DIEP+TRAM联合皮瓣与双侧DIEP皮瓣乳房再造比较

目的 比较DIEP+TRAM皮瓣与双侧DIEP皮瓣乳房再造的特点,并探讨其适应证.方法 2003年8月至2006年6月,共采用双蒂下腹部皮瓣进行29例、32侧二期乳房再造.其中,采用TRAM+DIEP联合皮瓣再造乳房21例,均为单侧乳房再造;双侧DIEP皮瓣乳房再造8例,5例为单侧,3例为双侧乳房再造.结果 随访3月～3年,2组均取得较满意效果,联合皮瓣组术后皮瓣尖端部分血运障碍1例(4.8%),双侧DIEP组皮瓣血运障碍2例(25%);腹部切口脂肪液化联合皮瓣组7例(33.3%),DIEP组1例(12.5%).结论 当供区和受区条件均较理想时,可以选择双侧DIEP皮瓣进行乳房再造.如果受区血管曾受到放射治疗的损伤,以及患者同时合并内科疾病等情况下,采用DIEP+TRAM联合皮瓣是理想的乳房再造方法.     

Reconstruction of a Complex Foot Injury With Free Remodeled Fibular Osteocutaneous Flap: A Case Report and Literature Review

Management of complex foot injuries, which involve open fractures and severe trauma to soft tissues, represent a challenge to orthopedic clinicians. In the present case report, we treated a complex foot injury with a remodeled fibular osteocutaneous free flap to reconstruct the anterior and lateral areas of the foot. The flap survived completely. At the 9-month follow-up examination, bony union of the graft bone was identified by radiographic examination. The reconstructed foot could bear body weight, and the patient could maintain a bipedal gait without discomfort. The remodeled fibular osteocutaneous free flap provides an option for functional reconstruction of foot defects.     

Reconstruction of Syndactyly and Polysyndactyly of the Toes With a Dorsal Pentagonal Island Flap: A Technique That Allows Primary Skin Closure Without the Use of Skin Grafting

Syndactyly and polysyndactyly are common congenital conditions involving the foot, and surgery to reconstruct the toes may be indicated for cosmetic, psychological, and practical reasons. A dorsal flap is traditionally used for web space reconstruction, with skin grafts for the bases of the toes. Skin grafting has associated morbidity and can result in pigmentation mismatch. Single-stage direct closure with a specially designed flap has advantages including a reduction of morbidity from avoidance of skin grafting and shorter surgery. Four patients (6 feet) were included in the study. There were 2 cases of syndactyly and 2 cases of polysyndactyly. Bilateral involvement occurred in 2 patients. The average age was 18 months at time of first surgery. Direct closure was achieved with a dorsal pentagonal island flap with dorsal and plantar triangular flaps. The average duration of follow-up was 19.8 months. At final follow-up, all patients had acceptable web depth and pulp contour. The distance between the proximal interphalangeal joints of adjacent toes and the web slope of the reconstructed web space were acceptable. Complications included partial synechiae, cellulitis, and keloid formation. The dorsal pentagonal island flap is an acceptable technique in providing another means for single-stage reconstruction of the web space in syndactyly and polysyndactyly. Good functional and cosmetic outcomes can be expected. However, the potential complication of keloid formation can affect cosmesis and overall outcome, and must be understood by patients and parents.     

Outcomes of the Pedicled Medial Sural Artery Perforator Flap for Soft Tissue Reconstruction Around the Knee: When to Use It and How to Look After It

Introduction  The medial gastrocnemius flap is an established workhorse flap to cover proximal leg defects due to its reliability and simplicity to raise. However, it has the disadvantage of being bulky, requiring a skin graft for coverage, and is associated with loss of muscle power. The pedicled medial sural artery perforator (MSAP) flap has gained popularity as a reconstructive alternative for defects of the lower extremities. We present a case series of pedicled MSAP flaps for reconstructing defects around the knee as an alternative to the medial gastrocnemius flap. Materials and Methods  A consecutive series of patients with proximal leg defects following trauma, osteomyelitis, burns, and chronic wounds were included. A hand-held Doppler was used to map out the MSAPs. Defects were reconstructed using pedicled MSAP flaps, preserving the nerve supply to the gastrocnemius muscle. Patient outcomes were recorded, including their Enneking scores postreconstruction. Results  A total of 10 pedicled flaps was performed to reconstruct defects around the knee joint between October 2017 and November 2018. All the patients were discharged 1 week postoperatively, and rehabilitation consisted of graduated flexion in a knee brace by means of controlled passive mobilization. Three out of the ten patients developed complications: one patient developed flap congestion, one developed epidermolysis of the tip of the flap, and the other patient had partial necrosis of the skin paddle. The average Enneking score was 29 out of 35. Conclusion  The pedicled MSAP flap is a good reconstructive option for proximal leg defects as it is associated with lower donor site morbidity and provides an aesthetically pleasing reconstruction.     

The “Standing Cone” Flap for Thumb: A Spinoff the Hypogastric Flap in Combined Defects of Dorsum of Hand and Thumb

Background: The management of combined defects of the dorsum of the hand and the thumb can be quite challenging. The conventional teaching has been to use more than 1 flap for such discontinuous defects of the hand. Methods: We present a novel technique to provide a reliable skin cover to a concomitant second defect over thumb, which otherwise would require an additional flap, by recruiting the excess skin available after closure of the primary flap donor site of the hypogastric flap being used for the defect on the dorsum of hand. We report a case series of 5 patients wherein this technique has been used successfully. Results: The modified technique was able to successfully manage the concomitant defects of the dorsum of hand and the thumb in 1 stage. Conclusions: We find this innovation can help cover 2 separate defects on dorsum of hand and the thumb in 1 stage by utilizing just 1 flap instead of the conventional method of raising 2 flaps for such defects     

The use of the ALT Flap and Lateral Femoral Cutaneous Nerve for the Reconstruction of Carpal Soft Tissue and Ulnar Nerve Defects: a Case Report

The anterolateral thigh (ALT) flap has become one of the workhorse flaps, with indications including diverse reconstructive problems. The lateral thigh area is also a useful donor site for nerve grafts. The lateral femoral cutaneous (LFC) nerve can be dissected along with the ALT flap for a substantial length, depending on the requirements of the recipient site. The LFC nerve can be used as a vascularized or non-vascularized nerve graft. The technique offers advantages and it can find clinical applications, satisfying the functional and aesthetic reconstructive requirements of a complex defect. We report the case of a patient who presented with traumatic soft tissue defect of the volar aspect of the wrist and ulnar nerve defect as a complication of a fracture of distal radius. An ALT flap was used to reconstruct the soft tissue defect. The ulnar nerve was resected due to necrosis and the gap was repaired with non-vascularized grafts of the anterior branch of the LFC nerve. The soft tissues were resurfaced successfully without complications. Functional recovery was good for the superficial branch of the ulnar nerve, whereas it was variable for the deep branch of the ulnar nerve. The anterolateral thigh area offers significant advantages as donor site in the reconstruction of complex soft tissue defects being a large source of vascularized skin, fat, fascia, muscle and nerve. This availability allows for single donor site dissection, minimizing the operating time and the associated morbidity.