Medial suralGASTROCNEMIUS muscle perforator free flap: an immediate cross-leg flap?

The advantage of the medial sural (GASTROCNEMIUS) muscle perforator free flap is that it is relatively thin, even in most obese individuals, and the donor site can be acceptable, if morbidity must preferably be restricted to the lower extremities. Unfortunately, anatomic anomalies of both the arterial and venous circulation are not infrequent, making this a somewhat less than perfect donor site in the author's total experience using this flap. Nevertheless, the contralateral calf skin was successfully used, as shown in a clinical example, to cover a transmetatarsal amputation stump. This allows the conclusion that, at least as a technical exercise, the medial sural (GASTROCNEMIUS) muscle perforator free flap as a microsurgical transfer can be used as an "immediate" cross-leg flap. This is reminiscent of bygone eras, where such a feat required multiple stages over many weeks.     

Treatment of superficial and perforator venous incompetence without deep venous insufficiency: is routine perforator ligation necessary?

PURPOSE: We investigated whether routine ligation of incompetent perforator veins is necessary in treatment of symptomatic chronic venous insufficiency (CVI) due to combined superficial and perforator vein incompetence, without deep venous insufficiency. METHODS: This was a retrospective review of prospectively collected data. Twenty-four limbs with both superficial and perforator venous incompetence but no deep venous insufficiency were identified at venous duplex scanning. Air plethysmography (APG) was performed preoperatively, to obtain venous volume (VV), venous filling index (VFI), ejection fraction (EF), and residual volume fraction (RVF) of the affected limb. Saphenous vein stripping from the groin to knee and powered transilluminated phlebectomy for varicosity ablation were performed in all patients. Postoperatively, all patients underwent duplex scanning and APG to determine the status of the perforator veins and hemodynamic improvement from surgery. RESULTS: Average patient age was 55.8 years; 62% of patients were women. CVI was class 3 in 4 limbs, class 4 in 12 limbs, and class 5 and class 6 in 4 limbs each. Postoperative duplex scans demonstrated that 71% of previously incompetent perforator vessels were now competent or absent. Significant improvement in all APG values was documented after superficial surgery. VFI improved from 6.0 +/- 2.9 preoperatively to 2.2 +/- 1.3 after surgery (P <.001); EF improved from 56.3 +/- 18 to 62 +/- 21 (P =.02); and RVF improved from 40.1 +/- 19 to 28.3 +/- 18 (P =.009). Mean preoperative symptom score (5.3 +/- 1.9) was significantly improved at mean follow-up of 18.3 months (1.4 +/- 1.2; P <.001). CONCLUSION: Patients with superficial and perforator vein incompetence and a normal deep venous system experienced significant improvement in APG-measured hemodynamic parameters and clinical symptom score after superficial ablative surgery alone. This suggests that ligation of the perforator veins can be reserved for patients with persistent incompetent perforator vessels, with abnormal hemodynamic parameters or continued symptoms after superficial ablative surgery.     

The gracilis (medial circumflex femoral) perforator flap: a medial groin free flap?

The superior medial thigh skin territory has previously been successfully transferred as a free flap as part of a gracilis musculocutaneous flap. However, muscle bulk can be avoided and its function preserved by instead retaining only the musculocutaneous perforators arising from the gracilis pedicle like in a true perforator flap. A clinical example of this new perforator flap is described as the gracilis (medial circumflex femoral) perforator flap. This could become an ideal skin flap because no muscle is included, a well-defined segment of skin can be reliably harvested, closure of the donor site leaves a scar in the groin that can be readily concealed, and its dominant vascular pedicle is consistent in location and already familiar to most reconstructive surgeons.     

Superficial circumflex iliac artery perforator flap in a case of Fournier’s gangrene

Fournier’s gangrene (FG) is a rare and acute form of necrotizing fasciitis involving the perineal region and genitalia with occasional extension up to the abdominal wall. The etiology of the FG is only partially understood, but in the majority of cases, aerobic and anaerobic bacteria are involved. FG is characterized by mortality rate ranging from 15 to 20 %, and for this reason, the disease must be treated aggressively. The key of management, after the emergency debridement of necrotic tissue, is a functional and esthetic reconstruction. We reported a case of FG in which the wide scrotal skin and fascia loss was managed with a propeller superficial artery perforator flap. Level of Evidence: Level V, therapeutic study.     

Subfascial endoscopic perforator vein surgery in patients with post-thrombotic venous insufficiency--is it justified?

