Waveform-arranged multiple skin paddles: A novel design to reconstruct complex soft tissue defects of the extremities with a modified multi-lobed perforator flap

BackgroundMulti-lobed perforator flap was one of popular approaches for one-stage reconstruction of complex soft tissue defects because of its minimal donor-site morbidity. However, the area of skin island that can be harvested on the donor site is limited on the angiosome distribution, Moreover, large defects require more than the conventional skin island provided by a traditional multi-lobed perforator flap. For further extended skin paddles, this study presented a novel design of waveform-arranged skin paddles to elevated a modified multi-lobed perforator flap for the reconstruction of complex soft tissue defects in the extremities.MethodsFrom March of 2015 to March of 2020, fifteen patients underwent complex soft tissue defects reconstruction with waveform-arranged multi-lobed perforator flaps. According the size, shape and localization of the defects, two strategies were performed to design this modified multi-lobed flap.ResultsA total of fifteen waveform-arranged multi-lobed perforator flaps were successfully harvested to reconstruct complex soft tissue defects of the extremities. Among of them, Waveform–arranged dual skin paddles perforator flap were performed in eleven cases, and the waveform–arranged tripaddle perforator flaps were used in four cases. All the flaps survived and no flap related complication was observed postoperatively. The donor sites were closed directly in all cases. The mean follow-up time was 15.6 months. Most of the cases showed satisfactory contour.ConclusionThe waveform design of multi-lobed perforator flap was an alternative approach for reconstruction of complex soft tissue defects; it can maximize the harvested skin area of the donor site to provide extended skin island.     

The role of fabricated chimeric free flaps in reconstruction of devastating hand and forearm injuries

Devastating hand and forearm injuries almost exclusively need free flap transfer if reconstruction is attempted. Early active and passive motion is only possible with aggressive, early, and comprehensive reconstruction. Despite recent advances in compound flaps, in selected cases it might be wise to harvest several smaller flaps and microsurgically combine them to one "chain-linked" flap "system." Four microsurgically fabricated chimeric free flaps were used in four patients for complex hand and forearm injuries. The combinations were sensate anterolateral thigh (ALT) flap plus sensate extended lateral arm flap (2x), ALT plus free fibula, and ALT plus functional musculocutaneous gracilis muscle. All flaps survived completely. Functional rehabilitation was possible immediately after flap transfer. There were no donor-site complications except two widened scars. The microsurgical fabrication of chimeric free flaps, as well established in head and neck reconstruction, can be successfully adapted to massive hand injuries as well. Individual placement of selected tissue components, early comprehensive reconstruction, and reduction of the number of operations are beneficial in cases that need more than one free flap.     

A case of degloving injury of the whole hand reconstructed by a combination of distant flaps comprising an anterolateral thigh flap and a groin flap

A case of degloving injury of the whole hand reconstructed by a combination of an anterolateral thigh (ALT) flap and a groin flap applied as a pedicled distant flap was reported. Despite complications of congestion of the ALT flap and superficial infection, both flaps were severed at 4 weeks after transplantation, and a useful hand was finally reconstructed. The combination of a pedicled groin flap and an ALT flap is not optimal for reconstruction of a whole-hand degloving injury but is considered to be an available procedure for covering a large skin defect without microsurgical procedures.     

The use of innervated radial artery superficial palmar branch perforator free flap for complex digital injuries reconstruction

Loco-regional flaps have been widely used for the reconstruction of digital injuries without requiring microvascular anastomosis, however, they result in scarring and compromised functional outcomes. This study demonstrates our experience utilizing the innervated radial artery superficial palmar branch (RASPB) perforator free flap for complex digital injury reconstruction. From May 2007 to March 2014, the innervated RASPB perforator free flap was used to reconstruct 79 distal complex hand and digital soft tissue defects of which 14 were used to re-vascularise the distal digit in a flow-through fashion. All free flaps were innervated by the palmar cutaneous branch of the median nerve. All 79 free flaps survived and all 14 digits re-vascularized successfully. One flow-through free flap developed distal skin necrosis which healed uneventfully without further procedure. The average follow-up was 21.5 months. Measurement of two-point discrimination ranged from 7 to 13?mm. All patients were satisfied with the aesthetic results. The innervated RASPB perforator free flap is a feasible and effective option for the reconstruction of complex digital defects and the flow-through concept, when utilized in cases with compromised vascularity, provides reliable re-vascularization. Level III, therapeutic study.     

