Der Saphenusperforatorlappen

Objective

Replacement of full thickness soft tissue defects in the lower leg and ankle, appropriate to the defect and following the course of blood vessels feeding the skin of a distally hinged fasciocutaneous flap most reliably based on the individual anatomy of distal perforators of the posterior tibial artery.

Indications

Full thickness soft tissue defects, up to 12 cm in length and up to 8 cm in width. Sufficient vascularization of the foot required, in osteomyelitis, and when joints, fractures, implants and tendons are exposed and when a split skin graft, a local flap, a suralis perforator flap or a free flap is not indicated.

Contraindications

For patients, in whom a 1–2 h operation is not possible; necessity of angioplasty; decollement or scars around the distal perforators of the posterior tibial artery; local infection or necrosis of soft tissues and/or bone, which cannot be totally excised.

Surgical technique

Radical debridement; flap dissection without tourniquet; microdissection; design of the flap on the skin: pivot point ~?10 cm (6–14 cm) proximal of the tip of the medial malleolus; base ~?5 cm in width, between the course of the saphenous nerve and of the great saphenous vein and the Achilles tendon; adipofascial pedicle up to 15 cm in length sited over the septum between soleus and flexor digitorum muscles, following the course of the saphenous nerve, with a central skin stripe, which expands into a proximal skin island; skin island is outlined similar to the defect, but larger by 1 to 2 cm, surrounded by an adipofascial border: adjustment of the planning as well as of the elevation of these flaps according to the individual position and the caliber of perforators requires in each case the search for a perforator at the estimated pivot point. Delay of transposition, if the division of more than one perforator proximal to the pivot point obviously diminishes circulation. No “tunnelling “of the pedicle; defects of skin due to the elevation of the flap are replaced by split and meshed skin grafts or temporary by “artificial skin”. A gap in the bandage over the skin island allows for observation.

Postoperative management

Protocol of controls of vascularization: color and time for revascularization; antibiotic treatment according to bacteriological testing. In case of edema or discoloration of the flap: immediate removal of sutures, administration of leeches, operative revision. Split skin graft 1 week after flap transposition, if the skin had been temporary substituted.

Results

Retrospective uncontrolled study with over 70 saphenous perforator flaps from 1995–2011. Full soft tissue defects 62 times with osteomyelitis, 3 times with endoprothesis, 3 times with fractures, 2 times with exposed tendons. From 1995–2006, 44/50 (88?%) flaps healed completely or at least to 3/4 without the necessity of further flaps; from 2007–2011, 13/20 (65?%) flaps healed completely and 6/20 (30?%) flaps healed at least to 3/4 without the necessity of further flaps, loss of one flap (5?%).     

低旋转点腓肠神经筋膜皮瓣修复足部中远端组织缺损的临床应用

目的：探讨应用低旋转点腓肠神经筋膜皮瓣修复足部中远端组织缺损的方法。方法：降低腓肠神经筋膜皮瓣的旋转点至外踝尖0～3cm范围,使皮瓣旋转后可以达到足远端,皮瓣一期转移,共修复10例,皮瓣面积5cm×6cm～12cm×18cm。结果：9例皮瓣全部成活,1例皮瓣远端出现约2cm2左右皮肤坏死,后行换药、植皮修复。结论：降低腓肠神经筋膜皮瓣的旋转点可用于修复足远端皮肤软组织缺损,解决了足部中远端组织缺损修复这一难题;其血供安全可靠,切取转移简便易行,拓展了该皮瓣的应用范围。     

小腿前外侧岛状皮瓣的临床应用

目的 介绍小腿前外侧岛状皮瓣的应用解剖、临床应用及手术方法。方法 采用带腓浅血管的岛状皮瓣修复小腿及跟部皮肤缺损5例,其中,顺行皮瓣2例（修复胫前皮肤缺损和慢性骨髓炎各1例）,逆行皮瓣3例（修复跟腱外露）。结果 5例皮瓣全部成活,术后4例随访3－18个月,皮瓣生长良好。结论 小腿前外侧岛状皮瓣是修复小腿及跟部皮肤缺损的一种简单易行的理想皮瓣。     

足背动脉逆行岛状筋膜瓣联合植皮在甲皮瓣切取后创面修复中的应用

目的 报告应用足背动脉逆行岛状筋膜瓣联合植皮修复甲皮瓣切取后创面的方法及临床疗效.方法 对8例拇指套脱伤应用甲皮瓣移植修复后,供区创面缺损面积最大为3.5 cm×6.8 cm,最小为2.5 cm×4.9 cm.以足背动脉足底穿支为旋转点,足背动脉体表投影为轴线,在踝前设计足背动脉岛状筋膜瓣,切取足背动脉周缘筋膜组织,结扎足背动脉近端分支,逆行转移至趾切取后的创面,并在筋膜上植全厚皮片、不打包.结果 8例甲皮瓣、筋膜瓣及植皮创面全部存活,对足部血供无影响.术后随访时间为3～18个月,修复后的趾保留正常长度,外形良好,植皮区无挛缩,恢复保护性感觉,趾屈伸活动及下肢行走正常.结论 足背动脉逆行岛状筋膜瓣切取简单,便于旋转,血供丰富,且保留了趾的长度,是修复甲皮瓣切取后遗留创面理想的修复方法.

