游离胸背动脉穿支皮瓣桥式移植修复小腿软组织缺损

目的总结游离胸背动脉穿支皮瓣或肌瓣桥式移植修复小腿软组织缺损的临床应用效果。方法自2006年9月至2009年1月,应用游离胸背动脉穿支皮瓣或肌瓣桥式移植修复小腿软组织缺损11例,缺损范围4cm×8cm至8cm×22cm。皮瓣切取连带肩胛下与旋肩胛血管,血管蒂呈T形,与健侧小腿胫后动脉行端端吻合,血管蒂用中厚网状游离植皮覆盖。结果除1例术后皮瓣远端发生小的表浅感染,经换药后愈合外,本组皮瓣全部成活。术后随访9个月至3.6年(平均2.9年),没有发现明显的供区功能障碍,供区与受区外形较好,健侧小腿经临床观察与Doppler检查,胫后动脉通畅。结论本方法适用于修复四肢软组织缺损后,患者仅存1条主要动脉者;行桥式游离胸背动脉穿支皮瓣或肌瓣移植不损伤健侧小腿胫后动脉,降低了对供区的损伤。     

Soft-tissue reconstruction of an open tibial wound in the distal third of the leg: a new treatment algorithm

Over the past 4 years, a total of 33 patients, each with an open tibial wound in the distal third of the leg, underwent a skin-grafted muscle flap reconstruction according to the new treatment algorithm developed by the author. When the size of the soft-tissue defect was less than 50 cm, a pedicled medial hemisoleus muscle flap was used for the soft-tissue coverage (n = 20). If the soleus muscle was traumatized, a small free muscle flap (ie, gracilis) was then used (n = 3). When the size of the soft-tissue defect was greater than 50 cm, a larger free muscle flap (ie, rectus abdominis or latissimus dorsi) was selected (n = 10). All patients were followed for up to 4 years. Three patients with a medial hemisoleus muscle flap developed insignificant distal flap necrosis and were treated subsequently with debridement and flap advancement. Five patients with a free muscle flap required an additional operation, and 2 patients had a subsequent debulking procedure of the flap for contour improvement of the leg. Reliable soft-tissue coverage with a well-healed tibial wound, evident fracture healing, and good contour of the leg were achieved in all 33 patients during follow-up. Following this new treatment algorithm, a selected option for an open tibial wound in the distal third of the leg can provide reliable soft-tissue coverage for different sizes of open tibial wounds and may offer a more cost-effective approach for managing such a complex clinical problem.     

Caveats of Local Fasciocutaneous Flaps for Distal Leg Defects—Anatomical Study and Clinical Application

The present trend for the management of distal leg defects is to opt for a free flap with local flaps being relegated to the backseat. We studied the perforator anatomy of the distal leg in the Indian population to see if there were any ethnic differences and then correlated it with a clinical study of local flaps used for the coverage of distal leg defects. A prospective observational study was carried out in 2 phases—anatomical study and clinical study from December 2018 to March 2020. In the anatomical study, 8 fresh cadavers, i.e., 16 lower limbs were dissected and the perforator anatomy in the distal leg was identified. In the clinical study, all patients undergoing local, pedicled fasciocutaneous flap cover for defects involving distal third leg were included with ages between 15 and 60 years. In the anatomical study, posterior tibial artery perforators in the distal-most part were found as a group of up to 3 perforators. In the clinical study, a total of 47 patients were included with a mean age of 38.0 ± 10.9 (range 17-55) years and female:male ratio being 1:2.6. The largest defect size was 120 cm² (mean 28.2 ± 23.8 [range 6-120] cm²) and the most commonly used flap was the reverse sural artery flap in 20 (42.6%) cases. Overall, complications were seen in 7 (14.9%) cases and there was no case of flap failure. Thus, local flaps are an excellent option for coverage of distal leg defects and offer results comparable to free flaps.     

