Modified distally based peroneal artery perforator flap for reconstruction of foot and ankle

The distally based sural fasciocutaneous flap has been used widely for reconstruction of foot and ankle soft-tissue defects. Here we report on a series of cases of foot and ankle reconstruction with a modified distally based sural flap. The vascular pedicle of the flap includes an axial perforator branch of the peroneal artery and two concomitant veins. This modified distally based perforator flap, measuring around 17 x 6 cm to 30 x 10 cm in size, was transferred for coverage of foot and ankle soft-tissue defects in 7 cases. All flaps survived completely. Neither arterial ischemia nor venous congestion was noted. As compared to other distally based sural flaps with neuro-veno-adipo-fascial pedicles, this modified sural flap with a thin perforator pedicle is easily rotated. The flap can obtain abundant blood supply through both axial perforator and longitudinal chain-linked vascular plexuses, and does not have the venous reflow problem. In conclusion, the invention of this perforator fasciocutaneous flap provides a valuable tool for repair of foot and ankle soft-tissue defects.     

保留桡神经浅支的血管筋膜蒂皮瓣的临床研究

目的 观察保留桡神经浅支的血管筋膜蒂皮瓣进行转位修复手部创面的可行性及临床效果.方法 临床应用前臂远端保留桡神经浅支的血管筋膜蒂皮瓣修复手腕部软组织缺损7例,皮瓣切取面积7 cm×4 cm～12 cm×7 cm.结果 7例皮瓣中4例完全成活,3例出现静脉回流障碍,其中1例表皮脱落,皮瓣全部成活,质地良好；1例远端皮肤有宽约1.5cm坏死区,经植皮愈合;另1例皮瓣远端有3 cm×2 cm斑片状坏死,经换药瘢痕愈合.术后5例桡神经浅支支配区皮肤感觉正常；2例有麻木感,术后4周恢复正常.经术后3～20个月随访,7例患者对皮瓣修复效果均表示满意,2例对皮瓣部分坏死后的局限性瘢痕及前臂植皮瘢痕有整形愿望.结论 保留桡神经浅支的血管筋膜蒂皮瓣对保留手部皮肤感觉有实用价值,进一步改善静脉回流是防止皮瓣部分坏死的关键因素.     

A dye study in fresh cadavers to outline retrograde flaps of the lower limbs and to examine clinical implications

The reconstruction of distal lower limb defects to meet functional and cosmetic requirements is challenging. The aim of this study was to ascertain the safe hemodynamic territory of various retrograde flaps that are frequently used. We carried out a dye study on both lower limbs of ten fresh cadavers using methylene blue to assess the safe limit of retrograde flaps of different types (i.e., fasciocutaneous flap, adipofascial flap, and fasciocutaneous flap with adipofascial extension) based on the two lower perforators of the posterior tibial artery. The dye penetrated the vascular network up to 20 cm in the fasciocutaneous flaps from a point 8 cm proximal to the tip of the medial malleolus. The extent of the dye was 40 and 20% less in adipofascial flaps and fasciocutaneous flaps with adipofascial extension, respectively, compared to fasciocutaneous flaps. In live subjects, the safe territory is expected to be about 2 cm more in each flap, based on our clinical observations. These findings are of significance since such flaps can be safely selected for various defects depending on their location, their dimensions, and the availability of suitable local tissues.     

前臂桡动脉皮支血管网逆行筋膜皮瓣修复手部创面

目的　根据前臂皮肤的解剖特点,形成较大面积的前臂逆行筋膜皮瓣,解决手部较大创面的修复。方法　利用前臂远端桡动脉皮支血管网供血,设计前臂逆行筋膜皮瓣,蒂部转折点在茎突近端３～５ｃｍ 处,皮瓣远端至肘横纹上方３ ～５ｃｍ ,皮瓣要覆盖手背、手掌较大创面。结果　采用前臂桡动脉皮支血管网逆行筋膜皮瓣修复手部创面４２ 例,手术全部成功,术后随访１８ 例,其外形及手功能的恢复达到满意效果。结论　前臂桡动脉皮支血管网逆行筋膜皮瓣可取皮瓣面积大,不损伤桡动脉主干,为手部皮肤缺损找到了简单、安全,损伤小的修复方法     