Free tissue transfers in head and neck reconstruction: Complications,outcomes and strategies for management of flap failure: Analysis of 2019 flaps in single institute

Background: Free tissue transfer has become the preferred option for complex reconstructions in head and neck cancer ablation. This study reviewed the surgical outcome and analyzed the evolution of microsurgical head and neck reconstruction over 20 years in single institute. Patients and Methods: A total of 1,918 patients underwent microsurgical head and neck reconstructions in 20‐year period. The surgical outcome and complications among these 2,019 flaps (1,223 anterolateral thigh flaps, 372 fibula flaps, 353 radial forearm flaps, 12 jejunal flaps, and 59 others) were retrospectively reviewed and analyzed. Results: A total of 201 cases required emergent surgical re‐exploration and the overall flap success rate was 96.2%. Venous insufficiency was the most common cause for re‐exploration. Other major complications included fistula formation (5.4%), partial flap necrosis (7.5%), and infection (17.8%). The fibula flap had frequent complications compared with soft tissue flaps. The familiarity to the ALT flap had minimized complications and allowed for widely versatile uses. Conclusion: Free tissue transfer is shown to be highly reliable option for head and neck reconstruction. For soft tissue defect, ALT flap is the first choice. Fibula flap is ideal for bone defect reconstruction. In case of complex composite defects, double flaps, which include ALT and fibula flaps could reconstruct bone and soft tissue defects simultaneously with high success rate. © 2013 Wiley Periodicals, Inc. Microsurgery 34:339–344, 2014.     

Thin and superthin free flaps: An innovative approach to pediatric extremity reconstruction

IntroductionPublished standards for the management of open extremity fractures have improved limb salvage, fracture union, and deep infection rates, but the aesthetic and functional importance of our flap choices has been overlooked. Thin and superthin free flaps exhibit advantages over traditional free flaps in some situations but have seldom been reported in children. The aim of this paper is to present our experience of thin and superthin free flaps in pediatric extremity reconstruction.MethodsChildren (≤13 years) who underwent soft tissue reconstruction using a thin and superthin free flap following major extremity trauma are presented.ResultsFive patients (5 flaps) met the inclusion criteria. The median age was 9 (range 6–13). There were 3 Gustilo IIIB open fractures and 2 multiplanar degloving injuries. The median mangled extremity severity score (MESS) was 4 (range 2–6). The median time from injury to definitive soft tissue closure was 72 h (range 28–120 h). Four anterolateral thigh (ALT) flaps were raised as thin flaps, and 1 superficial circumflex iliac artery perforator (SCIP) was raised as a superthin flap. There was one re-exploration owing to venous congestion, and a second venous anastomosis was performed to enhance flap drainage. The same ALT flap exhibited necrosis at one margin, which was debrided and grafted before discharge. There were no other flap complications. No flap-related secondary surgeries were required.ConclusionThin and superthin free flaps are viable options in pediatric extremity reconstruction. They exhibit excellent aesthetic and functional contouring when a slender fasciocutaneous flap is needed, especially when body habitus renders traditional options unfavorable.     