The reversed medial hemisoleus muscle flap and its role in reconstruction of an open tibial wound in the lower third of the leg

The usefulness of a reversed hemisoleus muscle flap as a local reconstructive option for soft-tissue coverage of an open tibial wound in the lower third of the leg has never been acknowledged. Over the past 2 years, 8 patients underwent soft-tissue reconstruction of an open tibial wound (3 x 3 to 10 x 6 cm) in the lower third of the leg with the reversed medial hemisoleus muscle flap modified by the author. The flap was dissected with attention to preserve several critical perforators from the posterior tibial vessels to the flap as possible while allowing adequate turnover of the flap to cover the exposed tibia or hardware. There was no total flap loss, and limb salvage was achieved in all patients. Only 2 patients developed insignificant distal flap necrosis, and they were treated subsequently with debridement and flap readvancement. All patients had reliable healing of their tibial wounds, with good reconstructive and cosmetic outcomes of their flap reconstructions during follow-up. Therefore, the author believes that the reversed medial hemisoleus muscle flap can be a good choice for soft-tissue coverage of a sizable open tibial wound in the lower third of the leg and may be used successfully to replace free tissue transfer in selected patients.     

应用穿支皮瓣治疗下肢远端慢性骨髓炎并皮肤缺损

目的 探讨游离或带蒂穿支皮瓣在治疗下肢远端慢性骨髓炎并皮肤缺损创面修复中的应用价值.方法 应用穿支皮瓣游离或带蒂移位修复胫前及足踝部慢性骨髓炎并皮肤缺损28例.游离移植13例:采用股前外侧穿支皮瓣修复胫前2例,踝前3例,足背2例,足跟2例;小腿外侧腓动脉穿支皮瓣修复足背4例.带蒂移位15例:胫后动脉穿支皮瓣修复胫前4例,修复内踝2例;腓动脉外踝后上穿支皮瓣修复足跟6例,外踝及足背各1例;第1跖背动脉穿支皮瓣修复近节(足母)趾背侧1例.抗生素液灌流伤口7例,万古霉素明胶海绵残腔填塞8例.结果 1例胫后动脉穿支皮瓣出现静脉回流不足,表浅坏死,自行愈合,其余皮瓣无坏死.随访6个月～2年,2例复发,分别经1次和2次手术后愈合,其余均一期愈合,皮瓣外形满意.3例行二期骨移植.最后一次随访时,患者可行走,患肢完全负重,按足部疾患治疗效果标准评定平均为84.5分.结论 游离或带蒂穿支皮瓣血供良好,可用于治疗残腔不大的慢性骨髓炎并皮肤缺损.     

Reverse sural island flap elevated from the proximal third of the leg: its reliability and versatility in distal leg and foot reconstruction

Soft tissue loss around the distal third of the leg and foot has remained a considerable challenge. A reconstructive option providing supple tissue, while avoiding the complexity and the high technical demand of free flaps is a welcome alternative. The sural island flap largely satisfies these criteria. A number of authors have suggested raising the skin island from the junction of the middle and upper third of the leg to improve its reliability. However, raising the flap over the upper third of the leg may provide a larger amount of tissue and often makes dissection of its most distal perforator unnecessary. This study aims to assess the reliability and versatility of the reverse sural island flap elevated from the proximal third of the leg for soft tissue reconstruction of the distal leg and foot. Consecutive patients with soft tissue loss around the distal third of the leg and the ankle region requiring flap cover who met the inclusion criteria were managed using the distally based sural island flap elevated from the upper third of the leg. The outcome has been analysed. There were 15 patients, 11 males and four females with an age range of 22 to 54 years. Thirteen patients had distal third open tibial fractures while two had open calcaneal injuries. Nine resulted from motorcycle accidents, four from motor vehicular accidents while two were gunshot wounds. Flap sizes ranged from 10 × 7 cm to 22 × 12 cm. Thirteen flaps had full survival while two flaps had partial necrosis. All donor sites were skin grafted with 95% to 100% graft take. The use of the reverse sural island flap elevated from the proximal third of the leg for coverage of soft tissue defects of the distal leg and foot is safe and reliable in our experience. It provides a sizeable amount of soft tissue while maintaining a robust blood supply.     