前臂桡动脉皮支血管网逆行筋膜皮瓣修复手部创面

目的 根据前臂皮肤的解剖特点,形成较大的前臂逆行筋膜皮瓣,解决手部较大创面的修复。方法 利用前臂远端桡动脉皮支血管网供血,设计前臂逆行筋膜皮瓣,蒂部转折点在茎突近端３￣５ｃｍ处,皮瓣远端至肘横纹上方３￣５ｃｍ,皮瓣要覆盖手背、手掌较大创面。结果 采用前臂桡动脉皮支血管逆行筋膜皮瓣修复手部创面４２例,手术全部成功,术后随访１８例,其外形及手功能的恢复达到满意效果。结论 前臂桡动脉皮支血管网逆行筋膜皮     

前臂桡动脉皮支血管网逆行筋膜皮瓣修复手部创面

目的根据前臂皮肤的解剖特点,形成较大面积的前臂逆行筋膜皮瓣,解决手部较大创面的修复。方法利用前臂远端桡动脉皮支血管网供血,设计前臂逆行筋膜皮瓣,蒂部转折点在茎突近端3～5cm 处,皮瓣远端至肘横纹上方3～5cm,皮瓣要覆盖手背、手掌较大创面。结果采用前臂桡动脉皮支血管网逆行筋膜皮瓣修复手部创面42例,手术全部成功,术后随访18例,其外形及手功能的恢复达到满意效果。结论前臂桡动脉皮支血管网逆行筋膜皮瓣可取皮瓣面积大,不损伤桡动脉主干,为手部皮肤缺损找到了简单、安全,损伤小的修复方法。     

Influence of the pedicle orientation and length on viability of unipedicled venous island flaps

The use of unipedicled venous flaps has been limited due to their unconventional perfusion patterns and inconsistent survival. Further information regarding the optimal conditions required for unipedicled venous flap coverage is needed to increase flap survival. The purpose of this study was to investigate the effect of the pedicle orientation and length on the viability of unipedicled venous flaps based on a review of our clinical experience. Thirty‐one skin and soft tissue hand defects of 29 patients were treated with unipedicled venous flaps. Sixteen defects were treated with proximally pedicled flaps and 15 were treated with distally pedicled flaps. Five of the 16 proximally pedicled flaps and eight of the 15 distally pedicled flaps had pedicle lengths ≥ 5 cm. All proximally pedicled flaps survived, and distally pedicled flaps with pedicle lengths <5 cm (n = 7) also survived. Distally pedicled flaps with pedicle lengths ≥5 cm (n = 8) developed congestion within 1–2 days after surgery, and external bleeding was applied. Four of the eight flaps survived completely, and partial necrosis developed in the other four. The results demonstrate that proximally pedicled venous flaps of the hand can survive regardless of pedicle length. Distally pedicled venous flaps can also survive completely when pedicle length is <5 cm. Distally pedicled venous flaps with pedicle lengths ≥5 cm should be used with caution. © 2013 Wiley Periodicals, Inc. Microsurgery 34:197–202, 2014.     

桡动脉穿支蒂岛状皮瓣修复腕及前臂创面

目的 探讨桡动脉穿支蒂岛状皮瓣的解剖以及修复腕及前臂创面的手术方法和临床疗效.方法 以桡动脉搏动及体表投影为中心,采用多普勒血管仪探测桡动脉穿支的部位,以靠近缺损创面部的皮支作为血管蒂及旋转点,根据缺损创面大小、形状设计皮瓣,修复腕及前臂创面12例.结果 术后12例皮瓣中有2例出现静脉危象,经拆除部分缝线后存活,创面愈合,其余10例皮瓣均顺利存活.随访时间3～18个月,皮瓣质地软,外形及功能满意.结论 桡动脉穿支在桡骨茎突近端2.0cm、4.0～ 5.0 cm、7.0cm处较恒定,以此为蒂的岛状皮瓣血供可靠,操作简单,不损伤主干血管,修复后外形好,是修复腕及前臂皮肤软组织缺损的有效方法之一.     

