游离复合组织瓣移植修复毁损性创面

目的 了解早期应用游离复合组织瓣修复毁损性创面的安全性与效果. 方法 2005-2009年,笔者单位采用游离皮瓣或复合组织瓣修复123例患者128处毁损性创面.所采用的复合组织瓣类型:背阔肌肌皮瓣58例、股前外侧皮瓣32例、旋肩胛皮瓣21例、足背复合组织瓣6例、拇甲瓣3例、前臂皮瓣3例、侧胸皮瓣1例.另行游离背阔肌肌瓣移植+植皮3例、带腓骨小腿外侧皮瓣移植1例. 结果 10例患者术后1～5 d发生血管危象,经紧急手术后修复6例.皮瓣或复合组织瓣移植成活率为95.3%(122/128).随访3个月～4年,皮瓣外形良好,部分功能得以重建.结论 游离复合组织瓣移植降低了截肢率,能Ⅰ期重建功能、更好地恢复外形、减少手术次数、降低并发症发生率、缩短住院时间、减少治疗费用,是修复较大毁损性软组织损伤的较佳方法 .     

Free flaps for reconstruction of the lower back and sacral area

Free flap reconstruction of the lower back and sacrum is complicated by a paucity of recipient vessels and difficulties in postoperative care. From 1983 to 1997, six patients with intractable wounds of the lower back and sacral area were treated with free flaps. The flaps used were latissimus dorsi (three), combined latissimus dorsi and serratus anterior (one), and filleted leg tissue (two). The recipient vessels were the deep femoral vessels, the perforator vessels of the deep femoral system, the inferior epigastric vessels, and the superior gluteal and inferior gluteal vessels. The patients were observed in the intensive care unit for 1 week and kept in prone position for 4 weeks. All flaps survived and wounds healed primarily. For large or multiple defects of the lower back and sacrum, free tissue transfer is effective in achieving primary healing, particularly when local flaps are inadequate or have failed.     

下肢静脉曲张微创旋切术后皮肤软组织坏死的原因及处理

目的：分析下肢静脉曲张微创旋切术后皮肤软组织坏死的原因,并总结治疗经验。方法：2007年12月～2009年2月,采用不同的修复方法治疗10例下肢静脉曲张微创旋切术后创面,对其临床治疗进行分析总结。结果：术后不同时期的创面均予以彻底切除坏死组织,培养新鲜肉芽组织;周围有正常组织者,采用局部皮瓣转移修复;周围无正常组织者,应用简易封闭负压治疗技术,创面局部环境改善后,行局部皮瓣或皮片移植修复。皮瓣转移4例,2例皮瓣100％成活;2例皮瓣部分坏死,经再次清创,移植皮片成活;其余6例均行皮片移植术,皮片均100％成活。经术后1～10月随访,功能恢复满意。结论：根据下肢静脉曲张行旋切术后皮肤软组织坏死的特点,必需在彻底切除坏死组织后,延期修复创面,以中厚皮片移植修复为首选,慎选局部皮瓣转移。     

Free tissue transfer to a difficult wound of the lower extremity

Amputation is still recommended to patients with a difficult wound of the lower extremity because limb salvage after free tissue transfer in these patients remains uncertain. During the past 3 years, the authors studied 15 patients (11 men, 4 women; age range, 17-71 years) with difficult wounds of the lower extremities who had free tissue transfers for limb salvage. Eleven patients had an extensive soft-tissue defect (nearly the entire length) of the legs or feet, and 4 had a composite-tissue defect of the legs or feet that required bony reconstruction. A total of 16 free tissue transfers (13 free muscle flaps, 2 osteomusculocutaneous flaps, and 1 adipofascial flap) were performed in 15 patients (1 patient had bilateral transfers). A saphenous vein loop or graft was used in 3 patients and a subsequent bone graft was done in 2 patients. Free tissue transfer was accomplished successfully in 14 patients (93%). Limb salvage was achieved ultimately in 12 patients (80%) who were able to ambulate during a 36-month follow-up. The authors believe that free tissue transfer for limb salvage in any patient with a difficult wound of the lower extremity is still a worthwhile procedure and should be attempted if possible. Meticulous preoperative preparation and intraoperative execution combined with the use of innovative microsurgical techniques are the keys for success.     

Latissimus dorsi free flaps for complex ischiosacral defects

BACKGROUND: Free tissue transfer for coverage of complex wounds in the ischial and sacral area can be limited by the lack of adequate recipient vessels. METHODS: We reviewed the records of 3 patients seen between August 2002 and December 2005 who underwent free tissue transfer to ischiosacral defects. RESULTS: Two patients were quadriplegic, and 1 patient was ambulatory. The gluteal vessels were used as recipients in 2 patients, and 1 patient had an arteriovenous loop to the femoral vessels. All flaps were successful and all wounds healed. CONCLUSIONS: A free latissimus flap to the ischiosacral area can be effective, and both local (gluteal) and regional (femoral) vessels can serve as recipient vessels.     

