Blood Perfusion of the Free Anterolateral Thigh Perforator Flap: Its Beneficial Effect in the Reconstruction of Infected Wounds in the Lower Extremity

Background In a prospective study, we evaluated the blood perfusion and the blood flow of anterolateral thigh (ALT) flap by both near-infrared spectroscopy and color Doppler ultrasonography. Moreover, we assessed the ability of the perforator flap to reconstruct infected wounds of the lower extremity in 11 patients. Methods Near-infrared spectroscopy showed excellent oxygen saturation, and Doppler ultrasonography documented excellent blood flow and decreased vascular resistance in the ALT flap postoperatively. Results All flaps were successful and all wounds healed uneventfully within 2 weeks without any signs of recurrences or persistent infection. All patients achieved acceptable gait function after rehabilitation. Conclusions Apart from the mandatory role of thorough debridement, our results indicate that the ALT flap offers rich blood supply to the recipient area, thus contributing to the sterilization and healing of an infected wound within a short time period.     

Coverage of supraumbilical abdominal wall defects: The tunnelled‐pedicled ALT technique

Abdominal wall defects are a challenge for reconstructive surgeons. Although the utility of anterolateral thigh perforator (ALT) flap has been well established for lower abdominal wall reconstruction, pedicled ALT flap is usually not considered for supraumbilical defects in the most recent algorithms. The purpose of this paper is to report the results of a tunneled pedicled ALT flap for reconstruction of supraumbilical defect from a series of patients. From July 2009 to September2014, six patients underwent delayed abdominal wall coverage using pedicled ALT flaps and reinforcement with polypropylene meshes. Defects occurred after surgical complications and abdominal trauma. Flaps were tunneled beneath the rectus femoris and sartorius muscles to increase the pedicle length. The size of the skin islands ranged from 22–29 × 10–14 cm. All flaps survived and the healing of the wounds was successful. Partial dehiscence of donor site occurred in one patient, and small wound dehiscence due to minimal distal necrosis was observed in another patient. No functional problems were reported in donor site, and no complications occurred in 6–68 months of follow‐up. The tunneled pedicled ALT flap may provide a reliable alternative method for abdominal wall reconstruction, including supraumbilical defects. © 2015 Wiley Periodicals, Inc. Microsurgery 37:119–127, 2017.     

The anteromedial thigh fasciocutaneous flap pedicled on the supragenicular septocutaneous perforator: application in 11 patients

Skin defects around the knee remain a challenge for the reconstructive surgeons. Choosing appropriate flaps for coverage is crucial to preserve the knee joint or to restore its function. On the basis of anatomic results in 20 cadaveric specimens, we found a constant supragenicular fasciocutaneous perforator within 3 cm above the adductor tubercle, which arose from the saphenous branch of the descending genicular artery. Based on it, the distally pedicled anteromedial thigh fasciocutaneous flap can be harvested from the anteromedial thigh. Between 2003 and 2009, we performed the distally pedicled anteromedial thigh flaps in 11 patients. The site of skin defects included the popliteal fossa, proximal ? leg, and amputation stump below knee. The size of skin defects ranged from 15 × 6 cm to 27 × 9 cm, and the corresponding size of the flaps ranged from 15 × 10 cm to 32 × 9 cm. Of 11 flaps, 10 flaps survived unevently, except 1 flap which suffered partial necrosis due to venous congestion. The patients were followed up for 3 weeks to 12 months. The donor site healed uneventfully without complications in all patients. Additionally, the skin paddle matched with the recipient in terms of skin color, texture, and thickness. The anteromedial thigh fasciocutaneous flap pedicled on the supragenicular perforator is a reliable and versatile alternative to cover skin defects around the knee.     

