足底内侧游离皮瓣,肌皮瓣移植修复足跟缺损

我们采用吻合血管，神经的足底内侧游离皮瓣，肌皮瓣移植修复足跟软组织缺损８例，皮瓣全部成活。４－６周后负重行走，经６－２４个月随访，移植皮瓣无１例出现溃疡，感觉恢复良好，两点分辨觉达２．０－３．０ｃｍ。我们强调了神经吻合的重要性，认为皮瓣的感觉恢复是防止溃疡发生，取得远期良好效果的首要条件。     

足底内侧游离皮瓣、肌皮瓣移植修复足跟缺损

我们采用吻合血管、神经的足底内侧游离皮瓣、肌皮瓣移植修复足跟软组织缺损8例,皮瓣全部成活。4～6周后负重行走,经6～24个月随访,移植皮瓣无1例出现溃疡,感觉恢复良好,两点分辨觉达2.0～3.Ocm。我们强调了神经吻合的重要性,认为皮瓣的感觉恢复是防止溃疡发生、取得远期良好效果的首要条件。     

足底缺损的修复及感觉重建的随访

目的探讨足底缺损的修复方法及感觉重建的必要性。方法 1990年 6月～ 1999年 12月对 29例足底缺损病例根据负重区和非负重区分别采用皮瓣和全厚皮片移植的方法进行修复,其中吻合皮神经和 (或 )带皮神经蒂移植者 16例,并对术式和疗效进行分析。结果术后皮瓣坏死 1例,其余病例一期愈合。随访 1～ 9年,平均 3.8年。皮瓣修整 1例,发生溃疡 1例,溃疡发生率为 3.4％。 16例行吻合皮神经和 (或 )带皮神经蒂皮瓣移植者术后感觉恢复达 S2～ S3级; 13例未感觉重建而只采用皮瓣和全厚皮片移植的方法进行修复者术后以深痛觉为主,即 S1级,皮瓣边缘 1～ 2 cm范围内有不同程度的浅感觉恢复,即 S2级。感觉重建与否与溃疡发生无明显的关系。结论足底负重区必须选择皮瓣修复,足内侧皮瓣、足底内侧皮瓣、趾动脉皮瓣和股前外侧皮瓣可作为该区修复的首选皮瓣。非负重区首选全厚皮片修复。因非感觉皮瓣移植后也能获得保护性感觉,故感觉重建是次要的。     

神经端侧吻合重建皮瓣感觉修复足跟软组织缺损

目的重建隐动脉皮瓣感觉修复足跟部软组织缺损。方法对３例足跟部软组织缺损采用隐动脉皮瓣交叉移植修复,应用神经端侧吻合技术重建皮瓣感觉并恢复供肢内踝、足内缘和口止母趾皮肤的感觉。结果３例均获得成功,随访６～１２个月,皮瓣感觉恢复良好,供肢内踝、足内缘和口止母趾皮肤感觉亦恢复。结论应用神经端侧吻合技术可重建皮瓣感觉功能     

端侧吻合神经恢复皮神经营养动脉逆行皮瓣感觉修复足跟软组织缺损

目的　端侧吻合皮神经恢复皮神经营养动脉逆行皮瓣感觉修复足跟软组织缺损。方法　对 5例足跟部软组织缺损用皮神经营养动脉逆行皮瓣移植修复 ,应用神经端侧吻合技术恢复皮瓣感觉功能。结果　 5例均获成功 ,皮瓣感觉恢复良好。结论　应用神经端侧吻合技术可恢复皮瓣感觉功能。     

端侧吻合神经恢复皮神经营养动脉逆行皮瓣感觉修复足跟软组织缺损

目的：端侧吻合皮神经恢复皮神经营养动脉逆行皮瓣感觉修复足跟软组织缺损。方法：对5例足跟部软组织缺损用皮神经营养动脉逆行皮瓣移植修复,应用神经端侧吻合技术恢复皮瓣感觉。结果：5例均获成功,皮瓣感觉恢复良好。结论：应用神经端侧吻合技术可恢复皮瓣感觉功能。     

端侧吻合神经恢复皮神经营养动脉逆行皮瓣感觉修复足跟软组织缺损

目的端侧吻合皮神经恢复皮神经营养动脉逆行皮瓣感觉修复足跟软组织缺损.方法对5例足跟部软组织缺损用皮神经营养动脉逆行皮瓣移植修复,应用神经端侧吻合技术恢复皮瓣感觉功能.结果5例均获成功,皮瓣感觉恢复良好.结论应用神经端侧吻合技术可恢复皮瓣感觉功能.     