翻转筋膜皮下瓣修复四肢创面

目的介绍应用局部远端蒂翻转筋膜皮下瓣修复四肢远端中小面积创面的临床经验。方法总结1994年1月～2003年12月应用局部远端蒂翻转筋膜皮下瓣加植皮的方法,修复深部结构暴露的四肢远端创面患者33例,其中男25例,女8例,年龄13～65岁。前臂创面19例,小腿14例。33例均在创面近侧切取局部筋膜皮下瓣,以远端蒂纵向切取的筋膜皮下瓣,包含1条皮神经和(或)浅静脉干,长度(蒂+瓣)9～18cm,筋膜皮下蒂宽3～4cm,长宽比例3～5∶1。将筋膜皮下瓣翻转180°,脂肪层朝下移位至受区,再在深筋膜面上植皮。结果术后33例筋膜皮下瓣(轴型瓣26例,随意型瓣7例)均完全成活。供区皮肤直接缝合,期愈合29例,余经换药均良好愈合。受区植皮覆盖均愈合良好。结论翻转筋膜皮下瓣修复四肢非受压摩擦部位的中小创面,临床应用简便可靠。     

前臂远端复合血管网带蒂皮瓣的血供特点及应用

目的探讨前臂远端蒂复合血管网皮瓣的血供特点及临床疗效。方法应用包含深筋膜、皮神经及浅静脉的前臂远端蒂复合血管网皮瓣修复手、腕部创面26例,皮瓣面积5cm×6cm～6cm×12cm。结果本组随访3～8个月,26例皮瓣完全成活,皮瓣不臃肿、耐磨、质地优良。结论皮神经、浅静脉营养血管网与真皮下及深筋膜血管网经穿动脉相互联系,构成三维、立体、轴向的血供构筑,是皮瓣存活的解剖基础,蒂部远端的主干血管穿支是皮瓣的血供来源,皮瓣操作安全,成活率高。     

Oblique radial forearm reverse-flow flap

A modifed design for the distally-based radial forearm flap is presented, in an oblique direction rather than longitudinally, based on the existence of skin laxity in the proximal forearm region. The skin paddle of the flap is designed in an oblique fashion pedicled on one of the proximal-row septocutaneous perforators, and elevated in the usual manner supplied by the distal radial artery. The oblique radial forearm flap thus created was successfully utilized for reconstruction of seven dorsal hand defects. Results showed that all the flaps could easily be transposed to the defect through a wide arc of rotation and all survived totally, with direct closure of the donor site in five cases, and significant reduction in size in the remaining two cases. It was concluded that the oblique design for the skin island of the reverse radial forearm flap could allow creation of a flap that has a smaller donor defect and yet presents a longer pedicle length, with a wider arc of rotation and better adaptation to a dorsal hand defect, than a conventional longitudinal-design radial forearm flap.     

Reconstruction of extensive upper extremity defects using pre-expanded oblique perforator-based paraumbilical flaps

The pedicled paraumbilical flap is a reliable tissue transfer for hand and forearm reconstruction. However, its size, pedicle length and/or thickness limit its application in resurfacing of extensive defects of the upper limb. To conquer those limitations, this flap was pre-expanded for 10-24 weeks prior to transfer in 25 patients and used as a pedicle flap to cover upper extremity defects. Extensive defects of upper limb were reconstructed by the pre-expanded paraumbilical flaps. The flaps ranged in size from 10 cm × 8 cm to 30 cm × 14 cm. The donor sites were closed directly in all cases. All flaps survived, but two had partial flap necrosis due to venous congestion or infection. With pre-transfer expansion, a large, well-perfused abdominal pedicle flap can be raised and transferred based on the paraumbilical perforators. This pre-expanded flap might be useful in the patients who have the extensive upper limb defects and sufficient time to allow tissue expansion.     

