Vastus medialis muscle flap and hemi V-Y skin flap for knee extensor and soft tissue reconstruction

Simultaneous reconstruction of extensor mechanism and skin defect of the knee joint is a difficult problem. We present a case of a 55-year-old man with loss of patella and 9 x 6 cm skin defect after total patellectomy for infected open patellar fracture. Vastus medialis muscle flap and hemi V-Y skin flap were elevated. Vastus medialis muscle flap was advanced and sutured to the remaining patellar tendon. Hemi V-Y skin flap covered the skin defect. The wound healed uneventfully. After a follow-up period of 30 months, active range of motion of the knee joint is 0-120 degrees, and extension strength of the knee joint is [4] in a manual muscle test. He can stand on his right leg without any assistance. The combination of vastus medialis flap and hemi V-Y skin flap is a valuable option in knee reconstruction after total patellectomy.     

Acute management of traumatic forequarter amputations: case reports

Traumatic forequarter amputation is a rare and very devastating injury. The arm, including the scapula, clavicle, and pectoral muscle, is torn from the body by a tremendous traction force, usually combined with a counteracting force from the body. The cases of three patients are presented. One patient was caught by the axle of a harvesting machine, resulting in a forequarter amputation of his right extremity and amputation of his left arm at the level of the upper arm. The other two patients had their arms caught in conveyer belts. All patients survived. Closure of the defect was performed acutely using a local pedicled musculocutaneous flap in one case and free vascularized musculocutaneous flaps from the amputated limbs in the two other cases.     

Repair of a soft tissue defect of medial malleolus with cross-leg bridge free transfer of anterolateral thigh muscle flap: a case report

A 38-year-old man sustained a traffic accident injury to his right medial malleolus and leg.It was an open fracture of the right tibia and fibula accompanied by a large soft tissue defect of the right ...     

Combination of posterior interosseous and hypogastric flap for skin defect reconstruction in hand injuries

A combination of degloving injury of the fingers and mutilation of other fingers with skin defect may be treated urgently with a combination of arterialised pedicle flaps from the forearm and distant axial pattern flap. This combination is an alternative to the combination of posterior interosseous and lateral arm flap. Application of flaps urgently in emergencies does not increase risk of complications and shortens hospitalisation time. In this article we present the case of a 26-year-old male who sustained a serious injury of the right hand. The patient underwent urgent skin defect reconstruction performed by posterior interosseous and hypogastric flap combination. Although it is not usual to make a combination of flaps urgently, the final outcome is satisfactory. The authors wish to point out that radical primary reconstructive procedures give equivalent outcome to delayed reconstruction.     

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。     

Combined cremaster muscle and inner thigh skin composite flap: a novel experimental flap model in the rat

Unlike the composite musculocutaneous flap models, the combined composite muscle-skin flap model allows evaluating muscle and skin viability independently, because it has an independent blood supply to the muscle and skin component. However, to our knowledge, only two combined muscle-skin flaps have been reported to date. During our cremaster dissection in our laboratory, we perceived a new vessel as a terminal continuation of the pudic-epigastric artery (PEA) on which the cremaster muscle flap is raised. Therefore, we designed this study to determine whether the scrotal and inner thigh skin can be harvested with the cremaster muscle as a combined cremaster muscle-skin composite flap. Thirty male Sprague-Dawley rats were used in this experiment. In five rats, ink study selective to the PEA marked a skin territory. In 15 rats, cremaster muscle and 4 x 3 cm ipsilateral scrotal and medial thigh skin flap was raised on the PEA. Fluorescein study after 4 hours showed fluorescein stain in the skin island. On postoperative day 7, both muscle and skin components of the flaps were viable. Microangiographic study after the flap elevation revealed the vascularity of all components of the flap and clearly identified the branch to the skin island. To the best of our knowledge, this is the first report describing the combined flap model including the cremaster muscle. Our flap seems to have an important advantage over the other combined muscle-skin flap models in terms of the cremaster muscle being suitable for the intravital microscopy. Additionally, the two components of the flap have separate nutrient vessels with adequate length, which gives the flap flexibility in the placement of the skin component in a location distant from the muscle component. The flap may be also be raised as a skin flap without the cremaster muscle. It can be used for different applications, including microcirculatory, pharmacological, physiological, biochemical, and immunological studies as well as for transplantation studies.     

