclusion The relaying lateral gastrocnemius artery perforator flap combined with distally sural flap is an idea choice to reconstruct foot and ankle defect, which can avoid donor site skin grafting, minimize donor site morbidity.
Objective To investigate the feasibility of human amniotic membrane-living skin equivalent (AM-LSE) in repairing the skin defect. Methods A 5-year-old boy with giant nevus at neck, shoulder, and back was admitted in July 2016. Normal skin tissue of the patient was harvested and keratinocytes and dermal fibroblasts were separated and expanded in vitro. Human AM was donated from a normal delivery and de-epithelialized for constructing an LSE as a matrix. Keratinocytes were seeded on the epithelial side of the AM which was previously seeded with fibroblasts on the stromal side and then the complex was lifted for air-liquid surface cultivation for 10 days and observed under naked eyes and sampled for histological study. The nevus was excised to deep fascia and the skin defect in size of 20 cm×15 cm was covered with artificial skin of collagen sponge for 2 weeks to enhance granulation tissue formation, and then the AM-LSE grafts of stamp size were grafted on. The dressing was changed until the wound healed. Results After 10 days of air-liquid surface cultivation, the AM-LSE developed a multilayered and differentiated epidermis with the fibroblasts-populated amnion as the dermal matrix. The LSE stamps survived and expanded to cover the whole wound. The grafted area showed normal skin color and soft contexture at 6 months after operation, and histological study showed well developed epidermis with compactly aligned basal cells, stratified and well differentiated squamous, granular layers and stratum corneum and well vascularized dermal compartment without inflammatory cells infiltration. Conclusion The cultivated AM-LSE with autologous cells can repair skin defect and survive for a long term without rejection.