Previous results following subfascial endoscopic perforator vein surgery were reported to be worse in post-thrombotic syndrome than in limbs with primary valvular incompetence. This report comprises a larger patient cohort with longer follow-up. The goal of this study was to determine if subfascial endoscopic perforator vein surgery is justified in patients with post-thrombotic venous insufficiency. The clinical data of 91 consecutive patients who underwent subfascial endoscopic perforator vein surgery with or without superficial reflux ablation over a 7-year period from May 1993 to June 2000 were retrospectively analyzed. Fifty-four females and 37 males (median age, 53 years; range, 20-77) underwent 103 subfascial endoscopic perforator vein surgery procedures. Forty-two limbs were classified as C6 (active ulcer), 34 as C5 (healed ulcer), and 24 as C4 (lipodermatosclerosis). Thirty procedures were performed in post-thrombotic limbs. Concomitant superficial reflux ablation was performed in 74 limbs (72%); saphenous vein stripping had been previously performed in 29 (28%). Deep venous incompetence was present in 89% of limbs; 13% had venous outflow obstruction on plethysmography. Cumulative ulcer healing in post-thrombotic limbs was not significantly different from limbs with primary valvular incompetence; 30-, 60-, and 90-day healing rates were 44%, 72%, and 72% vs 39%, 70%, and 87%, respectively (p = 0.35). On univariate analysis, the presence of ulcer greater than 2 cm in diameter was associated with delayed ulcer healing (p = 0.02). Cumulative ulcer recurrence in all limbs was 4%, 20%, and 27% at 1, 3, and 5 years, respectively. Ulcer recurrence in post-thrombotic limbs was higher than in limbs with primary valvular incompetence at 1, 3, and 5 years; 16%, 47%, and 56% vs 0%, 8%, and 15%, respectively (p = 0.001). Recurrent ulcers were small, superficial, and easier to heal. Clinical improvement was significant even in post-thrombotic limbs; median clinical score decreased from 9.5 to 3 (p = 0.001), and median outcome score was +2 (mean 1.9; range, -1 to 3). Median clinical score in patients with primary valvular incompetence improved from 6 to 1.5 (p = 0.0001). Subfascial endoscopic perforator vein surgery with superficial reflux ablation promoted ulcer healing, improved clinical outcome, and resulted in a low long-term ulcer recurrence rate in limbs with primary valvular incompetence. Despite good clinical outcome in post-thrombotic limbs, ulcer recurrence was high. These results imply that the role of subfascial endoscopic perforator vein surgery with superficial reflux ablation in patients with post-thrombotic limbs continues to be controversial.     

Is the nihilistic approach to surgical reduction of superficial and perforator vein incompetence for venous ulcer justified?

OBJECTIVE: Twenty-five years ago, the senior author showed a 55% postoperative ulcer recurrence rate after open perforator ligation. Those data contributed to a nihilistic attitude toward incompetent perforating veins. Conversely, since the introduction of subfascial endoscopic perforator surgery (SEPS), we have undertaken ablation of superficial and perforator reflux as initial treatment in patients with ulcers (C6) or healed ulcers (C5). This report outlines our long-term results. METHODS: Between December 1994 and November 1999, SEPS was performed on 51 limbs in 45 patients with C5/C6 disease. Sixteen limbs underwent SEPS alone, and 35 had additional surgery on the greater saphenous vein (GSV), the lesser saphenous vein, or the tributary varicies. Data were collected according to the reporting standards in venous disease. Preoperative duplex scan of deep, superficial, and perforating veins was performed. Data were analyzed with Kaplan-Meier method, Mantel-Cox log-rank test, or t test. RESULTS: Of the 51 limbs that underwent SEPS, the GSV was stripped in 28. Twenty-nine were C6, and 22 were C5. Etiology was primary (Ep) in 25 limbs and secondary (Es) in 26 limbs. All limbs had duplex scan evidence of perforator incompetence (Ap), and deep insufficiency (A(D)) was seen in 39 cases (76%). Reflux predominated (P(R)). The clinical follow-up period was 0 to 82 months (median, 38 months). Venous disability scores improved from 9.8 before surgery to 4.2 at last follow-up (P <.05). Kaplan-Meier analysis showed 74% healing at 6 months. The presence of an ulcer more than 2 cm in diameter, secondary etiology, and SEPS without concomitant GSV stripping were associated (P <.05) with delayed healing. Among patients in whom ulcers healed or who were seen with healed ulcers, the 5-year ulcer recurrence rate was 13%. Lesser saphenous vein reflux was the only factor that correlated with increased ulcer recurrence. Deep system reflux as measured with duplex scan valve closure times did not correlate with the rate of ulcer healing or recurrence. CONCLUSION: Nihilism has no place in the management of venous disease in the 21st century. An aggressive approach to superficial and perforating vein reflux in this cohort of patients with C5 and C6 disease resulted in rapid ulcer healing and low 5-year recurrence rates. Prior saphenous vein stripping, large ulcers, and secondary etiology were associated with delayed healing. A less aggressive posture toward lesser saphenous vein reflux contributed to a higher recurrence rate in this subgroup of patients. These risk factors are useful in counseling patients as to their expected postoperative course; however, no combination of factors should a priori preclude surgical intervention in this group of patients.     