One-stage arm-preserving shoulder resection with latissimus dorsi flap for basal cell carcinoma

A 60-year-old man was found to have a large invasive basal cell carcinoma involving the skin and surrounding bones of the shoulder joint. The Tikhor-Linberg procedure, a technique for preserving the arm in a shoulder resection, was combined with a latissimus dorsi muscle flap reconstruction in one stage to achieve a satisfactory functional result.     

Versatility of the abductor hallucis muscle as a conjoined or distally-based flap

Soft tissue coverage of the medial ankle and foot remains a difficult, challenging, and often frustrating problem to patients as well as surgeons. To our knowledge, the abductor hallucis muscle flap is not frequently used and only a few well documented cases were found in literature. The purpose of this paper is to report and to present the long-term results of a series of four patients who underwent reconstruction of foot and ankle defects with the abductor hallucis muscle flap.In two cases, the abductor hallucis muscle flap was transposed in combination with a medialis pedis flap to cover a medial ankle defect, whereas in another case it was combined with a medial plantar flap. In this latter case, the muscle flap served to fill up a calcaneal dead space after osteomyelitis debridement, whereas the cutaneous flap was used to replace debrided skin at the heel. The abductor hallucis flap was used as a distally-based turnover flap to cover a large forefoot defect in a fourth case. Follow-up period ranged between 18 and 64 months (mean 43.3). In the early postoperative period, two flaps healed completely In two patients marginal flap necrosis occurred which was subsequently skin grafted. No donor-site complication occurred in any of the patients. In all cases, protective sensation of the skin was satisfactory as early as 6 months. In two cases mild hyperkeratosis at the skin graft border to the sole skin (non-weight bearing area of medial plantar and medialis pedis flap donor site) was present, but probably related to poor foot care. All patients were fully mobile as early as 3 months after treatment. In the long-term follow-up (43.3 months), all flaps provided with durable coverage. Functional gait deficit due to consumtion of the abductor hallucis muscle was not apparent.Our long-term results demonstrated that the abductor hallucis muscle flap is a versatile, and reliable flap suitable for the reconstruction of foot and ankle defects. Utilizing the abductor hallucis muscle as a pedicled flap (distally or proximally-based) with or without conjoined regional fasciocutaneous flaps offers a successful and durable alternative to microsurgical tree flaps for small to moderate defects over the calcaneus region, medial ankle, medial foot, and forefoot with exposed bone, tendon, or joint.     

A modified free gracilis flap in the rat

We present in this paper the use of a combined neurovas-cularized flap of gracilis muscle and inguinal skin in the rat with the femoral vessels and obturator nerve serving as the pedicles. The epigastric, saphenous, and muscular branch vessels arising from the femoral vessels were preserved, and a portion of adductor magnus muscle was included in the flap to protect the delicate muscle vessels at their origins. The inguinal skin and muscle flap both had independent blood supplies, thus, separate assessment of muscle and skin rejection was possible in the single transplanted “packet.” The muscle flap with the reconnected motor nerve regained contractile ability upon nerve stimulation within 30 days after the iso-transplantation. The results suggest that the modified gracilis myocutaneous flap provides an ideal model for transplantation research. © 1994 Wiley-Liss, Inc.     

Dorsocommissural flap.

We present a case of dorsoradial skin loss over the middle phalanx of the middle finger with section of the central slip of the extensor tendon and loss of one lateral band following mechanical injury. Successful primary reconstruction of the central slip was performed by retrograde flap from the central slip of the extensor tendon tied with barb-wire over a padded button, splinted for 2 weeks with a K-wire, and skin cover with a dorsocommissural flap based on the second web space. Other reconstructive options are discussed.     

Reconstruction of the pelvis using a composite island flap salvaged from the remaining leg

The case of a patient who sustained horrific injuries resulting in the loss of his left leg and hemipelvis and damage to the right sacroiliac joint and leg is discussed. The remaining leg was paralyzed as a result of damage to the sacral plexus. As a salvage procedure, a right above-knee amputation was performed, preserving a large composite flap from the distal part of the limb. This flap, consisting of most of the skin and soft tissue of the lower leg, contained within it a 10 cm segment of tibia and fibula. By islanding the flap on a pedicle composed of the femoral vessels, saphenous, and sciatic nerves, it was possible to mobilize it sufficiently far proximally to reconstruct the bone and soft-tissue defect of the contralateral hemipelvis. Seven years after this appalling injury, the patient has achieved a remarkable psychological and functional rehabilitation. He is independent and is successfully pursuing a professional career. This case report is a dramatic illustration of what can be achieved in reconstruction following trauma using salvage techniques.     