Proximal pedicled anterolateral thigh flap for reconstruction of trochanteric defect

We describe our experience using the proximal pedicled anterolateral thigh (ALT) flap for the reconstruction of trochanteric defects. Seven ALT island flap procedures were performed in 6 patients between September 2006 and May 2007. Four of the 7 patients had trochanteric pressure sores because of paraplegia. In these patients, intramuscular perforators were dissected to raise a fasciocutaneous flap. Three myocutaneous flaps of the vastus lateralis muscle were used to treat osteomyelitis of the trochanter with implant extrusion. The mean follow-up was 7 months (range, 2-12 months), and all flaps survived. Trochanteric coverage with the proximal pedicled ALT flap gave excellent results. We conclude that the ALT flap is a reliable flap for trochanteric coverage.     

Main abdominal flap donor sites]

The main flaps derived from the abdominal wall are described, indicating the following points for each one: vascular anatomy, the cutaneous and/or muscle territory of the flap, the arc of rotation, the main applications and finally comments concerning certain specific anatomical or technical points. Rectus abdominis flaps are by far the most frequently used in routine clinical practice for mammary reconstruction and cover of the thorax, abdomen or groin areas. Groin flaps are also frequently used, either as pedicled flaps to cover defects of the upper extremity or abdomen, or as free flaps, especially for mandibular reconstructions.     

Pedicled superior epigastric perforator flap for reconstruction of a soft tissue defect at the ventral thoracic wall

The purpose of this paper is to present a new method of ventral chest wall reconstruction utilizing skin and fat from the abdominal wall pedicled on the superior epigastric artery and its comitant veins without sacrificing the rectus abdominis muscle. In a patient with a 13 × 15 cm left parasternal soft tissue defect of the thoracic wall, a paraumbilical perforator flap of skin and subcutaneous tissue was elevated with meticulous preparation of the perforators to the right superior epigastric vessels without sacrificing any muscle. The skin and fat island with its vascular pedicle was drawn through an epigastric subcutaneous tunnel to the ventral thorax and placed into the defect. Postoperative flap perfusion measured by laser Doppler flowmetry was excellent, abdominal wall reconstruction was easy, and 3 months after operation, the ability to perform sit-ups was as good as before the operation. In two further patients, we found the vascular anatomy to be unsuitable for this flap. The pedicled superior epigastric perforator (SEP) flap is suitable in certain cases but unreliable for reconstruction of soft tissue defects at the chest wall. Further investigations and operating experience may provide additional knowledge to allow wider and more secure use of the SEP flap.     

带脂肪筋膜蒂皮神经轴型皮瓣——探讨皮神经营养血管皮瓣命名问题

目的 总结带脂肪筋膜蒂皮神经轴型皮瓣修复四肢组织缺损的临床效果,探讨皮神经营养血管皮瓣命名问题.方法 自1997年1月2006年3月应用四肢带脂肪筋膜蒂皮神经轴型皮瓣12种修复组织缺损153例.其中股后皮神经轴型皮瓣共6例,腓肠神经轴型皮瓣共66例,腓浅神经轴型皮瓣共20例,隐神经轴型皮瓣18例.足背皮神经轴皮瓣12例,前臂外侧皮神经轴型皮瓣修复手背、手掌软组织缺损4例,前臂内侧皮神经轴型皮瓣4例,拇背皮神经轴型皮瓣修复拇指软组织缺损共10例,食指指背皮神经轴型皮瓣8例,手背尺神经轴型皮瓣5例.结果 移位皮瓣153例,坏死完全2例,部分坏死7例,完全成活率为92.8%.结论 带脂肪筋膜蒂皮神经轴型皮瓣是一种新型、简便、实用的软组织缺损修复方法,利于临床推广应用.     