感觉神经植入对中厚皮片感觉的影响

自１９９５年６月以来,我们为６例接了带神经皮瓣移植术后,皮瓣供区中厚皮片感觉恢复不佳者施行了感觉神经植入术。分别于术后３、６、１２个月进行感觉检测,效果较好。作者单位５１８０２９　广东省深圳市红十字会医院骨科手外组临床资料本组男１例,女５例。年龄１９～２８岁。皮片移植原因：带神经皮瓣切取后的供区创面。其中足背４例,小腿２例。取皮片区为大腿者３例,腹部３例。皮片厚度０６～０８ｍｍ。皮片移植术后时间１年～３年８个月,平均１年６个月。皮片面积５ｃｍ×３８ｃｍ～１０ｃｍ×９５ｃｍ。神经植入术后时…     

带感觉神经的静脉网动脉化皮瓣移植修复手指脱套伤

目的：报道带感觉神经的静脉网动脉化皮瓣修复单个手指脱套伤的效果。方法：在显微镜下清创找出伤者指断端的指动脉，指神经及指动脉吻合，２～３条浅静脉与指背静脉，在前臂掌侧设计相应的带３～５条浅静脉及皮神经的静脉皮瓣，顺行移植于伤肢皮肤缺损处，皮瓣内的皮神经与指神经缝合，２～３条浅静脉与指动脉吻合，２～３条浅静脉与指背静脉吻合。结果：６例７指皮肤脱套伤所植的皮瓣全部成活，伤指恢复良好的感觉，两点辩别觉５～１０ｍｍ。结论：此种皮瓣一次完成手指脱套伤皮肤及感觉缺损的修复，为临床提供了一种新的理想的修复方法。     

足组织缺损的显微修复

１９８４年～１９９４年共收治各种足部组织创伤缺损２３６例，均采用显微外科技术进行组织移植修复，其中单纯皮瓣移植修复１８７例，复合皮瓣移植修复４９例。吻合血管游离移植修复９７例，带血管蒂移位修复１３９例。４例前足缺损者用带肩胛骨的复合皮瓣移植修复，６例足跟严重缺损者用带血管的腓骨复合皮瓣移植修复。经１～１０年随访，皮瓣、复合皮瓣、移植或再植的骨骨各全部成活，愈合良好，足功能基本得到恢复，可行走、负重，１８６例恢复了原工作。认为，恢复足部结构完整与重建足跟、足底的感觉是获得良好功能的关键     

Functional Outcomes After Heel Pad Reconstruction: A Review of 7 Cases

Sensate, durable heel pad reconstruction is challenging. The present study assessed the functional outcomes after heel pad reconstruction using various flap techniques at our institution. From June 2011 to June 2016 (5-year period), 7 consecutive patients underwent heel pad reconstruction for various etiologies, with 3 microvascular free flaps (42.9%; 2 musculocutaneous flaps [66.7%] and 1 contralateral medial plantar flap [33.3%]) and 4 local pedicle flaps (57.1%; 3 instep medial plantar artery flaps [75.0%] and 1 distally based reverse sural flap [25.0%]). The patient records and demographic data were reviewed, and surgically related information was obtained and analyzed. The subjective components of the American Orthopaedic Foot and Ankle Society hindfoot clinical ratings scale were used to evaluate the pain and functional outcomes. Sensation was assessed using Semmes-Weinstein monofilaments, and ulcer recurrence was recorded. The mean age of the patients was 41.7 (range 11 to 70) years, the mean defect size was 59 (range 12 to 270) cm², and the mean follow-up duration was 22 (range 15 to 43) months. Complete flap survival was achieved without significant complications in all 7 patients. Patients treated with the sensate medial plantar artery flap recorded the highest mean American Orthopaedic Foot and Ankle Society score of 57.3 (maximum score of 60) and experienced a return of deep sensation at 6 (range 6 to 24) months and protective sensation at 1 year. This was followed by the reverse sural flap and the musculocutaneous flap. No recurrent heel ulceration was observed in our series of patients. In conclusion, the sensate medial plantar flap is a satisfactory method for coverage of small- to moderate-size heel defects.     

