Medial sural artery perforator flap for tongue and floor of mouth reconstruction

BACKGROUND: The radial forearm flap is frequently considered the first choice for tongue reconstruction, but the disadvantages of donor site morbidity are well known. The search for another thin skin flap as an alternative has led to the application of the medial sural artery perforator flap. METHODS: We used 12 medial sural artery perforator flaps to reconstruct tongue and floor of mouth following cancer ablation. We paid attention to the major perforator (vein >or= 1 mm) as the vascular relay. RESULTS: Most flaps were raised with a single perforator. The size of the skin paddle varied from 9 cm x 5 cm to 14 cm x 12 cm. The mean thickness of the flap was 5.2 mm. We reexplored 1 patient for venous insufficiency and could not salvage the flap. CONCLUSIONS: The thin medial sural artery perforator flap permits high accuracy of tongue restoration and reduces the morbidity at the donor site.     

Skin perforator flaps: an algorithm for leg reconstruction

The local fasciocutaneous flap has the advantage of low donor site morbidity when used for the coverage of lower limb defects. However, flap reliability remains a major problem with its use. Perforator flaps are indicated for several clinical problems. The versatility of the perforator flap makes it ideal for the reconstruction of extremities. Between September 2007 and November 2010, 34 skin perforator flaps were raised in 33 cases. Flaps which were executed as peroneal artery flaps were 13, 0.16 flaps were raised as posterior tibial artery perforator flaps, and 5 flaps as medial sural medial gastrocnemius muscle perforator skin flap. A segmental perforator was dissected and retained. Thirty-two flaps survived completely and none exhibited venous compromise. In one patient, flap was lost completely and the other showed partial tip necrosis. Complicated flaps were responded to conservative treatment. Skin perforator flap represents a technical advancement over conventional lower limb skin flaps because of its improved vascularity. It provides the surgeon with additional reconstructive options in reconstruction of difficult areas and injuries of leg. Clinical judgment is essential to assess the potential vascular territory of the flap.     

Free medial sural artery perforator flap for resurfacing distal limb defects

BACKGROUND: The need for thin flap coverage has increased, especially for contouring or covering shallow defects of distal limbs. The free medial sural artery perforator flap harvested from the medial aspect of the upper calf can be useful for this purpose. METHODS: Between January 2002 and February 2003, we used the free medial sural artery perforator flap for distal limb reconstruction in 11 clinical cases, including four hands and seven feet. This perforator flap is based on the proximal major perforator of the medial sural artery, which can be identified along the axis of the medial sural artery and usually emerges in an area between 6 and 10 cm from the popliteal crease and approximately 5 cm from the posterior midline of the leg. RESULTS: Most of the flaps were safely raised with a single perforator. One flap developed venous congestion during the postoperative course and finally underwent total necrosis. CONCLUSION: The main advantage of the medial sural artery perforator flap is that it only requires cutaneous tissue to achieve better accuracy in reconstructive site, and it preserves the medial gastrocnemius muscle and motor nerve to minimize donor-site morbidity. However, the tedious process of intramuscular retrograde dissection of the perforator and the unsightly scar of the donor region are the major concerns.     

腓肠内侧动脉穿支蒂皮瓣修复膝和小腿上1/3软组织缺损

目的 报道应用腓肠内侧动脉穿支带蒂皮瓣修复膝和小腿上1/3软组织缺损的临床应用效果. 方法 应用腓肠内侧动脉穿支带蒂皮瓣修复膝和小腿上1/3软组织缺损16例.其中,髌前4例,前外侧2例,前内侧l例;小腿上1/3 9例.供区均选用同侧小腿.结果 手术后经过顺利,1例术后发生表浅感染,经更换敷料逐渐愈合,皮瓣全部成活.随访3.0个月至3.5年,平均1.7年.供区愈合良好,未见明显的供区功能障碍.受区皮瓣质地、厚薄及颜色均较好,功能恢复较好,取得了较满意的效果. 结论 腓肠内侧动脉穿支带蒂皮瓣以腓肠内侧动脉的肌皮穿支为血供,具有血供丰富、血管解剖恒定、血管蒂长以及皮瓣较薄的优点.带蒂移植适宜修复膝和小腿上1/3软组织缺损.     