Reconstruction of chin and lower lip using bilateral segmental pectoralis major myocutaneous flap with functional support

Summary A 21-year-old man sustained an extensive high voltage electrical injury to his lower face, lower lip, chin, mandibular symphysis and floor of mouth. He lost all soft tissue as well as the outer cortex of the mandibular symphysis and lower teeth at the entry site. This soft tissue and skin loss was replaced by a left segmental pectoralis major myocutaneous flap [3] for lining of floor of the mouth and a right segmental pectoralis major myocutaneous flap augmentation of the chin and lower lip. The function of muscles and modiolus and orbicularis oris was reasonably regained by using bilateral temporalis muscle functional support [7]. The soft tissue on the left lower face was replaced by expanding the skin and soft tissue on the left submandibular area.     

He-Ne激光联合bFGF治疗减少腋臭术后并发症的疗效观察

目的：减少腋臭手术的并发症,促进切口的愈合。方法：60例腋臭,手术采用小切口皮瓣法,术后右侧腋窝采用氦氖激光照射6次,并在每次照射后用碱性成纤维细胞生长因纱布湿敷,左侧腋窝不采用任何治疗,两侧腋窝术后9天拆线。结果：患者右侧60侧腋窝皮瓣,58例痊愈,1例切口裂开,1例血肿。左侧60侧腋窝皮瓣,51例皮瓣痊愈,1例血肿,2例皮瓣坏死,3例切口裂开,6例皮瓣挛缩（其中包括2例皮瓣坏死,1切口裂开）,右侧腋窝并发症明显少于左侧（P〈0．05）,右侧腋窝皮瓣挛缩明显少于左侧（P〈0．05）。结论：小切口皮瓣法治疗腋臭,术后采用氦氖激光照射联合碱性成纤维细胞生长因子治疗促进切口愈合,减少并发症,减少腋窝皮瓣挛缩     

颈阔肌肌皮瓣五瓣Z成形术矫治重度肌性斜颈

目的介绍一种安全、实用的重度肌性斜颈修复术。方法以蹼状挛缩突出的胸锁乳突肌为轴，两端分别为胸锁乳突肌的乳突起点和下端锁骨头点，设计3瓣在内下、2瓣在外上的五瓣，每瓣臂跃大致为轴长的一半。局部麻醉下切开皮瓣至颈阔肌下层，直视下锐性分离各肌皮瓣，慎勿使颈阔肌与皮肤脱离，松解蹼状皮肤，即可见已经变细且纤维化的胸锁乳突肌及挛缩的颈鞘、颈浅静脉。于肌肉中点完全切断胸锁乳突肌，两断端回缩，切断并结扎颈浅静脉，松解挛缩的颈鞘，显露出短缩的颈动脉、神经，将头尽量摆正，在注意保护动脉、神经的前提下，松解其周围牵拉的筋膜组织，止血后将肌皮瓣对位缝合覆盖外露的动脉、神经、肌肉组织，放置橡皮引流条包扎固定。结果5例中有1例达到良，4例为中度。皮瓣均成活，效果满意。瘢痕不明显。结论采用颈阔肌肌皮瓣五瓣Z成形术，可良好地纠正同侧肌性斜颈畸形，用颈阔肌覆盖外露的神经、血管，就地取材，既能防止术后肌皮瓣区粘连、局部凹陷畸形，又能确保皮瓣的血供。     

The use of latissimus dorsi muscle flap in the aesthetical reconstruction of heat-press injury of the hand

We present a successful case of aesthetic reconstruction utilizing free latissimus dorsi muscle flap transfer. A large quantity of skin of the dorsum of hand and finger was lost. The dorsum of the index, long and ring fingers was severely damaged, such that extensor tendons were necrotic and all digital bones and the second metatarsal bone were exposed with partial necrosis. In addition, the proximal interphalangeal joints (PIP) were also exposed. To cover exposed bones and the tendons of dorsum of the hand, a free latissimus dorsi muscle flap was transferred, and then meshed skin covered the muscle, resulting in a mitten-like condition. After cutting the grafted muscle and skin to divide fingers, the grafted muscle was shaved to create the contour of fingers and dorsum of the hand, and then sheet grafting was performed. Six years after the operation, although the movement of fingers was restricted, an acceptable contour of the hand was obtained. The patient is satisfied with the result and does not desire any further surgery. In conclusion, the use of latissimus dorsi muscle flap is a method of choice not only to cover damaged hand but also to give contour in the aesthetic reconstruction of a hand presenting after heat-press injury.     