Perforator propeller flaps for lower extremity soft-tissue defect reconstruction: Shortening the learning curve

BackgroundThe perforator propeller flap is an advantageous option for soft tissue reconstruction in the lower limb as it ensures the preservation of the main artery and muscle, eliminates the need for microsurgical reconstruction as well as provides “like with like” resurfacing of the defects. Despite this, it remains a technically demanding reconstructive option for residents and surgeons with little experience in perforator dissection. We aimed to evaluate the clinical outcomes of our patients whose soft tissue defects were addressed with propeller flaps.MethodsA retrospective study of all propeller flap based reconstruction done on patients with soft tissue defects involving the distal third of the leg was undertaken from August 2018 to December 2020.Results28 patients were treated with propeller flaps for various lower extremity defects. The median defect size was 12 cm². The posterior tibial artery (PTA) was used in eleven cases (39.3%) and the peroneal artery (PA) in seventeen of the cases (60.7%). The complication rate was 28.6% (n = 8). The complete flap necrosis rate was 10.7% (n = 3) and partial flap necrosis rate was 7.1% (n = 2), The rate of venous congestion was 7.1% (n = 2) and wound dehiscence occurred in 3.5% (n = 1). There was a significant negative correlation between the number of cases performed by a resident and the operative time.ConclusionAlthough propeller flaps are a reliable option to address lower extremity defects, they have a long learning curve and require a good amount of experience and perforator dissection skills to reduce the probability of flap failure. We are of the opinion that residents should be adequately trained in this procedure to ensure optimal outcome delivery.     

双足带有同蒂多叶皮瓣的趾甲皮瓣移植治疗全手皮肤套脱伤

目的 探讨应用组合组织移植修复全手皮肤套脱伤的方法.方法 对3例全手皮肤套脱伤患者,分别采用一侧足部以胫前动脉为蒂的带踝前皮瓣、足背皮瓣、足内侧皮瓣和足外侧皮瓣的拇甲皮瓣再造拇指,修复桡侧手掌手背及虎口区皮肤缺损;另一侧足部带以上相同皮瓣的第二趾甲皮瓣再造示指(或中指),修复尺侧手掌及手背皮肤缺损.结果 术后3例,除一再造示指坏死外,其余组织瓣全部存活.术后随访3～12个月,修复后手部外形和捏、握、抓等功能基本恢复.皮瓣及再造拇、示指(或中指)感觉恢复至S2～S4.结论 双足带有同蒂多叶皮瓣的趾甲皮瓣移植治疗全手皮肤套脱伤是一种有效的治疗方法.     

A comparison of axial circumference between superficial circumflex iliac artery perforator flap and other workhorse flaps in dorsal foot reconstruction

Background: Management and reconstruction of dorsal foot defects present various difficulties and challenges. The main purpose of this article is to discuss experiences of using superficial circumflex iliac perforator (SCIP) flap in various defects of the dorsal foot region.

Methods: From August 2012 to February 2015, a total of 13 patients – nine males and four females – received a reconstruction operation for dorsal foot defects using SCIP flaps (the SCIP group). The defects were caused by trauma (n?=?9), diabetes (n?=?3), and malignancy (n?=?1). The mean age was 43.07 years, which ranged between 19–70 years. Additionally, 19 other patients, who underwent reconstruction operation of the foot dorsum using ALT and TDAP flaps during the same study period, were recruited for comparison. The axial circumference of the operated foot and unoperated contralateral foot was measured, and the difference were compared between all patients, as well as between the two groups.

Results: All of the flaps survived after the operation, but secondary procedures were performed in two cases due to partial skin necrosis. The mean follow-up period was 13 months. The mean axial circumference discrepancy of the SCIP group (12.08?±?2.96?mm) was significantly lower compared with ALT (25.21?±?3.16?mm) and TDAP (29.88?±?1.55?mm) groups (p?Conclusions: The authors experienced good results with using the SCIP flap in dorsal foot reconstruction. Reconstruction with the SCIP flap can be a good surgical option, with better postoperative symmetry and minimal donor sequelae, compared to conventional workhorse flaps.     

Experience with 60 inferior rectus abdominis flaps.

We report on our experience with the inferior rectus abdominis flap. Since 1984, 60 patients have been operated on with this technique. The inferior rectus abdominis flap was used as a free flap, island flap or pedicle flap (inferiorly based). Pure muscle flaps served to fill bone defects in patients with chronic osteomyelitis or as a biologic cover of infected vascular prostheses following multiple vascular surgery in the groin. The myocutaneous and fasciocutaneous rectus flaps served to cover soft tissue defects of the upper and lower extremities after accidents, degloving and radical tumour surgery. We present data from our collective patients to document the benefits of the inferior rectus abdominis flap and recommend this technique as a safe surgical modality to manage large-surface soft tissue defects.     