Abstract：

Objective To report the method and clinical outcomes of covering big toe defects after wrap-around flap transfer with dorsalis pedis artery reversed fascial island flap combined with skin graft. Methods Wrap-around flap transfer was used to reconstruct degloved thumbs in 8 cases,which left soft tissue defects of the big toe ranging from 2.5 cm×4.9 cm to 3.5 cm×6.8 cm. The reverse fascial island flap pedicled by the dorsalis pedis artery was designed at the anterior ankle with the plantar perforator as pivot point and the surface projection of dorsal pedis artery as axis. The fascia around the dorsalis pedis artery was included in the flap. Proximal branches of the dorsalis pedis artery were ligated and the flap was lifted and rotated to cover the big toe defect. Full-thickness skin was grafted on top of the fascial flap. Results All flaps and skin grafts survived. Blood supply of the foot was not compromised. Postoperative follow-up ranged from 3 to 18 months. The length of the donor big toes was preserved. The contour of toes repaired by flaps was good. There was no contracture of skin grafts. Protective sensation was restored. Walking and motion of the toes was normal. Conclusion Dorsalis pedis artery reversed fascial island flap is easy to harvest and rotate. It has rich blood supply. Transfer of this flap can preserve the length and contour of the big toe and therefore is an ideal method to cover donor site defects left by wrap-around flap harvest.     

第二掌背动脉岛状皮瓣的临床应用

目的：通过解剖学研究，设计第２掌背动脉岛状皮瓣，临床修复手部皮肤缺损，获得成功。方法：对５０只经动脉灌注红色乳胶的成人手标本，在放大镜下观察第２掌背动脉及伴行静脉的起端，皮支、终末支的走行；测量血管各部位的直径。结果：第２掌背动脉终末支分布于第２指蹼、示中指近节皮肤；皮支和其它掌背、掌指动脉间有丰富的吻合支。临床应用８例，顺行皮瓣７例，逆行１例。修复手背、拇指皮肤缺损，皮瓣全部成活。结论：临床应用第２掌背动脉为蒂的岛状皮瓣时，可设计成顺行或逆行皮瓣，均能成活。     

腓肠神经营养血管逆行岛状皮瓣修复踝关节周围皮肤缺损

目的探讨腓肠神经营养血管逆行岛状皮瓣修复踝关节周围皮肤缺损的临床疗效。方法对12例踝关节周围皮肤缺损患者行彻底扩创,根据创面大小选择腓肠神经营养血管逆行岛状皮瓣修复。结果 12例均获随访,时间6~20个月。1例术后因蒂部受压,皮瓣静脉回流不畅致远端部分坏死,经切痂植皮后痊愈;其余11例皮瓣全部成活。结论腓肠神经营养血管逆行岛状皮瓣具有操作简单、不牺牲知名血管、损伤小、皮瓣厚薄适宜、易成活等优点,是修复踝关节周围皮肤缺损的有效方法。     

Skeletonised retrograde distal perforator island fasciocutaneous flaps for leg and foot defects.

Defects involving the distal leg and foot are frequently encountered following various aetiological factors. Paucity of local tissue causes surgeons to resort to the retrograde peninsular flap, the cross leg flap or the free flap. With specific knowledge of perforators, the fasciocutaneous flap from the calf area can be transferred to the defect in a single stage based on skeletonised distal perforators. The surgical anatomy, flap planning and procedure have been detailed. Nineteen patients were treated during the period 1995 to 2005. The perforators were identified preoperatively by audio Doppler. The flaps were marked and dissected proximal to the defect skeletonising the distal perforators under loupe magnification and transferred to the defect in a single stage. The donor site was skin grafted. Out of 19 cases, 16 flaps healed uneventfully, one flap necrosed completely and in two cases there was marginal necrosis. The cases were followed up for 2-10 years with an average of 6 years. With detailed knowledge of perforators one can safely reconstruct distal moderate-size defects of the lower limb in a single stage, thus having the benefits of free tissue transfer without resorting to microsurgery. This technique has proved to be an advancement in the reconstructive repertoire allowing flaps of non conventional dimensions to be perfused by skeletonised perforators.     