腓肠内侧动脉穿支皮瓣修复上下肢创面

目的介绍吻合血管的腓肠内侧动脉穿支皮瓣修复上下肢创面的临床方法和经验。方法采用吻合血管的腓肠内侧动脉穿支皮瓣修复上下肢创面11例，女6例，男5例。皮瓣设计区域为同侧小腿，腓肠内侧肌肌腹以远1／2的表面部分，前内界为胫骨的内后缘，后外侧界为小腿后正中纵轴线，皮瓣的轴行线为前内界和后外侧界的中线。皮瓣长8～15cm，宽6～14cm。结果10例皮瓣成活，皮瓣质地柔软，富有弹性，不臃肿，恢复了一定的触觉；1例皮瓣全部坏死，经扩创、断层皮片修复创面；不影响供区的运动功能。结论腓肠内侧动脉穿支皮瓣可以用来修复上下肢创面，尤其对手足部创面的修复有较为满意的临床疗效。     

Free medial sural artery perforator flap for ankle and foot reconstruction

Resurfacing shallow defects over the ankle and foot with an appropriately thin flap is a common but difficult task. This can be accomplished by harvesting the medial sural artery perforator flap from the medial aspect of the upper calf. Based on the musculocutaneous perforator of the medial sural artery, this flap preserves the medial gastrocnemius muscle and avoids unnecessary flap bulkiness. Between January 2002 and February 2004, we used 2 variants of the free medial sural artery perforator flap for ankle and foot reconstruction in 13 patients (10 fasciocutaneous flaps and 3 adipofascial flaps). In these patients, skin defects were combined with bone, joint, or tendon exposure. The main advantage of this flap is that it provides a thin and pliable coverage to achieve better accuracy in the reconstructive site. Other advantages include maintaining the function of the medial gastrocnemius muscle, providing a long vascular pedicle, and avoiding the need to sacrifice major arteries of the leg. The main disadvantages are the tedious process of intramuscular retrograde dissection of the perforator and the unsightly skin graft over the medial calf.     

游离股前外侧皮瓣修复口腔软组织缺损

目的 探讨分析3种游离股前外侧皮瓣在口腔软组织缺损修复中的临床特点与治疗效果。方法 2008年12月至2010年12月收治67例口腔肿瘤患者,切除肿瘤的同时,应用游离股前外侧皮瓣修复缺损处,包括舌、颊、牙龈、口底,通常将皮瓣的旋股外侧动脉降支与受区的颌外动脉或甲状腺上动脉吻合,伴行静脉与受区的面总静脉或颈外静脉吻合。根据游离股前外侧皮瓣的厚度将其分成3种类型：股前外侧肌皮瓣、股前外侧脂肪筋膜皮瓣和薄型股前外侧皮瓣。结果 67例中股前外侧肌皮瓣为35例,股前外侧脂肪筋膜皮瓣17例,薄型股前外侧皮瓣15例。66例皮瓣存活,成功率为98.5％,其中1例糖尿病患者皮瓣发生小部分坏死,经清创换药后痊愈;1例皮瓣完全坏死。67例皮瓣中41例吻合2条静脉,26例吻合1条静脉。8例出现血管危象：6例为静脉血栓（5例抢救成功、1例皮瓣完全坏死）,1例为术区血肿,1例为穿支血管扭转,经过相应处理,血管危象均得到缓解。术后随访2～ 24个月,平均8.7个月,受区组织缺损修复效果满意,供区创面愈合良好。结论 游离股前外侧皮瓣的受区功能良好,供区并发症少,是一种修复口腔软组织缺损的较为理想的方法。     

穿支皮瓣移植修复四肢软组织缺损108例

目的 探讨应用穿支皮瓣修复四肢皮肤软组织缺损的临床效果. 方法2007年7月至2009年5月,分别采用腹壁下动脉穿支皮瓣、股前外侧穿支皮瓣、胸背动脉穿支皮瓣、股外侧穿支皮瓣、骨间背侧动脉穿支皮瓣、桡侧副动脉穿支皮瓣、腓肠内侧动脉穿支皮瓣、胫后动脉穿支皮瓣、旋髂深动脉穿支皮瓣、腓动脉穿支皮瓣移植修复四肢皮肤软组织缺损108例(游离移植98例,带蒂转移10例),皮瓣切取面积最小4 cm×2 cm,最大44 cm×9 cm,皮瓣供区均直接缝合.结果 术后5例发生静脉危象,其中1例松解包扎后危象解除,4例再次手术探查,2例成活,2例坏死,其余103例顺利成活,皮瓣受区与供区创121愈合良好.术后随访6-24个月(平均10个月),皮瓣颜色、质地好,外形不臃肿;皮瓣供区遗留线性瘢痕,功能无影响. 结论穿支皮瓣不携带肌肉、深筋膜及运动神经,对皮瓣供区影响小,还具有血供可靠、质地薄、不需二期去脂整形的优点,是修复四肢浅表创面的首选方法.     