带蒂股前外侧皮瓣修复手部大面积皮肤缺损

目的探讨带蒂股前外侧皮瓣在手部皮肤大面积缺损修复中的适应证。方法2002年4月~2005年8月应用带蒂股前外侧皮瓣移位修复手部皮肤缺损,或用于修复腹部皮瓣或髂腹股沟皮瓣移位至手部后遗留的供区创面5例,均为男性,年龄16~44岁,损伤部位:左手1例,右手4例,其中机器绞伤2例、烧伤3例、外伤为伤后6 h急诊手术;烧伤为伤后4~7 d行切痂、皮瓣移位修复术。手部皮肤缺损范围为12~19 cm×18~22 cm,切取带蒂股前外侧皮瓣为7~12 cm×16~24 cm;切取腹部皮瓣或髂腹沟皮瓣:13~20 cm×19~23 cm。修复手部的皮瓣术后3周断蒂。结果术后所有皮瓣均全部成活,未发生血管危象,创面Ⅰ期愈合。均获随访6~12个月,皮瓣质地柔软,血运好,其中3例分别在术后4~7个月行分指去脂术。手部皮瓣均恢复保护性感觉,能满足日常生活需要。结论带蒂股前外侧皮瓣修复手部皮肤缺损及腹部皮瓣或髂腹股沟皮瓣修复手部创面遗留的供区创面具有供皮量大,不吻合血管,手术风险小,皮瓣成活率高等优点,为修复手部创面提供一种较好的皮瓣选择。     

The distally pedicled gracilis flap for salvage of complex knee wounds

IntroductionSoft tissue defects around the knee joint resulting from trauma or because of wound breakdown after total knee arthroplasty present a challenge in a group of patients that often suffer from other co-morbidities. A pedicled gastrocnemius muscle flap remains a workhorse for this kind of wound. However, where the defect lies in the supero-lateral aspect of the proximal knee area, an alternative solution is required. The distally based pedicled gracilis flap has been described as an option for these cases where free-tissue transfer may not be an option and the pedicled gastrocnemius is not sufficient or has already been used. The purpose of this review is to evaluate the usefulness of this flap in the nine cases in which we have utilized it in our unit.MethodsNine patients underwent reconstruction of complex proximal knee wound defects with a distally based pedicled gracilis muscle flap. The mean age was 62 years (range 23–83). Five patients had wound breakdown following total-knee arthroplasty (TKR) and four patients had wound complications after road traffic accidents (RTA). Three of the nine flaps were delayed.ResultsEight of the nine patients had successful salvage of the knee with the use of the distally based gracilis flap. Although four of the flaps suffered partial loss, this did not compromise the joint salvage. The patients were moderately satisfied with the reconstruction and achieved a mean range of movement of 75° (±12°).ConclusionThe distally based pedicled gracilis flap can be a salvage solution for complex soft tissue defects with exposed knee joint, patella or proximal part of knee or exposed knee prosthesis in cases where a pedicled gastrocnemius muscle is inadequate or the patient is not suitable for a free flap.Evidence Level IV.     

腹部带蒂皮瓣设计改进及临床应用

目的　探讨传统腹部带蒂皮瓣切取后 ,皮瓣供区创面的闭合方法。　方法　按设计切取下腹带蒂皮瓣(供移位皮瓣 )后 ,以皮瓣蒂左右为起点分别以弧线向两侧延长切口至髂前上棘 ,通过分离形成可向移位皮瓣供区创面移动的对侧和同侧腹壁皮瓣 (供覆盖腹壁创面皮瓣 ) ,通过此皮瓣向相对应方向推移 ,闭合供移位皮瓣创面。 1998年 9月～2 0 0 3年 9月临床应用 12例 ,男 5例 ,女 7例。急诊手术 4例 ,择期手术 8例。病程 2 8～ 6 2 d。皮肤缺损为 7cm× 11cm～12 cm× 13cm。　结果　经皮瓣设计改进 12例 ,均一期闭合移位皮瓣供区创面 ,12例皮瓣全部成活。 1例覆盖腹壁创面皮瓣 (皮瓣对侧 )尖端坏死 ,范围 1.5 cm× 2 .0 cm,经换药后痊愈 ,其余供覆盖创面皮瓣均 期愈合。　结论　应用改进设计的腹部带蒂皮瓣 ,可免除较大皮瓣创面的植皮手术 ,为临床治疗提供了一种方法。     

Gastrocnemius pedicled muscle flap for knee and upper tibia soft tissue reconstruction. A useful tool for the orthopaedic surgeon