Sequential chimeric medial femoral condyle and anterolateral thigh flow‐through flaps for one‐stage reconstructions of composite bone and soft tissue defects: Report of three cases

Small recalcitrant non‐unions with poor perfusion require reconstruction with vascularized bone flaps. Cases with concomitant large soft tissue defects are especially challenging, since vascularized soft tissue transfer is often indicated and distant microvascular anastomoses may be required. We introduce a sequential chimeric free flap composed of a medial femoral condyle corticoperiosteal flap anastomosed to an anterolateral thigh flow‐through flap (MFC‐ALT flap) and report its use for reconstruction of small non‐unions with concomitant large soft tissue defects in three exemplary patients. Two female and one male patients ages 39–58 years suffered from composite bone and soft tissue defects of the lower extremity and clavicle caused by tumor resection and postoperative radiation resp. infected tibial pilon fracture. The sizes of the soft tissue defects ranged from 15–23 × 4.5–6 cm and the sizes of the bone defects ranged from 1.5–4 × 2–4 cm. Defect reconstructions were performed in all cases with sequential chimeric MFC‐ALT flaps with sizes ranging from 2–4 × 1.6–4 cm for the MFC and 21–23 × 7–8 cm for the ALT skin paddles. Functional reconstructions were achieved in all cases resulting in stable unions and soft tissue coverage enabling the patients to bear full weight without assistance on 5‐months follow‐up. Postoperative course was uneventful and complications were restricted to a small skin necrosis at the suture line in one case. MFC‐ALT flaps may be a safe, and effective procedure for one‐stage reconstructions of small, irregularly shaped bone defects with concomitant large soft tissue loss or surrounding instable scarring, particularly in cases of recalcitrant non‐unions after radiation exposure.     

Free posterior tibial perforator-based flaps

Free posterior tibial perforator-based flaps, fed by a perforator from the posterior tibial artery, were applied in 2 patients. The advantages of this flap are that they are reliable, relatively large and thin flaps, making it possible to use an innervated flap without sacrificing the posterior tibial artery. This flap provides great advantages for the reconstruction of skin defects at the extremities.     

髂腹股沟皮瓣联合股部皮瓣带蒂瓦合移植在手部大面积套脱伤治疗中的应用

目的 介绍髂腹股沟皮瓣联合股部皮瓣带蒂移植治疗手部大面积套脱伤的手术方法和临床效果.方法 对7例手、腕及前臂部广泛皮肤套脱伤的患者,采用髂腹股沟皮瓣联合股前外侧皮瓣带蒂移植修复4例,联合阔筋膜张肌皮瓣带蒂移植2例,联合股前侧皮瓣带蒂移植1例.髂腹股沟部供区创面直接闭合,股部供区创面取全厚层皮片植皮覆盖.术后半个月拆线,并进行皮瓣夹蒂训练,术后1个月根据皮瓣夹蒂训练情况酌情断蒂.急诊一期修复2例,二期修复5例.结果 术后7例皮瓣全部存活,供区伤口I期愈合,随访2～6个月,皮瓣柔软,质地良好,皮瓣外形较臃肿,无坏死及破溃.结论 髂腹股沟皮瓣联合股部皮瓣带蒂移植,二者瓦合可覆盖全手及前臂大面积皮肤套脱伤,手术操作简单,安全性高,易于推广;该皮瓣缺点是需二期手术断蒂,且移植皮瓣外形臃肿,需后期整形.     

Stepladder dorsal metacarpal flaps for dorsal finger and hand reconstruction.