Refinements of medial plantar flap used for covering nonweightbearing ankle and posterior heel defects requiring thin flaps

We present our clinical experiences with the refinements that we applied to avoid circular flap contraction and achieve thin flap coverage in the reconstruction of posterior heel and tendocalcaneal skin defects with medial plantar flap. Eight male patients, aged 18 to 35 (mean 24 years), with nonweightbearing skin defects, were treated with refined medial plantar flaps. All flaps survived and no circulation problem was encountered. The flaps adapted well to the recipient area, and thin and well-contoured skin coverage was achieved by postoperative month 6. As a conclusion, it is possible to reconstruct the nonweightbearing defects needing thin flap by medial plantar flap with adding refinements: (1) adding triangles around the flap, (2) harvesting a thin flap by excluding the thick plantar fascia, (3) harvesting a further thin flap by defatting of the flap, (4) application of pressure to the flap.     

Medial plantar artery island flap for heel reconstruction

Coverage of soft tissue defects of the heel has been a challenge to reconstructive surgeons in the past. The medial plantar artery flap has facilitated heel coverage since its development in the 1980s. This was a prospective study in 2 centers assessing the complications and durability of this flap primarily in patients with sensory impairment. All patients but 1 had chronic plantar ulceration due to sensory loss, and 5 patients also had developed squamous cell carcinoma. Fifty-one flaps were carried out in 48 patients. One flap underwent necrosis, and delayed healing was seen in 4 cases. Total flap survival was 98%. Minor revision of the flap or its pedicle was required in 3 cases. With a mean follow-up of 14 months, there were recurrences of ulceration in 7 feet (14%). The relevant literature is reviewed. The medial plantar artery flap is a reliable flap for heel coverage in both our centers and others. It is durable and long lasting even in insensate.     

An anatomic study and clinical application of medial pedis flap in Asians

Several investigators have reported their clinical experience with medial pedis flaps for reconstruction of soft tissue defects of the hand and digits. In a cadaveric study in 1997, Jayme and Hamilton described the anatomy of the medial branch of the deep division of the medial plantar artery, which is used in the medial pedis flap. However, they had only a few cases where this flap was used. There have been no such anatomic studies in Korea to date. We found the medial pedis flap to be a reliable option for reconstruction of soft tissue defects of the hand and digits, based on an anatomic study with 10 dissected fresh cadavers (20 cases) and analyzing the clinical outcomes in 17 patients. An anatomic study revealed that there were some racial differences in the diameter and length of the vessels. The diameter of vessels in the Korean population is larger than that in whites. Using a thin, flexible medial pedis flap, which has skin and subcutaneous tissue similar to that of the volar aspect of the hand and digits, we harvested and performed the reconstruction on 17 patients with soft tissue defects of the hands and digits. The vessels used for this flap were the medial branch of the deep division of the medial plantar artery and vena comitantes, or subcutaneous veins. The mean size of the flap was 2.82 cm x 4.15 cm. All flaps were successful without any significant complications. The medial pedis flap possesses several advantages: (1) it is very thin in comparison to other standard free flaps; (2) it has 2 draining venous pathways; (3) it provides a good color and texture match for the hand and fingers; (4) it has a satisfactory recovery of protective sensation.     

Retrograde-flow medial plantar island flap reconstruction of distal forefoot,toe, and webspace defects

Plantar forefoot defects have been reconstructed using a wide variety of techniques, including skin grafts, local flaps, and free tissue transfer. The distally based, retrograde-flow medial plantar island flap provides coverage with durable plantar skin from the nonweight-bearing instep area to reconstruct defects at the metatarsal heads. This technique requires careful flap dissection, and the anterior reach of the flap is limited by its pedicle length and vascular pivot point location. The authors describe two cases using this flap for reconstruction of tumor resection defects (5 x 6 cm and 5 x 8 cm) involving the distal forefoot, toes, and webspaces. One case required venous supercharging of a congested flap with an interpositional vein graft. Technical aspects of the design, elevation, and inset of the flap that enhance its versatility and reliability are presented. The reverse-flow medial plantar fasciocutaneous island flap should be considered an option for forefoot defects that extend anteriorly onto the metatarsal heads, including defects involving the toes and webspaces.     

