Alternative Regional Flaps When Anterolateral Thigh Flap Perforator is not Feasible

This paper presents the scheme to select alternative flaps limited to the region of the ipsilateral thigh when the perforator of the anterolateral thigh flap is not feasible. Total of 564 consecutive microsurgery cases using anterolateral thigh perforator flap was reviewed from March of 2001 to January of 2009. Total of 12 cases used a contingent flap due to anatomical and technical complications of the anterolateral thigh perforator. The alternatives were skin perforator flaps adjacent to the initial flap (3 cases of upper anterolateral thigh flap, 4 cases of anteromedial thigh flap), vastus lateralis muscle flap with skin graft (2 cases), and anterolateral thigh flap as septocutaneous flap without a prominent perforator on the septum (3 cases). All flaps survived and provided coverage as planned but one case using septocutaneous flap without a prominent perforator was noted with partial necrosis. Adjacent flaps around the anterolateral thigh perforator flap may provide useful alternative flaps in cases of failed elevation. Limiting the contingent secondary flap to this region may reduce further donor site morbidity and still provide an adequate flap for reconstruction.     

游离阔筋膜张肌穿支皮瓣修复手足部软组织缺损

目的总结游离阔筋膜张肌穿支皮瓣修复手足部软组织缺损的临床应用效果。方法2004年1月至2008年12月,应用游离阔筋膜张肌穿支皮瓣修复6例手和足部软组织缺损。结果除1例术后发生表浅感染经换药愈合外,6例皮瓣全部成活,术后顺利。术后随访22～52个月(平均30个月),无明显的供区功能障碍,疗效满意。结论游离阔筋膜张肌穿支皮瓣具有血供丰富,血管解剖恒定,以及皮瓣较薄的优点,适宜修复手和足背部软组织缺损。     

小型猪静脉增流DIEP皮瓣的血流动力学研究

目的 研究静脉增流对小型猪腹壁下动脉穿支(DIEP)皮瓣成活面积的影响及其血流动力学特点。方法 选取24头小型猪,在其腹部形成模拟增流DIEP皮瓣和传统DIEP皮瓣,并进行相应指标测量。包括皮瓣的血流灌注,静脉血管的压力,以及静脉血气分析。血流动力学测量后,所有腹部皮瓣原位缝合,随机选取12只形成静脉增流的DIEP皮瓣(实验组),其余12只为传统的DIEP皮瓣(对照组)。术后7 d进行活检,测量皮瓣的成活面积。结果 在静脉增流模式下,各血流动力学指标均较无增流情况下明显改善。对照组皮瓣成活率为(82.1±7.6)%,实验组为(99.4士1.2)%,差异显著。结论静脉增流技术可显著改善DIEP皮瓣灌注并增加皮瓣成活面积。就大面积皮瓣而言,静脉增流技术是改善静脉淤血和增大皮瓣成活面积的可靠方式。     

A Neurovascular Flap for Coverage of Distal Plantar Defects

Ulcers on the sole of the foot are very uncomfortable. A poor blood supply and a tendency to slow healing are common in these patients. Because of its weight-bearing and unique sensory function the glabrous skin of the sole is very specialized. To obtain a functional skin coverage, glabrous skin with a good blood supply and an intact nerve supply may be superior to other methods of soft tissue reconstruction. A neurovascular axial or island flap from the fibular side of the great toe may fulfill this demand with minimal donor site morbidity. Three cases are reported and the literature on the subject is summarized.     

Evaluation of Role of Arterialization of Venous Flaps in Abdomen in Rats

Introduction  Reconstruction forms the primary tenet in plastic surgery. Venous flaps are a known option but the survival is limited. Arterialization of venous flap can enhance its survival. While various techniques of arterialization of venous flaps are described, there are very few studies comparing them. Material and methods  The current study was conducted among 34 rats weighing 160 to 200 grams. The rats were divided into four groups. Group I—islanded epigastric flap was raised with superficial caudal epigastric vessels as pedicle. Group II—arterialized flow through venous flap was raised with superficial caudal epigastric vein (SCEV) as afferent and lateral thoracic vein as drainage vein. Side-to-side anastomosis was done between femoral artery and vein, lateral to the origin of superficial caudal epigastric artery. Group III—after raising the flap, as in group II, femoral vein was ligated proximal to superficial caudal epigastric vessels. Group IV—an arterialized flow through venous flap was raised with superficial caudal epigastric vein as afferent and lateral thoracic vein as drainage vein. End-to-side anastomosis was done between femoral artery and superficial caudal epigastric vein. Animals that died before completion of the study were excluded. The color changes of flaps were noted. Flap survival was expressed as a percentage of the total flap surface area. The patency of anastomosis was seen on postoperative day 5. Results  There was no total flap failure. On statical analysis, the flap survival area on day 5 between Group I and Group IV was not significant ( p value 0.431). The survival area in Group I (78.85 ± 10.54%) was comparable to Group IV (65.71 ± 20.70%). Group II and III had poor results as compared with Group I. In four rats, thrombosis of arteriovenous anastomosis was noted with flap survival area of 30 to 33%. Conclusion  It was noted that epigastric venous flaps with end-to-side anastomosis between femoral artery and superficial caudal epigastric vein (group IV) have survival area comparable to islanded flaps.     