Repair of soft-tissue defect close to the distal perforating artery using the modified distally based medial fasciocutaneous flap in the distal lower leg

In this study, we modified distally based posterior tibial artery perforator flaps for repair of soft-tissue defects close to the distal perforating artery in the distal lower leg. The flap was designed along the axial network around the saphenous nerve. Flap transfer was performed in 45 cases. The size of the defects after debridement ranged from 4 × 3 cm to 20 × 8 cm (mean, 13 × 5.5 cm). Flap size ranged from 9 × 3 cm to 25 × 10 cm (mean, 16 × 7 cm). In this series, 41 flaps survived completely. Venous congestion was not observed. At a mean follow-up of 16.5 months, all flaps matched the recipient sites in color, texture, and thickness. Donor site morbidity was minimal. The modified distally based posterior tibial artery perforator flap is a reliable and useful option for coverage of the soft-tissue defect close to the distal perforating artery in the distal lower leg.     

Soft-tissue coverage of an open tibial wound in the junction of the middle and distal thirds of the leg with the medial hemisoleus muscle flap

A relatively simple but reliable option for soft-tissue coverage of a less extensive tibial wound in the junction of the middle and distal thirds of the leg has never been determined. In this series, the author reports his clinical experience utilizing the medial hemisoleus muscle flap as a local reconstructive option for management of this unique clinical problem. Over the past 2 years, 14 patients underwent a soft-tissue reconstruction of an open tibial wound (4 x 3 to 10 x 5 cm) in the junction of the middle and distal thirds of the leg with the proximally based medial hemisoleus muscle flap. Only the medial half of the soleus muscle was elevated, with attention to preserving critical perforators from the posterior tibial vessels to the flap while allowing adequate arc of flap rotation to cover the exposed fracture site and hardware. All patients were followed for up to 2 years. Only 1 patient developed insignificant distal flap necrosis and was treated with debridement and flap readvancement. All patients had primary healing of their wounds, reliable soft-tissue coverage, evidenced fracture healing, and good cosmetic outcome during follow-up. Therefore, the medial hemisoleus muscle flap described by the author can be a reliable local option for soft-tissue coverage of a less extensive tibial wound in the junction of the middle and distal thirds of the leg with good outcome and minimal morbidity.     

Foot and ankle reconstruction: An experience on the use of 14 different flaps in 226 cases

The aim of this report was to present our experience on the use of different flaps for soft tissue reconstruction of the foot and ankle. From 2007 to 2012, the soft tissue defects of traumatic injuries of the foot and ankle were reconstructed using 14 different flaps in 226 cases (162 male and 64 female). There were 62 pedicled flaps and 164 free flaps used in reconstruction. The pedicled flaps included sural flap, saphenous flap, dorsal pedal neurocutaneous flap, pedicled peroneal artery perforator flap, pedicled tibial artery perforator flap, and medial plantar flap. The free flaps were latissimus musculocutaneous flap, anterolateral thigh musculocutaneous flap, groin flap, lateral arm flap, anterolateral thigh perforator flap, peroneal artery perforator flap, thoracdorsal artery perforator flap, medial arm perforator flap. The sensory nerve coaptation was not performed for all of flaps. One hundred and ninety‐four cases were combined with open fractures. One hundred and sixty‐two cases had tendon. Among 164 free flaps, 8 flaps were completely lost, in which the defects were managed by the secondary procedures. Among the 57 flaps for plantar foot coverage (25 pedicled flaps and 32 free flaps), ulcers were developed in 5 pedicled flaps and 6 free flaps after weight bearing, and infection was found in 14 flaps. The donor site complications were seen in 3 cases with the free anterolateral thigh perforator flap transfer. All of limbs were preserved and the patients regained walking and daily activities. All of patients except for one regained protective sensation from 3 to 12 months postoperatively. Our experience showed that the sural flap and saphenous flap could be good options for the coverage of the defects at malleolus, dorsal hindfoot and midfoot. Plantar foot, forefoot and large size defects could be reconstructed with free anterolateral thigh perforator flap. For the infected wounds with dead spce, the free latissimus dorsi musculocutaneous flap remained to be the optimal choice. © 2013 Wiley Periodicals, Inc. Microsurgery 33:600–604, 2013.     