Can skin islands of free muscle flaps be used as pedicled perforator flaps years after free flap transfer?

Free muscle flaps are sometimes raised with skin islands which are vascularized with a perforator of the pedicle. In this case, the skin island used for monitorization of a free latissimus dorsi (LD) flap was raised as a pedicled perforator flap to cover a defect secondary to contracture release 1?year after free tissue transfer. We present a case of a 3-year-old child who presented with a left foot defect that was reconstructed with a musculocutaneous LD flap. One year after initial surgery, a contracture of the great toe was released and reconstructed with a perforator flap harvested from the original musculocutaneous flap.     

Elective spare parts free flap—calcaneal fillet of foot flap

Severe lower limb trauma with significant soft tissue injury can be managed with reconstruction or, if this is impossible, amputation. If amputation is considered, below-knee amputation preserving limb length is optimal for long-term functional outcome. At times, soft tissue/bony injury can limit the ability to preserve limb length, particularly with proximal tibial injuries. We present a case of elective below-knee amputation where leg length and adequate soft tissue coverage was only possible by using an osteocutaneous fillet of foot and lower leg spare parts free flap, maintaining the tibial nerve pedicle for sensation and the posterior tibial artery for vascularity of the nerve. The procedure was technically challenging and required follow-up debulking operations. However, the technique provided the significant advantage of immediate sensation of robust glabrous distal stump cover and optimising leg length to enhance functional outcome.     

About perforator flaps…20 years later

Despite the birth of reconstructive surgery 2000 years ago, the main advances in this field appeared in the second half of the 20th century. Born in Asia, it is from that same continent that the last improvement has occurred through the perforator flap concept. Combining advances in the understanding of cutaneous blood supply and advances in surgical instrumentation to optimize the reconstruction while reducing morbidity is gradually becoming a reality. Twenty years after the first perforator flap described by Koshima and Soeda, the authors review the history, the concept and nomenclature of these flaps. Furthermore, through an analyze of the international literature, the authors attempt to achieve an assessment of the reliability and morbidity of perforator flaps after 2 decades of existence.     

Recovery of forehead sensation after extended coronal flap or ”dismasking flap”

By using an extended coronal flap or ”dismasking flap,” a large area of the cranio-orbitofacial region can be viewed directly. To achieve this, the supraorbital nerves must be sectioned. The sensory recovery in the forehead of patients treated with ”dismasking flaps” was studied as was that in normal adult controls. In the patient who had nerve anastomosis, the Semmes-Weinstein (S-W) test result was 2.36 monofilament number (follow-up period: 9 months). Static 2-PD and moving 2-PD were 15 and 14 mm, respectively. In the patients who did not have nerve anastomosis, the mean S-W test result was 5.46 (n=10, mean follow-up period: 25 months). Five points in three patients showed no recovery of static and moving 2-PD,and two points in two patients showed 25 and 22.5 mm, respectively. Of the patients whose nerves were resected, two did not show recovery of the S-W test results, and one patient showed 6.45 (mean follow-up period: 19 months ). In conclusion, the supraorbital nerve should be anastomosed to obtain good sensory recovery. Received: 12 July 1999 / Accepted: 11 October 1999     

An anterolateral thigh perforator chimeric flap combined with calcium sulfate impregnated with vancomycin for treatment of chronic fracture-related infection complicated with extensive soft-tissue defects北大核心CSCD