皮神经营养血管组织瓣的临床应用原则与命名

目的 探讨皮神经营养血管组织瓣的临床应用原则，并提出新的命名方法。方法 总结皮神经营养血管组织瓣的解剖研究和临床经验。结果 皮神经多与皮静脉伴行，在其周围均存在丰富的链式吻合血管丛，显著增加了这类组织瓣的血供。临床以远端(31例)或近端(3例)为蒂，在前臂(26例)和小腿(8例)切取带皮神经和皮静脉营养血管的岛状筋膜皮瓣(20例)和筋膜皮下组织瓣(14例)共34例，长宽比例2．7～5．1：1，平均3．5：1，完全成活。结论 带皮神经营养血管的组织瓣是传统筋膜皮瓣和筋膜皮下组织瓣的特殊范例，临床应用应遵循一定的原则。     

The radial (Chinese) flap in hand surgery

The radial (Chinese) flap is an fascio-cutaneous flap raised on the volar aspect of the forearm based on the radial pedicle axis which can be used either pedicled or by microsurgical free transfer. In hand and thumb reconstruction, it is used as an island flap vascularized by a reverse flow from the ulnar artery via the palmar arch, keeping the pivot point at the snuff box level. The possibility to raise a composite flap with vascularized bone or tendons make the chinese flap very useful in hand reconstruction. Of the 35 cases presented, there were 30 pedicled and 5 free flaps from the opposite forearm. The island flaps were reverse flow in 30 cases and with proximal pedicle in 5. In 4 cases the flap contained flexor carpi radialis longus tendon, and in 2 cases a bone graft from the radius. The five free radial flaps transferred from the contralateral side were used as flow-through flap. There were no vascular complications. The advantages and disadvantages of the methods are discussed.     

Dorsal forearm adipofascial turnover flap among the elderly

We have assessed the results of soft tissue cover on the back of the hand using an adipofascial turnover flap. From 2004 until 2007, 14 patients (mean age: 62 years) underwent reconstruction of extensive defects in the dorsum of the hand, using a forearm adipofascial turnover flap based on the perforators of the anterior interosseous artery covered with a split skin graft. The pivot point of the flap is typically 4-6?cm proximal to the level of the radial styloid process. In 93% of patients, the reconstruction healed without any problem. The adipofascial turnover flap is a useful and reliable method of reconstruction of the dorsum of the hand even in elderly patients.     

Distally based sural fasciomyocutaneous flap: Anatomic study and modified technique for complicated wounds of the lower third leg and weight bearing heel

The reconstruction of the distal third leg and weight‐bearing heel, especially when complicated with infection and/or dead space, remains a challenge in reconstructive surgery. The distally based sural neurofasciomyocutaneous flap has been proved a valuable tool in repair of the soft tissue defects of those areas. In this report, we present the results of the anatomical study on vascular communication between the suprafascial sural neurovascular axis and the deep gastrocnemius muscle and a modified technique in clinical applications for reconstruction of the soft tissue defects in the distal lower leg and heel. Six lower limbs of fresh cadavers were injected with red gelatin and dissected. A constant vascular connection with average four musculo‐fasciocutaneous perforators with diameter 0.2–0.5 mm was identified in the overlapping area between the suprafascial sural neurovascular axis and the deep gastrocnemius muscle. Based on these findings, a modified distally based sural neurofasciomyocutaneous flap including the distal gastrocnemius muscle component was designed and used for repairs of the soft tissue defects in the distal lower limb and plantar heel pad in six patients. The blood supplies of flaps comprised either the peroneal perforator and adipofascial pedicle or the peroneal perforator only. The average size of the fasciocutaneous flap was 51 cm², and the muscle component 17.7 cm². All flaps survived uneventfully. Our results suggest that this technical modification could provide wider range for applications of the distally based sural neurofasciomyocutaneous flap in repair of the soft tissue defects of the lower extremity and heel. © 2008 Wiley‐Liss, Inc. Microsurgery, 2009.     