股前外侧穿支皮瓣桥接旋髂浅动脉蒂组织瓣组合移植修复四肢骨与软组织缺损

目的 探讨股前外侧穿支皮瓣桥接旋髂浅动脉蒂组织瓣组合移植修复四肢骨与软组织缺损的应用特点.方法 回顾性分析2009年3月至2011年1月,用股前外侧穿支皮瓣制备血流桥接皮瓣串联旋髂浅动脉为蒂的髂骨骨皮瓣、髂骨膜骨瓣或皮瓣修复10例四肢骨与软组织缺损患者资料,男9例,女1例;年龄21～57岁,平均39.7岁;血流桥接髂骨骨皮瓣7例,髂骨膜骨瓣2例,髂腹股沟皮瓣1例;重建手3例,足4例,小腿3例;平均皮肤缺损面积20 cm×9.7 cm.结果 股前外侧穿支皮瓣平均17.8 cm×9.4 cm,髂腹股沟皮瓣平均8.4 cm×4.5 cm,髂骨膜骨瓣平均5.4 cm×2.1 cm×0.8 cm,血管桥平均长10.5 cm.1例髂骨骨皮瓣远端部分坏死,经换药后植皮愈合,余皮瓣顺利成活.10例患者均获得6～36个月(平均12个月)随访.手损伤者平均骨愈合时间3个月,平均臂肩手残疾问卷评分43分;足损伤者平均骨愈合时间4个月,日本外科协会足部疾患治疗效果评分平均71.3分;小腿损伤者平均骨愈合时间4.5个月,Puno等评分平均91分.供区瘢痕颜色白、平软,6例大腿瘢痕增宽,2例瘢痕周围有麻木感,3例髂腹股沟区瘢痕增宽.结论 股前外侧穿支皮瓣桥接旋髂浅动脉蒂组织瓣移植可自由调整组织瓣位置,供区副损伤小,是修复大面积、结构复杂或类型特殊四肢骨与软组织缺损的一种较好方法.     

Arteriovenous Vascular Loops in Latissimus Free Flap Reconstruction of Cervical and Cervicothoracic Spine Wounds

Introduction  Wound dehiscence is the most common complication after spinal fusion procedures, resulting in an increase in mortality rate and hospital length of stay. Reconstruction of these wounds presents a challenge, as the spine is dependent on these implants for stability and must be maintained throughout the wound dehiscence treatment protocol. We describe a method for extending the thoracodorsal pedicle with an arteriovenous loop to permit an increased excursion of the latissimus dorsi muscle in patients with exposed implants and present the results of this procedure. Materials and Methods  A retrospective review of patients treated with a latissimus free flap with saphenous vein pedicle extension for posterior spinal wounds from 2010 to 2020 were reviewed. Patient charts were reviewed for demographic information including comorbidities, previous spine operations, wound size and location, and postoperative complications including total flap loss, flap dehiscence, and need for secondary surgery. Results  Six patients were identified who underwent a total of eight extended pedicle free flaps. Mean age was 64.8 years with a mean follow-up of 12.3 months (range, 6–20 months). Four wounds were in the cervicothoracic region with two wounds in the cervical region. Mean number of previous spine surgeries was 3.5 (range, 2–4). Mean wound size was 189 cm ² with a mean vein graft length of 28 cm. Wound coverage was successful in five of six patients. Major complications occurred in five of six patients. Total flap loss occurred in two patients (33%) and both underwent a second extended latissimus flap from the contralateral side. Three patients developed postoperative flap dehiscence which resolved with regular dressing changes. Conclusion  Extended pedicle latissimus flaps are an effective treatment for posterior spine wounds but are associated with a high complication rate, secondary to medically complex patients with multiple prior surgeries. Careful patient selection is critical for success.     