Soft tissue defect coverage has always been a challenge for the orthopaedic surgeon. Over the last decades the surgery of flaps has completely changed the prognosis for large defects. The purpose of this study is to retrospectively review our experience with the gastrocnemius muscle as pedicled local flaps for reconstruction of knee and upper third of the tibia soft tissue defects.Twenty-seven patients underwent reconstruction of soft tissue defects around the knee using pedicled gastrocnemius muscle flaps. There were eighteen men and nine women ranged in with a mean age of 50.3 years. Medial gastrocnemius was used in 21 cases, and lateral gastrocnemius in 5 cases. In one patient, soleus and medial gastrocnemius were transferred simultaneously. All but one had at the same time split thickness skin graft for coverage of the muscle.All muscle flaps transferred were successful. There were no complications and all flaps survived completely without vascular compromise, satisfactory coverage of the defect, and good primary wound healing. There has been no recurrence of osteomyelitis. The donor sites healed perfectly with no remarkable resultant functional disability. A mean follow-up of 4.4 years revealed acceptable cosmetic results with high patient satisfaction.Our results indicate that the gastrocnemius muscle transfer is a useful technique for coverage of soft tissue defects in the upper tibia and around the knee in our orthopaedic practice. It is a reliable option for the coverage of exposed bone, the filling up of deep cavities and the treatment of bone infection. The principal advantage of a muscle flap is to bring a real blood supply to the recipient site and to improve the trophicity of the surrounding tissues. The pedicled muscle flap is our preference for the management of soft tissue defects around the knee, when no other procedure, apart from free flap is suitable. The pedicle flap is easier, quicker and with less complications than a free flap. Orthopaedic surgery has gained much from the use of island flap, however, it requires knowledge of the vascular anatomy and its variations promoted through cadaveric dissections and flap dissection courses.     

THE TENSOR FASCIAE LATAE MYOCUTANEOUS FLAP CLOSURE OF MAJOR CHEST AND ABDOMINAL WALL DEFECTS

Background : The usual methods of closure of major chest and abdominal wall defects have significant disadvantages. Skin grafts provide no structural support and result in incisional hernias. Synthetic mesh requires skin cover and is prone to infection and wound breakdown. The tensor fasciae latae (TFL) myocutaneous flap offers skin cover and a semi-rigid fascial layer. We document our unit'experience in pedicled and free TFL flaps. Methods : The TFL flap closure of trunk defects was undertaken in 10 patients between August 1989 and April 1997. All cases were not amenable to primary closure and repair with synthetic mesh or skin grafts. Results : The defect was satisfactorily repaired in all cases without subsequent herniation. The closure techniques using a pedicled TFL flap and a TFL flap for a free-tissue transfer are described. Conclusions : We conclude that the TFL flap is the method of choice for repairs of major truncal defects.     

Coverage of difficult wounds around the knee joint with prefabricated,distally based sartorius muscle flaps

The coverage of soft-tissue defects around the knee joint presents a difficult challenge to the reconstructive surgeon. Various reconstructive choices are available depending on the location, size, and depth of the defect relative to the knee joint. However, the knee joint frequently accompanies injuries to the lower leg that may limit the use of muscle flaps, especially the gastrocnemius muscle. The use of a free flap is preferred for reconstruction involving obliteration of large-cavity defects, but the isolation of recipient pedicle can be difficult because of the extent of injury zone and in cases of chronic infection around the knee. To provide muscle bulk with a reliable vascular supply, the distally based, prefabricated sartorius muscle flap was used as a last resort to reconstruct difficult wounds with chronic osteomyelitis around the knee joint in 6 patients from June 1995 to May 2001. This method is a two-stage procedure. First, the sartorius muscle is prefabricated by denervation and vascular delay. Silicone sheets are used to increase the vascularity and dimension of the flap. Second, after 3 weeks, the muscle is transposed based on a distal pedicle to reconstruct the soft-tissue defect around the knee. The prefabricated sartorius muscle can provide efficient bulk to obliterate the dead space and to cover moderate-size soft-tissue defects around the knee joint. This method can be considered to reconstruct the soft tissue around the knee joint when local muscle flaps and free flaps are not feasible.     