Delay by Staged Elevation of Flaps and Importance of Inclusion of the Perforator Artery

“Surgical delay” is aimed at increasing blood flow to adjacent angiosomes by opening choke vessels, to obtain larger and more reliable flaps. We hypothesized that staged elevation (delay) from distal to proximal, in addition to preservation perforator artery near the base will improve survival. Thirty-two Sprague–Dawley rats were divided into 4 groups and 3x8cm caudal McFarlane flaps were elevated. In “delay” groups the 3 × 4 cm distal part was elevated and sutured back, with complete elevation (3 × 8 cm) after 4 days. The deep circumflex iliac artery (DCIA) at the base was either preserved or transected. The groups were: group A (Delay/DCIA preserved), group B (Delay/DCIA transected), group C (No Delay/DCIA preserved), group D (No Delay/DCIA transected). The percentage of surviving flap area was measured after 7 days with digital planimetrics. Statistics were done with ANOVA and unpaired T-test. The survivals were: 98.44 ± 3.13 %(group A), 69.33 ± 5.51 %(group B), 76.50 ± 8.91 %(group C) and 52.89 ± 3.15 %(group D). Delay lead to a greater degree of survival whether the arteries were preserved (p = 0.002) or transected (p = 0.01). In groups where the DCIA was preserved, the delay lead to a greater area of survival (p = 0.002). Inclusion of arteries lead to a greater degree of survival whether delay was performed (p = 0.003) or not (p = 0.005). Necropsy showed that the DCIAs were dilated bilaterally when preserved with vascular arcades reaching all viable areas. When the DCIA was transected, the gluteal perforators were dilated bilaterally with the vascular arcades reaching all viable areas. Staged elevation is an effective method of delay in both random and rando-axial flaps. When this is combined with preserving the perforator artery, survival rates are further enhanced.     

Recovery of Sensitivity in the Hand after Reconstruction with Arterialised Venous Flaps

Loss of soft tissues of the fingers were repaired in 22 patients using 25 arterialised venous flaps harvested from the thenar, hypothenar, or forearm regions. Twenty-one of the flaps survived completely, 16 of which were raised from the thenar or hypothenar region, and the other five from the forearm region. We studied the sensory recovery and skin characteristics of the flaps harvested from the three regions. Good sensory recovery was obtained for the thenar or hypothenar venous flaps, which were characterised by durable skin and suitable texture for replacement of defects in the finger pulp. On the other hand, no moving two-point discrimination was recorded during the follow-up period in the group given forearm venous flaps. These flaps showed instability during pinching and grasping. However, larger flaps and longer veins can be harvested from the forearm region. This type of flap is therefore considered useful for covering dorsal defects of the finger or large and multiple skin defects.     

扩展穿支皮瓣血供范围的基础和临床研究进展

穿支皮瓣是临床广泛应用的组织缺损修复技术,但因穿支血管的管径细小,供区面积有限,使得穿支皮瓣在体表大面积缺损修复中的应用受到限制。本文从穿支皮瓣血管解剖、血供特点,以及增加皮瓣血运和促进组织血管化的相关治疗策略出发,对扩展穿支皮瓣血供范围的基础和临床研究进展进行综述。     

低分子肝素对指动脉逆行岛状皮瓣静脉危象的预防

目的探讨应用低分子肝素预防指动脉逆行岛状皮瓣静脉危象的发生,提高皮瓣存活质量。方法自2008年3月至2012年3月,应用指动脉逆行岛状皮瓣修复手指创面17人,共19指,皮瓣面积1．8cm×1-4cm～3．5cm×2．5cm,蒂长1．5cm～2．2cm。术后除常规处理外,皮下注射低分子肝素5000IU,每日一次,共5d。术后观察皮瓣血液循环情况。结果皮瓣早期血液循环良好。皮瓣持续渗血时间及渗血量较多,在皮瓣外形成质软的凝血块,用药过程中皮瓣边缘不易形成黑色血痂,过程中均未出现静脉危象,所有皮瓣均存活且存活质量高。术后随访3周～6个月,皮瓣颜色和周围皮肤基本一致,质地较软,手指活动功能满意。结论皮下注射低分子肝素能延长逆行岛状皮瓣术后皮瓣渗血时间,减轻皮瓣早期静脉回流的负荷,有效预防皮瓣发生静脉危象,提高了皮瓣的存活质量。