血管变异型前臂背侧皮瓣修复手部皮肤软组织缺损

目的 探讨骨间后动脉血管变异时前臂背侧皮瓣的切取方法.方法 以骨间后动脉为蒂逆行岛状皮瓣转移修复手部皮肤软组织缺损时,遇到血管变异共9例,采取以骨间后动脉桡侧支为蒂切取逆行岛状前臂背侧皮瓣、以骨间后动脉近端为蒂切取游离骨间后动脉皮瓣、以骨间后动脉穿支为蒂切取游离前臂背侧穿支皮瓣等方法,进行皮瓣转移或移植修复手部创面.结果 9例皮瓣中有8例顺利存活;1例术后2 d皮瓣远端出现肿胀、青紫、小水泡,及时对症处理,5 d后部分皮缘形成干痂,皮瓣颜色恢复正常,脱痂后存活.9例随访3个月至2年,皮瓣质地柔软,弹性好,外形满意.结论 以桡骨间后动脉侧支为蒂的前臂背侧皮瓣逆行转移,以骨间后动脉近端或骨间后动脉穿支为蒂的前臂背侧皮瓣游离移植修复手部创面,是解决骨间后动脉血管变异较理想的方法.     

血管变异型前臂背侧皮瓣修复手部皮肤软组织缺损

目的 探讨骨间后动脉血管变异时前臂背侧皮瓣的切取方法.方法 以骨间后动脉为蒂逆行岛状皮瓣转移修复手部皮肤软组织缺损时,遇到血管变异共9例,采取以骨间后动脉桡侧支为蒂切取逆行岛状前臂背侧皮瓣、以骨间后动脉近端为蒂切取游离骨间后动脉皮瓣、以骨间后动脉穿支为蒂切取游离前臂背侧穿支皮瓣等方法,进行皮瓣转移或移植修复手部创面.结果 9例皮瓣中有8例顺利存活;1例术后2 d皮瓣远端出现肿胀、青紫、小水泡,及时对症处理,5 d后部分皮缘形成干痂,皮瓣颜色恢复正常,脱痂后存活.9例随访3个月至2年,皮瓣质地柔软,弹性好,外形满意.结论 以桡骨间后动脉侧支为蒂的前臂背侧皮瓣逆行转移,以骨间后动脉近端或骨间后动脉穿支为蒂的前臂背侧皮瓣游离移植修复手部创面,是解决骨间后动脉血管变异较理想的方法.     

血管变异型前臂背侧皮瓣修复手部皮肤软组织缺损

目的 探讨骨间后动脉血管变异时前臂背侧皮瓣的切取方法.方法 以骨间后动脉为蒂逆行岛状皮瓣转移修复手部皮肤软组织缺损时,遇到血管变异共9例,采取以骨间后动脉桡侧支为蒂切取逆行岛状前臂背侧皮瓣、以骨间后动脉近端为蒂切取游离骨间后动脉皮瓣、以骨间后动脉穿支为蒂切取游离前臂背侧穿支皮瓣等方法,进行皮瓣转移或移植修复手部创面.结果 9例皮瓣中有8例顺利存活;1例术后2 d皮瓣远端出现肿胀、青紫、小水泡,及时对症处理,5 d后部分皮缘形成干痂,皮瓣颜色恢复正常,脱痂后存活.9例随访3个月至2年,皮瓣质地柔软,弹性好,外形满意.结论 以桡骨间后动脉侧支为蒂的前臂背侧皮瓣逆行转移,以骨间后动脉近端或骨间后动脉穿支为蒂的前臂背侧皮瓣游离移植修复手部创面,是解决骨间后动脉血管变异较理想的方法.     

岛状股前外侧皮瓣修复腹股沟及会阴部创面

目的探讨一种皮瓣修复会阴部及腹股沟创面的方法。方法设计以旋股外侧动脉降支为血管蒂的岛状股前外侧皮瓣,掀起皮瓣后经过皮下隧道将其转移至会阴部及腹股沟创面。结果临床治疗12例,皮瓣面积为8cm×11cm～18cm×20cm。除1例皮瓣靠近肛门处部分表皮坏死外,其余成活良好,外形恢复满意。结论以旋股外侧动脉降支为血管蒂的岛状股前外侧皮瓣是修复会阴部及腹股沟创面较好的方法。