Use of the lateral intercostal perforator-based pedicled abdominal flap for upper-limb wounds from severe electrical injury

BACKGROUND: Upper-extremity wounds can be covered with a variety of flaps. However, pedicled distant flaps still have a place in treatment, especially in the early stages of wound restoration after a severe electrical injury. The purpose of this clinical study was to present the use of the pedicled abdominal flap, using the blood supply of the lateral intercostal perforator vessel, to cover defects caused by severe electrical injury. METHODS: Between 2003 and 2005, 6 cases of deep burn wounds were treated with a lateral intercostal perforator-based pedicled abdominal cutaneous flap, with the blood supply originating from the lateral perforator branches of the seventh to 10th intercostal arteries. This flap was used to repair deep burn wounds on the elbow, forearms, and hands that were the result of severe electrical injuries. RESULTS: Flaps were harvested in sizes ranging from 16 cm x 12 cm to 9 cm x 7 cm. The pedicle was separated from 18 to 21 days after the operation. Five flaps survived entirely. The sixth underwent marginal necrosis (1.5 cm x 3 cm) at the distal portion of the flap because flap cutting exceeded the paraumbilical line. Results were cosmetically satisfactory for all patients. CONCLUSIONS: This flap is suitable for covering defects in hands, forearms, and elbows. The procedure was performed easily, safely, and reliably, and the flap has several advantages over other commonly used techniques for upper-limb wounds from severe electrical injury. We recommend this flap as the treatment of choice.     

Reconstruction of large soft tissue defects of the lower torso with rectus abdominis musculocutaneous flaps

Summary Seven large defects of the lower torso were closed with rectus abdominis musculocutaneous flaps: two large roin defects, three abdominal wall defects, and two open lateral pelvic wounds. Five of the flaps were inferiorly based and two superiorly based. The donor site was closed primarily unless a large skin paddle was taken, in which case the donor site was skin grafted. The central location, excellent blood supply (superior and inferior epigastric arteries plus abundant cutaneous perforators), and length and thickness of the rectus abdominis muscle make it a versatile flap for abdominal wall and lower torso defects.     

腓动脉主穿支蒂腓肠神经营养血管皮瓣修复跟腱区创面

目的 探讨应用改良腓肠神经营养血管皮瓣修复跟腱区创面的方法及疗效.方法 设计切取以最低位腓动脉主穿支为蒂的矩形腓肠神经营养血管皮瓣,修复跟腱后皮瓣旋转180°,远、近端交换覆盖创面.供区一般直接缝合,个别病例需小面积全厚植皮.结果 2005年6月至2008年10月临床应用15例,皮瓣切取面积13 cm ×15 cm～ 18 cm ×9 cm,均全部成活.术后随访10～ 17个月,足踝功能良好,外形轮廓接近正常.结论 该皮瓣血供确切,修复后外形平整美观,利于正常穿鞋行走,适用于跟腱区创面缺损的修复.     

股前外侧组织瓣临床应用112例分析

目的 总结分析股前外侧组织瓣解剖规律及其在组织缺损修复重建中的适应证和应用价值。方法1985年3月-2004年8月，对112例股前外侧组织瓣移植进行临床总结。其中男67例，女45例。年龄5～65岁，平均38．5岁。针对受区不同情况，将股前外侧组织瓣切取分为4类：吻合血管的游离皮瓣移植78例；吻合血管的游离脂肪筋膜瓣移植22例；带蒂顺行岛状皮瓣移位5例；远端为蒂逆行岛状皮瓣移位7例。对面、颈、肢体、躯干等部位的软组织缺损所致功能障碍或外观缺陷进行修复，并对术后效果和供区恢复情况进行评价。结果营养股前外侧组织瓣的动脉皮支出现率100％，具有肌间隙皮穿支（33％）和肌皮穿支（67％）两种基本解剖类型。组织瓣源血管均为旋股外侧动脉降支或横支。皮瓣移植成活107例，成活率达95．6％。术后33例获随访6个月～11年，远期随访效果满意率91％，供区无功能受限。结论股前外侧组织瓣解剖恒定，具有多种突出优点，是修复软组织缺损的理想材料。尤其是穿支皮瓣形式，可保持受区形态，降低供区损伤，成为应用趋势。     