The authors demonstrate successful cases of stepladder dorsal metacarpal V-Y advancement and rotation-advancement flaps for reconstructing defects on the dorsum of the finger and hand. One side of the flap is designed in a multilobed shape, and each lobed flap is designed on the dorsum of adjacent fingers. These flaps are supplied by dorsal metacarpal vessels. Consequently, this method has the elements of the stepped incision technique, in combination with the V-Y and rotation-advancement principle. All flaps survived completely. This technique may be a useful option for reconstruction of defects of the dorsum of the finger and hand.     

Preliminary experience with perforator flaps in reconstruction of soft-tissue defects of the foot and ankle

BACKGROUND: Microsurgical reconstruction has improved limb salvage in patients who because of many etiologies have soft-tissue loss from the lower extremities. Free-tissue transfer to the foot and ankle often interferes with postoperative function and footwear because of the bulk of a muscle flap. The foot and ankle often are best treated using thin flaps that will not contract and fibrose, particularly if secondary procedures are required. We hypothesized that perforator flaps, which are thin free-tissue transfers consisting of skin and subcutaneous tissue, both diminish donor site morbidity and are ideally suited for soft-tissue reconstruction of the foot and ankle. METHODS: Ten patients had free- tissue transfers to the foot and ankle using perforator flaps during a 2-year period. Four had acute posttraumatic wounds, three had soft tissue defects with exposed hardware or bone graft after reconstructive surgery, and three had large soft-tissue defects after foot infection secondary to diabetes. Nine had reconstruction with anterolateral thigh perforator flaps and one had reconstruction with a deep inferior epigastric artery (DIEP) perforator flap. RESULTS: All flaps survived. There were no deep infections. Three flaps had minor tissue loss requiring subsequent small skin grafts, all of which healed. There were no donor site complications and no interference of muscle function at the donor sites. Custom shoewear was not required to accommodate the flaps. CONCLUSION: This series highlights the success and utility of perforator flaps in microsurgical reconstruction of the foot and ankle. The greatest advantage of perforator flaps is the diminished donor site morbidity, which was achieved while maintaining high microsurgical success rates. These skin and fat flaps remained pliable and contracted less than muscle flaps, allowing for smooth tendon gliding and easy flap elevation for secondary orthopaedic procedures.     

Salvage of a Thumb Replant Using a Bilobed Dorsal Metacarpal Artery Island Flap: Case Report and Literature Review

Amputations and degloving injuries of the hand are highly disabling, especially when they affect the thumb. Dorsal metacarpal artery (DMCA)-based flaps have been well-documented in the literature for use in extensive degloving injuries of both dorsal and palmar aspects of the thumb surface. Modifications on these flaps, such as the bilobed island flap, offer additional advantages when larger surface areas or more distal defects of the thumb are present. We present a review of the literature on the DMCA flap and describe its use to salvage a partial survival of a thumb amputation through the metacarpophalangeal joint.     

Propeller flap: Orthoplastic approach for coverage of distal leg and ankle defects

BackgroundCovering soft tissue defects of the distal one-third of the leg and the Achilles tendon region and is a challenging problem for an orthopedic surgeon. With recent advancements in the anatomical knowledge of perforating vessels, perforator-pedicled propeller flaps have become increasingly popular in recent decades. We aimed to evaluate the clinical outcomes of our patients whose soft tissue defects in the distal leg were reconstructed with propeller flaps and assessed association of complications with age, gender, flap size and arc of rotation.MethodsPatients that had a reconstruction with a propeller flap at the ankle from 2013 to 2019 were retrospectively reviewed. The main indications for the propeller flap were small- and medium-sized soft tissue defects of the distal lower limb. 20 propeller flaps were applied to 19 patients (14 male, 5 female) for various lower extremity defects.ResultsThe mean follow-up duration was 2 years (range, 6 months to 6 years). The average flap size was 82 cm² (range, 48–125 cm²). The flap was rotated 180 degrees in nine patients The source of the perforator vessel was the tibialis posterior artery in 14 cases, the peroneal artery in 4 cases, both the tibialis posterior and peroneal arteries in 1 case. Four complications (20 %) occured postoperatively. Two patients developed partial necrosis at the tip of the flap, and two patients developed superficial epidermolysis. No correlations were found between complications and flap size and the arc of rotation.ConclusionsThe propeller flap is a reliable option for reconstruction of small to moderate defects in the lower extremity with good clinical results and minimal donor-site morbidity. It is applicable for orthopedic surgeons who do not have microsurgical experience or an available microscope in the operating room.     