The utility of both muscle and fascia flaps in severe upper extremity trauma

BACKGROUND: Severe isolated upper extremity injuries are rarely lethal; however, they invariably are resource intensive, create significant disability, and promote resistance to a return to gainful employment. Appropriate soft tissue restoration is an essential component of any treatment protocol, and often requires a vascularized flap to protect the superficial neurovascular and musculotendinous structures. A basic schema to facilitate flap selection in the upper extremity is introduced. METHODS: The role of local muscle and fascia flaps or free tissue transfers for severe upper extremity injuries was retrospectively reviewed from a two-decade experience. Excluding digital injuries, primary treatment of soft tissue traumatic wounds requiring some form of vascularized flap occurred in 33 limbs in 31 patients. The choice of flap donor site, type, specific complications and benefits as related to the severity of injury, and the effect of timing of wound closure were compared. RESULTS: Initial coverage after significant upper extremity trauma in these 33 limbs required 16 local fascia flaps, 22 free flaps, 1 multistaged distant pedicled flap, and 1 local muscle flap. Flaps were selected in a nonrandom fashion on the basis of wound location, severity of injury, and flap availability. Complication rates were similar for local fascia and free flaps. The upper extremity could be divided into three regions that were differentiated according to the observed incidence of flap preference. Free flaps were more commonly used for hand and wrist wounds, or anywhere the defect was moderately large in size or extremely severe in overall injury. Local fascia flaps were a simpler option most applicable for the central upper limb. Local muscles as flaps were intentionally avoided to minimize any functional derangement. CONCLUSION: A schema to guide flap selection for upper extremity coverage is introduced that is predicated on using the best available option. The shoulder girdle and axilla are reached by many local trunk muscle or fascia flaps. The central upper limb about the elbow often is conducive to coverage with specific local fascia flaps. The distal upper extremity may be best served by a free flap, as would any large wound in all upper limb regions.     

游离穿支皮瓣修复足踝部软组织缺损的临床效果

背景：足踝部软组织缺损是创伤骨科临床治疗难点,皮瓣移植仍然是不可替代的治疗手段之一。目的：探讨利用两种不同游离穿支皮瓣修复足踝部软组织缺损的临床技术。方法：2006年8月至2012年4月,30例足踝部软组织缺损伴骨外露患者行皮瓣移植术。男24例,女6例,年龄3～52岁,平均28岁。术前应用负压封闭引流技术处理,创面范围6cm×8cm-11cm×23cm。其中游离胸脐穿支皮瓣修复12例,游离股前外侧穿支皮瓣修复18例。结果：术后30例皮瓣全部成活。随访时间为3～24个月,平均11．0个月。皮瓣修复后外形大部分满意,皮瓣末梢二点分辨觉为10-22mm,胸脐穿支皮瓣和股前外穿支皮瓣组术后3个月左右恢复S2以上感觉百分比分别达58．3％和68．8％。结论：足踝部软组织缺损的游离皮瓣选择采用股前外穿支皮瓣或胸脐动脉穿支皮瓣均可。穿支皮瓣能够减少二次手术比例。负压封闭引流技术能显著减少皮瓣感染比例。     

Microsurgical reconstruction: experience with free fascia flaps

Microsurgical reconstruction can often benefit from the thin, pliable, and vascular characteristics of free fascia flaps. Investigation to identify donor sites and to maximize reliability of these flaps continues. Microfil injections of the thoracodorsal artery confirm the ability to use the fascia overlying the serratus anterior muscle as a free flap based on this vessel. We have used this flap in distal extremity wounds in 4 patients with one failure (venous thrombosis). Free fascia flaps from other donor sites have been used in 9 patients in a variety of locations (head and neck, hand, and extremity) with excellent results. We conclude that when thin, well-vascularized tissue is required for reconstructive purposes, the skin-grafted free fascial flap provides excellent durable coverage with minimal donor site complications.     

Distant pedicle flaps for soft tissue coverage of severely burned hands: an old idea revisited

Burns to the hand that are complicated by exposure of bone, joint or tendon cannot be closed with conventional skin grafts and require flap procedures to prevent further damage. Local or regional flaps may be unavailable if electrical or blast trauma produces a large zone of injury, or when forearm burn injury extends beyond fascia. Free tissue transfer may not be tolerated by critically ill burn patients. In these circumstances, distant pedicle flaps are one option for safe and effective soft tissue coverage. Over a 5-year period, we have performed six distal pedicle flaps for coverage of exposed hand structures when local or free flaps were contraindicated or unavailable. The patients required an average of 4.5 surgical procedures to complete hand reconstruction and soft tissue coverage. Soft tissue coverage was completely successful in five patients and partially successful in one patient. Single stage local or free flaps remain the treatment of choice when burned hands cannot be covered with skin grafts. When these flap options are not available, distant pedicle flaps provide a safe alternative.     