Bauchwandrekonstruktion mit gestieltem Rectus-femoris-Muskellappen

INTRODUCTION: Large abdominal hernias or abdominal wall defects often require the use of prosthetic mesh, local tissue transposition or even distant muscle flaps for proper reconstruction of the abdominal wall. The disadvantages of meshes are well known. The use of muscle flaps is an appreciated alternative. PATIENTS AND METHODS: We present 12 cases with reconstruction of the abdominal wall using pedicled rectus femoris muscle flaps after tumor resections, incisional hernias, and infection. Follow up time ranged from 6 months to 4 years. Abdominal wall stability was examined clinically. The aesthetic and the functional result were assessed using a standardized questionnaire. To objectively evaluate the loss of force in the quadriceps muscle the maximal voluntary knee extension torque was measured. RESULTS: In all patients except one a stable abdominal wall was achieved. No major complications occurred. The loss of torque in the operated leg was tolerable. DISCUSSION: The donor site morbidity is relatively low and the flap provides an easy and save possibility to reconstruct the abdominal wall. The rectus femoris muscle flap should be considered as an alternative for abdominal wall reconstruction.     

Reconstruction of extensive abdominal wall defect using an eccentric perforator‐based pedicled anterolateral thigh flap: A case report

Reconstruction of extensive abdominal wall defects is a challenge for reconstructive surgeons. In this report, a case of reconstruction of a large abdominal wall defect using an eccentric perforator‐based pedicled anterolateral thigh (ALT) flap is presented. A 30‐year‐old man presented with recurrent desmoid‐type fibromatosis in the abdominal wall. The recurrent tumor was radically excised, and the en bloc excision resulted in a full‐thickness, large abdominal wall defect (25 cm × 20 cm). An eccentric perforator‐based pedicled ALT flap, including wide fascial extension, was transferred to the abdominal defect; fascial portions were sutured to the remnant abdominal fascia. Plication of the fascia along the sutured portion was performed to relieve the skin tension between the flap and the marginal skin of the abdominal defect. Eight months after surgery, the reconstructed abdomen had an acceptable esthetic appearance without tumor recurrence or hernia. The use of an eccentric perforator‐based pedicled ALT flap may be an alternative method for the reconstruction of extensive abdominal wall defects. © 2013 Wiley Periodicals, Inc. Microsurgery 33:482–486, 2013.     

旋股外侧动脉降支多叶组织瓣修复手部多部位软组织缺损

目的 探讨旋股外侧动脉降支多叶瓣修复手部多部位软组织缺损的手术方法和临床效果。方法对手部多部位软组织缺损15例,采用旋股外侧动脉降支多叶瓣修复,根据手部缺损情况设计股前外侧皮瓣,沿皮瓣穿支血管向远端继续解剖旋股外侧动脉降支,考虑好手部各缺损处间距,按需切取分叶穿支皮瓣、阔筋膜瓣、股直肌肌瓣、股外侧肌肌瓣、股中间肌肌瓣或旋股外侧动脉降支远端肌间隔瓣。形成以旋股外侧动脉降支为主干的一蒂多叶瓣,在肌瓣及阔筋膜瓣上植皮,一次修复手部多部位软组织缺损。 结果 术后无血管危象发生。修复各创面在肌瓣、阔筋膜瓣或旋股外侧动脉降支远端血管肌间隔上植皮均成活良好,外形无臃肿,植皮处恢复保护性感觉,供区创面愈合好,股四头肌肌力及膝关节屈、伸活动均正常。全部病例获得随访,随访时间6 ～ 20个月,平均8.7个月。按中华医学会手外科学会上肢部分功能评定标准：优3例,良9例,可3例,优良率80％。 结论 旋股外侧动脉降支多叶瓣能一次修复手部多部位软组织缺损,缩短手术时间及疗程,手部功能恢复良好,外形满意,是修复手部多部位软组织缺损的理想方法。