Utility of both muscle and fascia flaps in severe lower extremity trauma

BACKGROUND: The evolving technology in trauma management today permits salvage of many severe lower extremity injuries previously even considered to be lethal. An essential component for any such treatment protocol must be adequate soft tissue coverage that often will use vascularized flaps. Traditionally, calf muscles have been used proximally and free flaps for the distal leg and foot. The reintroduction of reliable local fascia flaps has challenged this dictum, proving to be a simpler and yet versatile option. MATERIALS AND METHOD: The role of both muscle and fascia flaps in lower extremity injuries has been retrospectively reviewed from a 2-decade experience. Soft tissue deficits requiring some form of vascularized flap occurred in 160 limbs in 155 patients. The frequency of use of flap types, specific complications and benefits, effect of timing of wound closure, and rate of limb salvage were compared. RESULTS: Initial coverage after significant lower extremity trauma in these 160 limbs required 60 local muscle flaps, 50 local fascia flaps, and 74 free flaps. These flaps had been selected on a nonrandom basis according to wound location, its severity, and flap availability. Complications were directly related to the severity of injury, and for free flaps as a group (39%), although these were not independent variables. Local muscle (27%) or fascia flaps (30%) were similar with regard to this morbidity. Healing was more likely to be uneventful if coverage were accomplished during the acute period after injury, regardless of flap type. Muscle flaps were still used in two thirds of all cases, with the soleus muscle used as often for the distal leg as the mid-leg. Local fascia flaps were most valuable for smaller defects, especially in the distal leg or foot, and often as a reasonable alternative to a free flap. CONCLUSION: The traditional role of the gastrocnemius muscles for flap coverage of knee and proximal leg defects and the soleus muscle for the middle third of the leg was reaffirmed. The soleus muscle often also reached distal leg defects as could local fascia flaps, where classically, otherwise, a free flap would have been necessary. The largest or most severe wounds, irrespective of limb location, required free flap coverage. Local fascia flaps proved to be a valuable alternative.     

Reconstruction of soft tissue defects in the extremities with a pedicled perforator flap: series of 25 patients

Since the introduction of perforator-based flaps, new flaps have been described for reconstruction of soft tissue defects in the extremities. Pedicled perforator flaps, often called propeller flaps, are based on a single perforator and are local axial flaps that can be rotated up to 180(0) with the single perforator as the pivotal point. Pedicle perforator flaps have gained popularity because they have a shorter operating time than free flaps. However, some concern has been raised about their reliability. Here we report our results of 11 soft tissue reconstructions in the lower leg and 14 in the upper extremity. The defects were mostly traumatic or caused by release of burn scars. The mean size of the flaps in the lower leg was 52 cm(2) (range 126-15 cm(2)). In the upper extremity it was 24 cm(2) (range 12-35 cm(2)). All patients were followed until the wound had healed. In the upper extremity there was only one partial necrosis of the flap, and one patient had an infected wound. One haematoma was evacuated postoperatively, and all the rest healed uneventfully. In the lower leg we had one total necrosis and one partial necrosis of the flap and one infected wound. A free scapular flap was used for salvage in one case, and revision and skin grafting in two. The pedicled perforator flap is reliable, particularly in the upper extremity. The operation is quick and can be done under regional anaesthesia. The flap is thin and has a local texture that gives a good functional and aesthetic result. The pedicled perforator flap is a little unpredictable in the lower leg, probably because the directions of the vessels that arise from the perforator are not consistent.     

Non-microsurgical skin flaps for reconstruction of difficult wounds in distal legand foot

Purpose

To express the versatility of a variety of non-microsurgical skin flaps used for coverage of difficult wounds in the lower third of the leg and the foot over 4 years period. Five kinds of flaps were used. Each flap was presented with detailed information regarding indication, blood supply, skin territory and technique.

Thirteen-Year Follow-Up Reverse Sural Artery Flap for Plantar Calcaneal Wound: A Case Report

Reconstruction of soft tissue defects in the lower leg and foot after traumatic injury is a challenging problem owing to lack of locally reliable flaps. The traditional options for wound coverage often do not provide feasible or adequate treatment for many of these wounds. The lack of skin laxity in the lower leg and foot often make local flaps unavailable. Split-thickness skin grafts will not be robust enough. Free tissue flaps have a litany of potential complications and guaranteed comorbidities. The present case reinforces that appropriately selected patients with significant open bony and soft tissue trauma to the foot and ankle can be treated with a reverse sural artery fasciocutaneous flap. The reverse sural artery flap allows for full-thickness skin coverage with its own blood supply, maximizing the healing potential and should be considered a viable first option for soft tissue coverage.     