Medial sural artery perforator flap for repair of the hand

We report our experience of using the medial sural artery perforator flap in the reconstruction of soft tissue defects in the hand in seven cases with 1 to 2 year follow-up. The flap is harvested from the posteromedial aspect of the leg, just below the knee and superficial to the medial head of the gastrocnemius muscle. It is based on the perforator arteries and veins supplied by the medial sural artery. The flaps ranged in size from 14 x 10 cm to 8 x 6 cm. The donor area was closed directly or by a skin graft. All but one flap survived. The cosmetic results were satisfactory and without apparent bulkiness. Similarity of colour and thickness of the donor and recipient sites are advantages. We feel that this new flap is a satisfactory option for use in the hand, particularly for extended soft tissue defects on the dorsal hand.     

Perforator Propeller Flap “Relay” for Distal Lower Extremity Soft Tissue Reconstruction

The peroneal artery perforator propeller flap is commonly used for distal lower extremity reconstruction; however, closure of the donor site defect can limit the utility of this flap. To overcome this limitation, we introduced a perforator propeller flap relay technique to reconstruct the donor-site defect. Between July 2015 and February 2019, the propeller flap relay technique was applied in 9 patients. In each case, a peroneal artery perforator propeller flap was transferred to repair a defect in the distal lower leg or the foot. In addition, a neighboring perforator propeller flap was transferred to close the donor-site defect. The peroneal artery perforator propeller flaps ranged from 14 × 4 to 29 × 8 cm² in size. Donor-site closure was accomplished using the relaying propeller flaps based on perforators from the peroneal, medial sural, and lateral sural arteries. Normal contour of the lower leg was preserved with acceptable scars. Additional time for the second flap procedure was less than 1 hour in each case. One peroneal artery perforator flap presented with partial flap necrosis. Other flaps survived completely without complication. Coverage of the donor-site defects of the peroneal artery perforator flaps can be achieved using various perforator propeller flaps. The perforator propeller flap relay technique allows surgeons to harvest a large peroneal artery perforator flap without being limited by significant donor-site morbidity. This technique can reconstruct defects at distal lower extremity with low morbidity and improved overall reconstructive results.     

腓肠肌内侧头岛状肌瓣修复胫骨上端感染创面

目的：总结腓肠肌内侧头岛状肌瓣修复胫骨上端感染创面的临床应用结果。方法：胫骨上端感染创面9例,男7例,女2例;年龄21～60岁,平均34岁。应用改进的腓肠肌内侧头岛状肌瓣修复,供区均选用同侧小腿。肌瓣表面行Ⅰ期中厚网状游离植皮,供区直接缝合。结果：仅1例术后发生表浅感染,经换敷料逐渐愈合。所有患者肌瓣和其上植皮全部成活。术后随访13个月～4年,平均21个月,供区愈合良好,未发现明显功能障碍。结论：腓肠肌内侧头岛状肌瓣以腓肠内侧动脉为血供,具有血供丰富,血管解剖恒定,血管蒂长,以及肌瓣较薄的优点,带蒂移植适宜修复胫骨上端软组织缺损。     

Distally Based Adipofascial Flaps for Dorsal Foot and Ankle Soft Tissue Defects

Soft tissue defects of the dorsal foot and ankle are difficult to reconstruct because the contour of the foot must be maintained for shoe fitting. The adipofascial flap, covered with a skin graft, is a suitable method of reconstruction that fulfills this important requirement. Twelve patients with soft tissue defects of the dorsal foot and at the ankle were treated in our unit with this method. Ten (83%) were children, 2 (17%) were adults. All defects were due to road traffic accidents. Three (25%) patients were women; 9 (75%) were men. The right foot was affected in 10 (83.4%) patients, with 2 (16.6%) patients having the left foot involved. The flaps used were the peroneal artery perforator flap (distally based lateral adipofascial flap) in 9 (75%) patients, the superficial sural artery flap in 2 patients (17%), and the posterior tibial artery perforator flap (distally based medial adipofascial flap) in 1 patient (8%). All flaps were successful, providing adequate contour of the foot for wearing ordinary shoes. There were 2 partial skin graft necroses, and, in 1 patient, the tips of the donor site skin flaps were necrosed. In conclusion, the distally based adipofascial flap, covered with skin graft, is a suitable method for reconstruction of soft tissue loss of the dorsal foot and ankle and provides optimum functional and aesthetic outcome with minimum donor site morbidity.     