Use of single saphenous interposition vein graft for primary arterial circuit and secondary recipient site in head and neck reconstruction: a case report

BACKGROUND: Autologous vein grafts are a valuable tool in microsurgical free tissue transfer. Interposition vein grafts offer the surgeon greater freedom when placing the free flap and choosing the recipient vessels, providing valuable options in case recipient vessels are not available for those patients with large wounds. Free flaps transferred to head and neck regions carry a higher risk of failure, which may be expected to increase more with the use of vein grafts. METHODS: We present our case with the double use of a single vein graft for both primary arterial conduit in end-to-end fashion and secondary end-to-side recipient site in the microsurgical reconstruction of a complicated head and neck defect. RESULTS: All these anastomoses and flaps survived perfectly, and the patient was discharged 14 days after the transfer of the second flap. CONCLUSION: Although the anastomosis of 2 flaps to a single vein graft was successful in our case, it represents a higher risk option than different recipient vessels. We provide this alternative procedure in selected patients, as there is no other receipt vessel or recipient blood flow strong enough to supply more than 1 flap.     

Free tissue transfer at an army medical center

Free tissue transfer has been demonstrated to be an effective modality of treating a variety of wounds and conditions in the civilian population. The use of these procedures has been underreported by American military surgeons. Military surgeons face unique hurdles that make the effective performance of these procedures difficult. We report our experience with free flap reconstruction at an American Army medical center. We performed 44 free flaps in 38 patients; although operative times and hospital length of stay were comparatively long, our success rates were excellent with only one partial flap loss. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of the Department of the Army or the Department of Defense.     

Reliability of primary vein grafts in lower extremity free tissue transfers.

Free flaps transferred to the lower extremity have a higher risk of failure, which may be expected to increase further with the use of vein grafts. The results of 103 consecutive free flaps to the lower extremities of 98 patients who were operated from March 1994 to December 1999 were evaluated to assess the reliability of vein grafts in lower extremity reconstruction. Five flaps were lost and the overall success rate was 95.1%. Eighty-four free tissue transfers in 79 patients were performed for the reconstruction of traumatic cases, and 81 of these flaps were performed in a delayed manner, between 1 week and 4 months after the injury. Interpositional vein grafts were used primarily in 22 flaps--all in traumatic cases--and 21 of them survived completely (95.4%). Primary vein grafts were used both for arteries and veins in 15 flaps and for arteries only in 7 flaps. The most common cause of tissue loss in these patients was a crush injury in earthquake survivors, followed by electrical injuries, gunshot injuries, motor vehicle accidents, and chronic infections. Free muscle flaps in 13 patients, skin flaps in 4 patients, osseous flaps in 2 patients, and temporal fascial flaps in 2 patients were the flaps of choice in vein graft reconstructions. Although a higher incidence of flap loss has been reported with the use of interpositional vein grafts than with regular transfers, and the technical and pathophysiological problems in flap transfers are also high in the lower extremity, the success rate in vein-grafted free flaps did not differ from that of the simple free flap transfers in the current series. This appears to be the result of meticulous preoperative planning and proper selection of recipient vessels during optimal operative conditions.     

小腿创伤的显微外科修复暨美学思考

目的：探讨小腿及足部创伤的显微外科修复方法。方法：回顾一年多来应用各种游离组织瓣修复小腿及足部皮肤软组织缺损、骨外露骨缺损创面,总结经验教训。结果：25例患者26个游离组织瓣成功移植25个,1个骨组织复合瓣移植失败,但创面全部得到一期修复。结论：受区血管选择、组织供区选择、手术设计操作及术后观察处理是小腿创面显微外科修复成功的四个关键环节;修复创面的同时亦要兼顾供区和小腿的功能与美观。     

Die Deckung von Weichteildefekten und instabilen Narben über der Achillessehne durch freie mikrochirurgische Lappenplastiken