Lower‐limb reconstruction with chimeric flaps: The quad flap*

Early soft‐tissue coverage is critical for treating traumatic open lower‐extremity wounds. As free‐flap reconstruction evolves, injuries once thought to be nonreconstructable are being salvaged. Free‐tissue transfer is imperative when there is extensive dead space or exposure of vital structures such as bone, tendon, nerves, or blood vessels. We describe 2 cases of lower‐extremity crush injuries salvaged with the quad flap. This novel flap consists of parascapular, scapular, serratus, and latissimus dorsi free flaps in combination on one pedicle. This flap provides the large amount of soft‐tissue coverage necessary to cover substantial defects from skin degloving, tibia and fibula fractures, and soft‐tissue loss. In case 1, a 51‐year‐old woman was struck by an automobile and sustained bilateral tibia and fibula fractures, a crush degloving injury of the left leg, and a right forefoot traumatic amputation. She underwent reconstruction with a contralateral quad free flap. In case 2, a 53‐year‐old man sustained a right tibia plateau fracture with large soft‐tissue defects from a motorcycle accident. He had a crush degloving injury of the entire anterolateral compartment over the distal and lower third of the right leg. The large soft‐tissue defect was reconstructed with a contralateral quad flap. In both cases, the donor site was closed primarily and without early flap failures. There was one surgical complication, an abscess in case 2; the patient was taken back to the operating room for débridement of necrotic tissue. There have been no long‐term complications in either case. Both patients achieved adequate soft‐tissue coverage, avoided amputation, and had satisfactory aesthetic and functional outcomes. With appropriate surgical technique and patient selection, the quad‐flap technique is promising for reconstructing the lower extremity.     

股前外侧皮瓣的临床运用

目的：总结回顾我院运用股前外侧皮瓣的临床体会。方法：从1998年12月－2001年9月运用股前外侧皮瓣修复全手脱套伤2例，前臂、腕部软组织缺损、瘢痕粘连6例，小腿足背部软组织缺损16例。其中组合皮瓣2例，顺行股前外侧皮瓣修复骨盆部感染1例。结果：1例由于肌皮穿支持寻困难，术中放弃改为游离小腿内侧皮瓣。1例组合皮瓣术后发生动脉危象，经探查后成活。余均无血管危象发生。所有病例均获随访，随访时间6－30月，平均12.5月。全手脱套伤修复后手部显臃肿，余均获满意功能及外形。结论：股前外侧皮瓣可切取面积大，血运丰富，不损伤主要血管，是修复软组织缺损、瘢痕挛缩、局部感染的理想皮瓣。对全手脱套伤的治疗亦是一种可以借鉴的选择。     

Consecutive flap transfer for repairing massive soft tissue defects in the opisthenar with improved donor site closure

Objective：To explore a surgical model of utilizing consecutive free scapular flap and adjacent pedicled flap transfer for repairing massive soft tissue defects on the dorsum of the hand while minimizing the donor site morbidity.Methods：Six patients with massive soft tissue injuries on the opisthenar and forearm were treated with free scapular flaps.Afterwards,a pedicled flap adjacent to the donor site was transferred to cover the donor site defect by direct closure.Results：All six free scapular flaps survived without signs of infection.Three adjacent pedicled flaps presented minor signs of insufficient blood flow on the distal apex,which resolved after six weeks with only conservative therapy.All the incisions healed without other complications.At six-month follow-up,the patients regained full shoulder function.Conclusion：With the assistance of an adjacent pedicled flap,the scapular flap is a highly applicable approach in repairing massive soft tissue defects in the opisthenar.It can achieve positive outcomes in both reconstructive and aesthetic aspects.