Wound coverage considerations for defects of the lower third of the leg

Anatomical features of the lower third of the leg like subcutaneous bone surrounded by tendons with no muscles, vessels in isolated compartments with little intercommunication between them make the coverage of the wounds in the region a challenging problem. Free flaps continue to be the gold standard for the coverage of lower third leg wounds because of their ability to cover large defects with high success rates and feasibility of using it in acute situations by choosing distant recipient vessels. Reverse flow flaps are more useful for the coverage of the ankle and foot defects than lower third leg defects. The perforators in the lower third leg on which these flaps are based are often damaged during the injury. In medium-sized defects of less than 50 cm² size, local transposition flaps, perforator flaps, or propeller flaps can be used. Preoperative identification by the Doppler is essential before embarking on these flaps. Of the muscle flaps, the peroneus brevis flap can be used in selected cases with small defects. In spite of all recent developments, cross-leg flaps continue to remain as a useful technique. In rare occasions when other flaps are not possible or when other options fail it can be a life boat. In the author''s practice free flaps continue to be the first choice for coverage of wounds in the lower third leg with gracilis muscle flap for small and medium defects, latissimus dorsi muscle flap for large defects and anterolateral thigh flap when a skin flap is preferred.KEY WORDS: Free flaps, perforator flaps, lower leg defects     

应用胫后动脉穿支皮瓣修复足踝部复杂开放性骨折创面

目的：探讨胫后动脉穿支皮瓣在足踝部创面修复中的临床应用。方法应用胫后动脉穿支皮瓣逆行转移修复足踝部复杂开放性骨折创面6例。皮瓣切取面积：5.0 cm＆#215;6.0 cm～10.0 cm＆#215;15.0 cm。结果本组4例皮瓣全部成活,2例皮瓣边缘部分坏死,经换药及游离植皮后愈合。术后随访5～24个月,皮瓣外形满意,血供良好,无感染病例发生,足踝部骨折均骨性愈合,患肢均能负重行走。结论胫后动脉穿支皮瓣具有血供良好、操作简单、皮瓣供区破坏小等优点,适合修复足踝部皮肤软组织缺损。     

穿支皮瓣移植在手指创面修复中的应用

目的 探讨穿支皮瓣游离移植修复手指皮肤软组织缺损的设计和手术技巧.方法 切取小腿前外侧、小腿内侧下部、小腿外侧血管穿支皮瓣以及远段骨间背血管蒂穿支皮瓣,移植修复手指小创面13例.结果 13例皮瓣全部存活,受区与供区的功能、外观均良好.结论 在肢体部位以皮穿支或轴型血管为蒂设计穿支皮瓣,游离移植修复手指创面,患者痛苦小、损伤小,创面能获得满意覆盖.这为手外伤修复提供了一种新的选择,对术者也提出了更高的要求.     

Reverse Dermis Flap for Coverage of Distal Leg and Ankle Defects

Soft tissue defects of the distal third of the leg and ankle, which frequently expose tendon, bone or osteosynthesis material, are difficult to cover and pose a major challenge to the plastic surgeon. Traditional reconstructive options for this region usually require complex flaps which made them unsuitable for elderly patients or those with multiple comorbidities. We hereby present the reverse dermis flap as an easy and reliable choice to cover this type of wounds and refer our experience in 9 cases in which clinical, operative, and follow-up data were recorded. Of the 9 flaps performed, 8 survived completely and 1 presented a partial flap necrosis, requiring additional surgery. No other operative procedure was required. In conclusion, the reversed dermis flap is a simple, quick, noninvasive, and safe technique for coverage of noble structures such as tendon or bone in the distal third of the leg that every plastic surgeon should incorporate in his surgical armamentary.     

Radial forearm free flap for coverage of postoperative lateral heel wounds after open reduction and internal fixation of the calcaneus

For intraarticular calcaneus fractures, open reduction and internal fixation has become commonplace for the reduction of morbidity of postinjury arthritis. Despite adequate surgical results, there are often associated postoperative wound complications. The purpose of this study was to describe a unique application of the radial forearm free flap for coverage of lateral postoperative heel defects seen after calcaneal fixation. Seven lateral heel wounds after open reduction of calcaneal fractures in 6 patients were covered with radial forearm free flaps. The technique used involved passage of the pedicle of the laterally placed flap anteriorly to the Achilles tendon so that it can be anastomosed to the posterior tibial artery. Flap application was 100% successful, with good functional and cosmetic results in all patients. The radial forearm free flap provides a quick, reliable, and easily harvested source of coverage for lateral heel wounds seen after open reduction and internal fixation of the calcaneus. Tunneling of the flap pedicle anterior to the Achilles tendon is simple and provides the additional advantages of access to reliable vessels, reduced scarring, and avoidance of further wound problems often seen with incisions used to access the anterior tibial artery.