The thin circumflex scapular artery perforator flap.

The development of microsurgery has most recently been focused upon the evolution of perforator flaps, with the aim of minimising donor site morbidity, and avoiding the transfer of functionally unnecessary tissues. The vascular basis of perforator flaps also facilitates radical primary thinning prior to flap transfer, when appropriate. Based upon initial clinical observations, cadaveric, and radiological studies, we describe a new, thin, perforator flap based upon the circumflex scapular artery (CSA). A perforator vessel was found to arise within 1.5cm of the CSA bifurcation (arising from the main trunk, or the descending branch). The perforator arborises into the sub-dermal vascular plexus of the dorsal scapular skin, permitting the elevation and primary thinning of a skin flap. This thin flap has been employed in a series of five clinical cases to reconstruct defects of the axilla (two cases of hidradenitis suppurativa; pedicled transfers), and upper limb (one sarcoma, one brachial to radial artery flowthrough revascularisation plus antecubital fossa reconstruction, and one hand reconstruction with a chimeric flap incorporating vascularised bone, fascia, and thin skin flaps; free tissue transfers). No intramuscular perforator dissection is required; pedicle length is 8-10cm and vessel diameter 2-4mm. There was no significant peri-operative complication or flap failure, all donor sites were closed primarily, patient satisfaction was high, and initial reconstructive aims were achieved in all cases. Surgical technique, and the vascular basis of the flap are described. The thin circumflex scapular artery perforator flap requires no intramuscular dissection yet provides high quality skin (whose characteristics can be varied by orientation of the skin paddle), and multiple chimeric options. The donor site is relatively hair-free, has favourable cosmesis and no known functional morbidity. This flap represents a promising addition to the existing range of perforator flaps.     

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.     

Suitability of the anterolateral thigh perforator flap and the soleus perforator flap for intraoral reconstruction: a retrospective study

Perforator flaps are suitable for numerous reconstructive purposes. However, there are few data about their usefulness for intraoral reconstruction. We reviewed data of 101 patients who were reconstructed by two types of perforator flaps after oral cancer. Forty-six soleus perforator flaps and fifty-five anterolateral thigh (ALT) perforator flaps were performed. Procedural data and outcome measures were analyzed. One ALT and four soleus perforator flaps were lost, resulting in success rates of 97.8% and 91.4%, respectively. Soleus perforator flaps were more challenging due to short and small-caliber vessels, higher susceptibility to vascular spasm, and difficult prediction of the location of the vascular pedicle. All donor sites in both groups except one were closed directly, and their morbidity was negligible. Perforator flaps from both donor sites can be used for intraoral reconstruction with good functional results; however, despite primary thinning, the ALT flap can be voluminous in small and flat defects. Here, soleus perforator flaps adapt better to the oral mucosa. The ALT perforator flap is more reliable and serves as a safe alternative to the radial forearm flap.     

三种修复手部创面皮瓣的临床疗效评价

目的 比较骨间背侧动脉皮瓣、股前外侧皮瓣和腓肠内侧动脉穿支皮瓣的临床疗效,为临床的皮瓣选用提供参考.方法 对应用骨间背侧动脉皮瓣、股前外侧皮瓣和腓肠内侧动脉穿支皮瓣修复手部创面的23例患者进行随访,比较分析DASH(disability of the arm,shoulder and hand)分数、损伤的部位、触觉压觉(Senunes-Weinstein单丝法)、两点分辨觉(动、静态,m2PD、s2PD)、温度觉、臃肿程度和供区瘢痕挛缩程度.结果 三种皮瓣的DASH评分、瘢痕挛缩程度、皮瓣的臃肿程度、触觉压觉、两点分辨觉和温度觉的结果 ,差异均没有统计学意义;股前外侧皮瓣的臃肿程度高于其他两种皮瓣,差异具有统计学意义.结论 三种皮瓣各有特点,临床选择应该根据各种客观要求,不要主观臆测.     