Instep free flap for plantar soft tissue reconstruction: indications and options

Pedicled instep flaps are frequently used in weight-bearing plantar reconstruction, but may not be available after severe foot injuries. Although free instep flaps offer a viable option, they have scarcely been reported. A posttraumatic plantar forefoot defect was reconstructed with a sensate, instep free flap, because local flaps were not available and defect size did not require a distant free flap, and the current literature was reviewed for therapeutic options. The instep free flap yielded an excellent functional and aesthetic long-term result. In the literature, pedicled instep flaps are advocated for moderate size defects of the weight-bearing heel and sole, while free flaps from distant sites are preferred for large defects. Although skin-grafted muscle flaps and fasciocutaneous flaps yield similar results, reconstruction by like tissues appears favorable. We suggest the instep free flap for weight-bearing plantar foot reconstruction, when pedicled instep flaps are not available and distant free flaps are avoidable.     

足跟部皮肤恶性肿瘤切除术后皮瓣修复的临床疗效分析

目的探讨足跟部皮肤恶性肿瘤切除术后的创面采用皮瓣修复的临床疗效。方法本组11例患者中，患恶性黑色素瘤者8例、交界痣恶变者2例、慢性溃疡恶变者1例。对所有患者的肿瘤部位首先行距病灶边缘0．5～2．0cm广泛切除，然后分别采用四种不同类型带蒂皮瓣进行修复。结果术后随访患者6个月至3年10个月，所有皮瓣均存活，皮瓣感觉恢复良好，有2例患者肿瘤局部复发。结论为避免肿瘤局部复发，切除足跟部皮肤恶性肿瘤时，需距病灶边缘2cm以上行扩大切除。修复切除后的创面不宜应用局部旋转皮瓣。采用足底内侧皮瓣对足跟部负重功能的修复效果较好，足跟部外侧和内侧的创面可采用足外侧皮瓣或内踝上皮瓣修复。腓肠神经伴营养血管蒂皮瓣可修复整个足跟部创面。     

足踝部皮肤软组织缺损的显微外科修复选择

目的 探讨应用带蒂皮瓣及游离皮瓣修复足踝部软组织缺损的方法和临床疗效.方法 2008年3月至2010年3月共收治28例足踝部软组织缺损患者,男21例,女7例;年龄6～62岁,平均34.0岁.致伤原因:交通伤13例,机器压砸伤11例,坠落伤2例,慢性溃疡1例,烫伤1例.皮肤缺损面积4.0 cm×7.0 cm～11.0 cm×44.0 cm.术前根据患者足踝部软组织缺损及其他组织损伤情况,急诊或择期选择带蒂皮瓣或游离皮瓣移植修复足缺损,其中应用股前外侧皮瓣10例,腓肠神经营养血管皮瓣8例,内踝上穿支皮瓣4例,跗外侧皮瓣3例,足底内侧皮瓣2例,背阔肌皮瓣1例.术后对皮瓣的存活情况和愈合质量进行随访. 结果 28例患者术后获4～24个月(平均14个月)随访.2例术后出现皮瓣远端坏死,2例皮瓣边缘部分坏死,经换药、抗感染和植皮术后创面愈合;其余移植的皮瓣均成活,创面一期修复,皮瓣外形良好,质地、弹性好,足踝部功能恢复,行走正常. 结论 足踝部软组织缺损修复应根据损伤部位、面积及程度来决定选用邻近带蒂组织或游离组织移植修复.足跟及踝部缺损可选用腓肠神经营养血管皮瓣、足底内侧皮瓣、内踝上皮瓣和跗外侧皮瓣等;大面积或广泛剥脱伤需选用游离皮瓣,如股前外侧皮瓣或背阔肌皮瓣;前足小范围缺损,应用跗外侧皮瓣进行修复有其优势.     

Reconstruction of distal forefoot burn defect with retrograde medial plantar flap

Burn reconstruction of forefoot remains as a difficult challenge, because the local flap alternatives are limited. We evaluated the efficiency of distally based medial plantar fasciocutaneous island flap in the coverage of forefoot defects resulting from release of toe contracture and burn debridement. Four patients with toe contractures and two patients with third degree burn in forefoot were treated between June 2004 and February 2006. The mean follow-up period was 10.4 months. The flaps were elevated as with a fasciocutaneous base on the distal medial plantar artery. The dimensions of the flaps ranged from 4cmx3cm to 5cmx4cm. The skin over the pedicle was included as a part of flap in three cases. Concomitant vein of the pedicle was anastomosed with the first plantar digital vein in four cases. In the early postoperative period, one flap used to cover third degree burn due to high-voltage electric injury was lost completely. We concluded that this flap was an appropriate alternative reconstructive option for the forefoot defect. Including skin and subcutaneous tissue over the pedicle to flap protects the pedicle against kinking and compression. Venous supercharging of the flap improves venous drainage.