INTRODUCTION: Coverage of the exposed Achilles tendon requires thin, supple tissue to provide adequate range of motion and a satisfying aesthetic result for the distal lower extremity. Various local flaps and free flaps have been described for reconstruction of small and large defects. Small defects can be closed with local tissue, whereas free flap coverage may be necessary for coverage of large defects. METHODS: From July 1993 to September 1998 14 patients between the age of 15 and 74 years (mean 47 years; 3 female, 11 male) underwent free flap coverage for the exposed Achilles tendon due to primary trauma, chronic wounds or tumors. The mean duration of follow-up was 33.3 months. The defect size ranged from 8 x 8 to 25 x 28 cm. RESULTS: Six parascapular flaps (three with a vascularized scapular fascial extension), four radial forearm flaps and four latissimus dorsi flaps (one combined with free serratus fascia) were used for soft tissue coverage over the Achilles tendon. Thirteen flaps survived. In one case a parascapular flap had to be removed due to venous thrombosis and a free latissimus dorsi flap was used as secondary salvage procedure. The donor site morbidity was acceptable for most patients after flap harvesting in the subscapular region and also satisfactory in the forearm region. Average active range of motion in the upper ankle joint was 15-0-40 degrees for extension/flexion. All patients were satisfied with the functional and aesthetic result. CONCLUSION: Soft tissue coverage over the exposed Achilles tendon requires an optimal solution for each patient to achieve an aesthetically pleasing result and acceptable function. Microvascular free flaps can be used to reconstruct medium and large defects and to provide gliding tissue for the Achilles tendon. The complication rate of microvascular flaps is comparable with that of local flaps.     

The reverse sural neurocutaneous flap for hindfoot and ankle coverage: experience and review of the literature

Soft-tissue defects about the ankle are common in orthopedic surgery. The wounds usually involve exposed bone or hardware, making skin grafting a poor option. Free tissue transfer remains a mainstay of treatment. Recently, the reverse sural neurocutaneous flap has gained popularity. At our institution, 11 fasciocutaneous flaps have been performed for defects averaging 53cm2. All flaps achieved stable coverage. One patient required repeat skin grafting. Given its reliability, easy dissection, and outpatient capability, this flap should be considered for coverage in this region.     

Tertiary resurfacing after one of the first free flaps in Europe, a reflection on 30 years of microsurgical progress.

Free flaps have been used for over 30 years. During this period, improved anatomical understanding has increased donor options and available pedicle lengths, permitting safer, single-stage reconstructions with simpler anastomoses. Refinements, such as perforator flaps in particular, have greatly improved donor morbidity, recipient site cosmesis, and the ability to replace 'like with like' while retaining options for innervation. This case highlights the evolution from one of Europe's first free tissue transfers, effectively a perforator flap, through the advent of free muscle flaps to the current generation of contourable perforator flaps. Free flap transfer has become increasingly sophisticated, safer, and more predictable, yet the potential quality of reconstructive outcome has changed little.     

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     

Free temporoparietal flap in burn reconstruction

A series of 12 patients with deep burns resulting in exposed bones, joints, and tendons, in whom temporoparietal free flaps were used for reconstruction, are presented. Flap loss was 8.3%; good and satisfactory results were achieved in 91.7% of healed defects. Patients with large total body surface area burns are severely compromised, and the use of free flaps requiring prolonged periods of anesthesia and surgery should be a judicious decision. Prior to the availability of free flaps, most of these patients are left with chronic wounds and compromised functional results. Although our experience is limited, we think that in well-selected cases a one-stage reconstruction with free tissue transfer is expeditious, safe, and economical.     

应用不同类型皮瓣修复电烧伤深度创面

目的　总结采用不同类型皮瓣修复严重电烧伤患者创面的临床经验。　方法　应用游离皮瓣、轴型血管蒂岛状皮瓣、局部邻近皮瓣、肌皮瓣等修复 4 9例电烧伤患者的 6 4个创面。　结果　皮瓣完全坏死 2例 ,边缘淤血坏死 4例 ,其余皮瓣均完全成活 ,创面Ⅰ期愈合。　结论　根据电烧伤程度选择恰当的皮瓣修复创面 ,能较好地防止深部组织感染和渐进性坏死 ,是一种有效、可靠的治疗手段。     

头面颈部皮肤软组织缺损的显微外科修复

目的 总结探讨头面颈部皮肤软组织缺损的游离皮瓣修复方法 . 方法 2007年7月-2010年5月,笔者单位共收治此类患者31例,包括头皮缺损10例、面部皮肤软组织缺损4例、颈部皮肤软组织缺损17例.其中由外伤引起的皮肤软组织缺损20例,瘢痕挛缩松解后继发缺损11例.采用游离皮瓣(背阔肌皮瓣13例、侧胸皮瓣3例、肩胛皮瓣5例、股前外侧皮瓣10例)修复创面,皮瓣面积8 cm×5 cm～25 cm × 18 cm. 结果皮瓣全部成活,创面均一次性愈合.患者平均住院时间为16.7 d.28例患者随访2个月,皮瓣外观、功能良好. 结论 以显微外科为基础的游离皮瓣移植可一次性修复头面颈部皮肤软组织缺损创面,减轻患者痛苦、缩短住院时间.