穿支游离皮瓣修复头颈肿瘤术后缺损

目的 探索更为理想的穿支游离皮瓣修复技术，运用于头颈肿瘤术后缺损。方法 2003年12月-2005年5月用于头颈部手术缺损修复的穿支游离皮瓣共14例（股前外侧皮瓣8例，腹壁下深动脉穿支皮瓣6例）。其中10例为复发后挽救手术，12例曾行放疗（平均63．5Gy）。头颈部肿瘤手术缺损部位分别为舌体3例，颊黏膜3例，口咽壁3例，舌根2例，颅底、头皮以及中面部各1例。受区供吻合动脉主要是甲状腺上动脉和面动脉；静脉为颈内静脉。结果 13例穿支游离皮瓣成功（93％），有1例穿支皮瓣因吻合侧的颈内静脉血栓形成导致皮瓣坏死。受区未发现其它明显并发症。供区均直接缝合关闭并一期愈合，未发现腹壁疝和运动受限等手术并发症。结论 穿支游离皮瓣保留了供区的肌肉、筋膜和神经，将供区的并发症降到最低限度，是头颈部缺损修复新的可靠技术。     

Head and neck reconstruction with the deep inferior epigastric perforator flap: A report of two cases

Rectus abdominis musculocutaneous (RAMC) free flaps are preferred for head and neck reconstruction because of the abundant blood supply to the rectus abdominis musculocutaneous. In contrast, the indications for deep inferior epigastric perforator (DIEP) free flaps in head and neck reconstruction are limited. In this report, two cases of oral cavity reconstruction with DIEP free flaps are described. In both cases, the defect was reconstructed with a DIEP free flap because it could avoid functional damage to the donor site. Successful reconstruction with a two skin‐island method was performed in both patients. Furthermore, donor site morbidity was minimal in both patients. When a DIEP free flap is used for head and neck reconstruction, elimination of dead space is the most difficult problem, because a DIEP free flap does not contain well‐vascularized muscle tissue. We compensate for this disadvantage with a flap designed to include a de‐epithelialized skin flap. Although this technique is not always the first choice for head and neck reconstruction, it is suitable for patients who wish to avoid donor site morbidity. © 2009 Wiley‐Liss, Inc. Microsurgery, 2009.     

穿支皮瓣修复四肢创面临床应用56例

目的 探讨应用穿支皮瓣修复四肢创面的临床效果。方法 自2016年11月至2018年10月,采用股前外侧穿支皮瓣(ALTP)、腹壁下动脉穿支皮瓣(DIEP)、骨间后动脉穿支皮瓣(PIAP)、胸背动脉穿支皮瓣(TDAP)、腓肠内侧动脉穿支皮瓣(MSAP)、桡侧副动脉穿支皮瓣(RCAP)游离移植修复四肢创面56例,软组织缺损面积1.5 cm×1.5 cm~ 10.0 cm×24.0 cm,皮瓣切取面积2.0 cm×2.0 cm~ 11.0 cm×25.0 cm。供区均直接缝合关闭。术后观察皮瓣成活与创面愈合情况,定期随访皮瓣外观、质地、肢体功能恢复及皮瓣供区外形及功能。结果 1例DIEP移植术后第3天发生静脉危象,经手术探查重新吻合静脉后成活,皮瓣远端部分表皮坏死,经换药治疗后愈合;其余55例皮瓣均顺利成活,皮瓣受区与供区创口均一期愈合。术后6~ 18个月随访,皮瓣颜色正常,质地柔软,肢体功能恢复良好,皮瓣供区仅残留线形瘢痕,功能无影响。结论 穿支皮瓣修复四肢创面疗效可靠,可以推广应用。     

A novel reconstruction technique for the knee and upper one third of lower leg.

Various reconstructive choices for the coverage of soft tissue defects around the knee joint or upper one third of lower leg are available depending on the location, size and depth of the defect. The authors have found the medial sural artery perforator island flap a useful method for reconstruction of the upper one third of lower leg and knee. From January 2003 to November 2005, medial sural perforator island flaps were used on six patients, five were men and one was a woman. The largest flap obtained was 16 x 7 cm. In three cases, defects were located on the upper one third of lower leg and in the other cases, on the knee. Four of them bone exposed, and two cases had a post-burn contracture. All six flaps survived completely, without even minor complications. Postoperative follow up of the patients ranged from 2 to 33 months. The main advantages of the medial sural perforator island flap are a constant location and reliable blood supply without sacrifice of any main source artery and underlying muscle. This procedure is a valuable extension of local flap for defect coverage with minimal functional deficit of donor site and good aesthetic result on the defect and is a useful method for reconstruction of the upper one third of lower leg and knee.