Harvesting the abductor digiti minimi as a muscle plug with the lateral calcaneal artery skin flap

The abductor digiti minimi muscle flap and the lateral calcaneal artery skin flap were raised as one combined flap and were used to cover plantar heel wounds with chronic osteomyelitis of the calcaneus. The combined flap was used successfully in 4 patients. The muscle component of the flap obliterated the dead space and provided a vascularized muscle over the debrided calcaneus, and the skin component acted as a sensate flap in the plantar heel.     

One-stage reconstruction of facial paralysis associated with severe skin scar deformity,using combined flexor carpi radialis muscle and radial forearm free flap

The authors present a case of free microsurgical transfer of combined flexor carpi radialis muscle and radial fasciocutaneous forearm flap in reconstruction of facial paralysis associated with severe ipsilateral skin scar deformity after removal of a giant cavernous hemangioma 22 years previously. The flexor carpi radialis muscle was used to reanimate the paralyzed face, and its fasciocutaneous radial forearm part restored overlying hemifacial skin, with good functional and rather pleasing aesthetic results. The follow-up period was 5 years.     

Restoration of elbow flexion by latissimus dorsi myocutaneous or muscle flap

Summary Six patients with flail elbow as a consequence of brachial plexus injury or traumatic loss of arm muscles underwent bipolar transposition of latissimus dorsi myocutaneous or muscle flaps to the biceps brachii to restore elbow flexion. The muscle strength achieved was 1.5–2.5 kg and the total range of active excursion is about 95°. The muscle strength is sufficient to carry out most of the activities of daily life but insufficient to achieve active supination or to perform heavy manual work. Elbow flexion of more than 120° is necessary for the affected hand to reach the mouth and should be one of the goals of the operation. Versatile use of the myocutaneous flap facilitates skin closure and improves the contour of the arm.     

急诊组织瓣移植(位)修复伴有严重血管损伤的上肢复杂性组织缺损

目的 介绍急诊组织瓣移植或移位一期修复伴有严重血管损伤的上肢复杂性组织缺损的手术疗效.方法 对10例伴有严重血管损伤的上肢复杂性组织缺损的患者,在修复血管重建肢体血运的同时,根据组织缺损需要采用皮瓣、肌皮瓣、骨皮瓣甚至组织瓣组合移植的方法急诊进行一期修复.其中上臂肱动、静脉长段缺损,合并肱二头肌及上臂内侧大面积皮肤缺损,血管修复后背阔肌皮瓣移位覆盖创面并重建屈肘功能3例;肘部血管损伤合并肘关节周围大面积皮肤撕脱缺损,血管修复后移植胸脐皮瓣覆盖创面2例;前臂尺、桡动脉损伤合并皮肤肌肉缺损,血管修复后移植股前外侧皮瓣覆盖创面3例;前臂尺桡动脉损伤并尺桡骨缺损,血管修复后移植腓骨皮瓣重建尺骨缺损,二期再移植腓骨皮瓣重建桡骨缺损1例;前臂尺、桡动脉损伤合并桡骨及大面积皮肤缺损,血管修复后股前外侧皮瓣加髂骨皮瓣组合移植1例.结果 术后10例患肢及移位组织瓣全部存活.术后随访3～6个月,3例上臂损伤患者,肘关节最大屈曲度为105,屈肘肌力为M_3～M_4地,手功能恢复基本正常;肘及前臂损伤的7例患者,肢体及移植皮瓣完全存活,骨皮瓣和腕部已达骨性愈合,并恢复部分手功能.结论 对严重血管损伤且合并有复杂组织缺损的上肢损伤,急诊在施行血管修复重建肢体血运的同时,采用组织瓣单独或组合移植一期有效覆盖创面,可提高复杂性患肢的成活率,并为二期功能重建术提供良好的软组织条件.     

The composite anterolateral thigh flap for knee extensor and skin reconstruction

The simultaneous reconstruction of a skin defect and lost extensor mechanism of the knee joint is difficult. We present a 31-year-old male who lost the patella and had a 9 × 10 cm skin defect after a total patellectomy for an infected open patellar fracture. A composite anterolateral thigh (ALT) flap including vascularized skin and fascia lata (FL) was elevated. The FL was folded and sutured to the remaining patellar tendon. The skin flap covered the skin defect. The wound healed uneventfully. Thirty months later, the active range of motion of the knee joint was 0°–120° and the extension strength of the knee joint was normal. He could stand on his right leg and walk without assistance. The composite ALT flap is a valuable option in knee reconstruction after a total patellectomy.