Objective To investigate the efficacy of an anterolateral femoral chimeric perforator flap combined with vancomycin-loaded calcium sulfate in the treatment of chronic infection after internal fixation of calf fracture with soft tissue defects. Methods Retrospectively analyzed were the data of 16 patients with chronic infection combined with extensive soft tissue defects after internal fixation of calf fracture who had been admitted to Department of Orthopedics, Shenzhen Hospital Affiliated to Peking University from September 2008 to November 2020. There were 11 males and 5 females, aged from 16 to 62 years (average, 37 years). Infection sites: the upper tibia in 4 cases, the middle and lower tibia in 10 cases, and the middle fibula in 2 cases. According to the Cierny-Mader classification, all patients were anatomical type III and by the host classification, there were 14 cases of type B and 2 cases of type C type. The areas of soft tissue defects ranged from 6 cm × 4 cm to 23 cm × 14 cm. All patients were treated by transplantation of an anterolateral thigh chimeric perforator flap combined with vancomycin-loaded calcium sulfate therapy. At the last follow-up, the curative efficacy was evaluated according to the Paley fracture union scoring. Results All patients were followed up for 8 to 24 months (mean, 16 months). Complete flap survival was achieved in 15 flaps and partial survival in one. According to the Paley fracture union scoring at the last follow-up, the curative efficacy was evaluated as excellent in 15 cases and as good in one. Both the grafted artificial bone and the tibia and fibula achieved bone union after 6 to 12 months (mean, 8.9 months). Infection with chronic sinus tract pus recurred in one case at post-operative one year. After re-debridement, the infection was controlled and the wound healed. The plate internal fixation was replaced by the unilateral or annular external fixator in 14 patients and retained in 2 patients. The lengths of the bone defects averaged 2.4 cm and the time for the external fixation 10.5 months (from 8 to 14 months). Conclusion In the treatment of chronic infection after internal fixation of calf fracture with extensive soft tissue defects, the efficacy of an anterolateral femoral chimeric perforator flap combined with vancomycin-loaded calcium sulfate is satisfactory, because the flap can fully cover the bone and soft tissue defects while the vancomycin-loaded calcium sulfate can effectively control the infection. © 2023 Chinese Journal of Orthopaedic Trauma. All rights reserved.     

Does thigh compression improve venous hemodynamics in chronic venous insufficiency?

OBJECTIVE: The aim of this study was to investigate the hemodynamic effects of thigh compression in patients with deep venous incompetence. PATIENTS AND METHODS: This diagnostic test study was set in a municipal general hospital. Twelve patients with venous leg ulcers (CEAP classification, C6 Es Ad Pr; four men and eight women), with a mean age of 56.5 +/- 16.8 years, with popliteal venous reflux of more than 1 second detected with duplex scan, underwent investigation with the following methods: 1, the pressure exerted under thigh-length compression stockings class II and short-stretch adhesive compression bandages was measured with an MST tester (Salzmann, Switzerland) and a CCS 1000 device (Juzo, Germany), respectively; 2, the great saphenous vein and the femoral vein on the thigh were compressed with a pneumatic cuff (0, 20, 40, and 60 mm Hg) containing a window through which the diameters of these veins could be measured with duplex ultrasonography; and 3, with the same thigh-cuff occlusion procedure, the venous filling index (VFI) for each experiment was measured with air plethysmography. These values reflected the presence and extent of venous reflux in each experiment depending on the degree of venous narrowing. RESULTS: The mean pressure of a class II compression stocking was about 15 mm Hg at the thigh level, and adhesive bandages achieved a pressure of more than 40 mm Hg in the same location. A statistically significant reduction of the diameters of the great saphenous vein and the femoral vein could be obtained only when the cuff pressure on the thigh was equal to or higher than 40 mm Hg (P <.001). A reduction of the venous reflux (VFI) was achieved only with a thigh pressure of 60 mm Hg (P <.001). No significant reduction was seen of VFI with a thigh pressure in the range of the class II stockings. Previous investigations have shown that, in patients with deep venous incompetence, a pressure cuff on the thigh with 60 to 80 mm Hg is able to reduce ambulatory venous hypertension. CONCLUSION: Thigh compression as exerted with class II thigh-length compression stockings is not able to significantly reduce venous diameter or venous reflux. However, with a pressure of 40 to 60 mm Hg on the thigh that can be achieved with strongly applied short-stretch bandages, considerable hemodynamic improvement, including reduced venous reflux, can be obtained in patients with severe stages of chronic venous insufficiency from deep vein incompetence. The practical value of these preliminary findings should be investigated with further clinical trials.