Distally based radial forearm flap with preservation of the radial artery: anatomic,experimental, and clinical studies

In this article we report on the anatomical, experimental, and clinical investigations of the distally adipofascial pedicled radial forearm flap based on the small perforators around the radial styloid process. There are about 10 small perforators (0.3-0.5 mm in diameter) from the distal radial artery around the radial styloid process. The longitudinal chain-linked vascular plexuses (suprafascial, paraneural, and perivenous) formed by the forearm ascending and descending branches of septofasciocutaneous perforators meet and cross over with the transverse carpal vascular plexuses around the radial styloid region. Based on these directional-oriented plexuses, distally based adipofascial pedicled radial forearm fasciocutaneous and adipofascial flaps were designed and successfully applied in 34 clinical cases. The pivot point was located at 1-2 cm above the radial styloid. The skin island plus adipofascial pedicle measured between 9-18 cm in length, with the adipofascial pedicle 3-4 cm in width. The length-to-width ratio is 3-5:1. The venous drainage of this distally based flap was investigated anatomically and experimentally. The cephalic vein has no positive role for venous drainage in distally based flaps. The difference between distally based flaps and reverse-flow flaps, clinical selection of fasciocutaneous and adipofascial flaps, advantages and disadvantages, and technical tips for operative success are discussed.     

前臂骨间背动脉蒂岛状皮瓣创面修复12例疗效分析

目的探讨前臂背侧骨间动脉蒂岛状皮瓣行创面修复的手术方法和效果。方法2001年3月~2006年3月采用该皮瓣修复创面12例,其中逆行皮瓣修复手部创面9例,顺行皮瓣转移修复肘部创面3例。结果皮瓣全部成活,无坏死及感染。术后随访3个月~2年,患肢功能恢复满意。结论前臂骨间背动脉蒂岛状皮瓣修复上肢创面操作简单,疗效可靠,值得推广。     

The keystone design perforator island flap. Part II: clinical applications.

BACKGROUND: This curvilinear- and trapezoidal-shaped flap essentially consists of two conjoined V-Y flaps end to side. The vascular supply is supported by the subcutaneous vascular network and is dependent on fascial and muscular perforators. A review of 15 clinical cases was performed to assess the reliability and versatility of the flap. METHODS: Twelve keystone flaps were performed following excision of skin tumours or post-traumatic defects in various locations, from the head and neck region, the trunk and the limbs. RESULTS: No flap necrosis, even partial, was observed regardless of the site and the type of keystone used. Patients were almost pain free in the postoperative course. The aesthetic results are quite satisfactory, as the flap is aligned locally without evidence of the 'pincushioning' appearance sometimes seen around island reconstructions. DISCUSSION: Elevation of the flap seems to evenly distribute the tensional forces without undermining. The flap is particularly useful in the repair of defects following skin cancer removal. Bulk is not a problem and good skin cover is achieved. CONCLUSION: The presence of perforators and subcutaneous network distributed throughout the body create an environment which makes this flap universally applicable and extremely reliable.     

顺行股前外侧岛状皮瓣和肌皮瓣的临床应用

目的 探讨应用顺行股前外侧岛状皮瓣和肌皮瓣修复髂部,大转子部和腹股沟等处软组织缺损的临床效果。方法 应用顺行股前外侧岛状皮瓣和肌皮瓣修复１２例软组织缺损,其中,岛状皮瓣９例,肌皮瓣３例。供区直接缝合。结果 除１例岛状皮瓣远端发生尖部坏死经植皮愈合。其余病例术后全部成活。随访１－５年,平均２．５年,供区愈合良好,受区外形,质地及厚薄均较满意。结论 该皮瓣以旋股外侧动脉降支为其血供,具有血运丰富,血管     

The reverse posterior interosseous flap: A solution for flap necrosis based on a review of 87 cases.

PURPOSE: The relationship of the flap necrosis to the placement of the flaps on the forearm was outlined and a solution in avoiding flap necrosis is discussed. METHODS: The relationship of the flap necrosis to the placement of the flaps on the forearm was investigated in 87 consecutive posterior interosseous island flaps used for the reconstruction of the hand and wrist. Fifty-eight flaps were taken from the middle and proximal thirds of the forearm, the distal edges being within the middle third of the forearm in 24 and the distal edges being within the distal third of the forearm in 34. Twenty-nine flaps were harvested within the boundaries of the distal two-thirds of the forearm, the distal edge being proximal to the distal third of the forearm in 23 and the distal edge being distal to the third of the forearm in six. The Length of the flaps varied from 6.5 cm to 12 cm. The pedicle length measure 4-13 cm. The number of perforators for each flap was recorded also. RESULTS: Flaps survived complete in 78 (89.6%) patients. Six patients had superficial necrosis of the distal part of the flap (6.8%). Three flaps were totally lost and alternative coverage was used (3.8%). The flaps that ended up with partial necrosis appeared to be in related to the site it was taken from. One flap with total necrosis and one with partial ncrosis were taken within the boundaries of the proximal third of the forearm while the distal edge was proximal to the level of distal third. One flap with total necrosis and one with partial necrosis were taken from the proximal third of the forearm while their distal edge were at the limits of the distal third of the forearm. The remaining flap ending up with total necrosis was taken from the distal third of the forearm with a short pedicle. CONCLUSIONS: For the reverse posterior interosseous flap to be reliable the flap should include the septocutaneous perforators in the distal third of the forearm. To cover distant defects reliably by a flap with a long pedicle, the flap should extend up to the distal third of the forearm to include a piece of skin with numerous perforators.     

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.     

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.     

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.