Free flap coverage of upper and lower limb tissue defects in children: a series of 22 patients

Free tissue transfer has become the most important means of limb salvage treatment after severe trauma. This one-step procedure shortens healing and hospitalization time and minimizes the danger of infection. However, very few studies have considered the use of free tissue transfer for the reconstruction of traumatic limb injuries in children. This study reports 22 such cases treated in the authors' unit between 1993 and 2000 (17 boys and 5 girls; mean age, 8.9 years; age range, 18 months-15 years; 16 lower and 6 upper limbs). All flaps were indicated for repair of acute traumatic defects (20-500 cm2). Five different flaps were used: 12 scapular, 4 latissimus dorsi, 4 serratus anterior, 1 groin, and 1 temporalis fascia. All were successful, except for partial necrosis with the free groin flap. Three flaps requiring reexploration for venous insufficiency had a successful outcome. The microsurgical success rate in this pediatric population is very high, and the state and size of the donor site and recipient vessels have caused no problems. No long-term complications have been noted (mean follow-up, 3.8 years).     

吻合血管的游离组织移植在四肢创伤急诊修复中的应用

目的 报道应用吻合血管的游离组织移植急诊修复四肢创伤的效果。方法 1988年4月至2004年8月，进行急诊游离组织移植86例，修复肢体54例，再造拇指32例。移植的组织包括背阔肌肌皮瓣、股前外侧皮瓣、小腿内侧皮瓣、足背皮瓣、足底内侧皮瓣、废弃肢体的复合组织块及躅趾皮甲瓣。手术在伤后1～5d内进行。结果 术后发生血管危象8例，均行血管探查手术，5例危象解除，3例失败。移植组织的成功率为96．5％（83／86）。随访1～16年，平均7．5年。修复的肢体均保留或恢复了有用的功能，再造拇指功能优良率为87、5％。结论 急诊游离组织移植是实现创伤肢体急诊修复及拇指再造的有效方法。     

背阔肌皮瓣在上肢严重组织缺损的临床应用

目的报道应用背阔肌皮瓣修复严重上肢组织缺损的临床效果。方法对2002年3月-2011年9月收治的28例严重上肢组织缺损,同时创面伴有骨质、肌腱外露或骨缺损潜腔形成、骨髓炎者采用背阔肌皮瓣进行修复。急诊修复17例,其中2例修复组织缺损的同时行屈肘功能重建,1例行伸肘功能重建;5例游离移植背阔肌皮瓣填塞死腔治疗前臂骨髓炎。皮瓣供区创面行植皮或直接缝合。结果术后28例皮瓣成活良好,供区植皮成活良好。术后随访6～30个月,皮瓣外形、创面闭合及患肢功能改善满意。其中1例屈肘功能重建术后肌力恢复至M3＋,另1例术后肌力恢复至M3．1例伸肘功能重建术后肌力恢复至M3＋;1例术后出现静脉危象,探查修复后皮瓣坏死约1／4,经扩创植皮后创面闭合：2例于术后1年因皮瓣臃肿行皮瓣修整术。结论背阔肌皮瓣切取方便．对严重上肢组织缺损的创面闭合、骨髓炎的治疗及患肢功能重建疗效满意。     

急诊显微外科修复肢体复杂组织缺损

目的：报道急诊复合组织游离移植和游离组织组合移植修复肢体复杂组织缺损的临床效果。方法：组织移植包括单侧背阔肌肌皮瓣游离移植、带蒂转移，废弃肢体复合组织瓣游离移植，带伸趾肌腱足背皮瓣游离移植，背阔肌肌皮瓣与腓骨组合移植，以及双侧背阔肌肌皮瓣组合移植等。结果：移植组织共３０例，其中完全成活２４例，部分皮肤坏死经换药后愈合５例，失败１例。经８～１８个月随访，所有经修复的肢体均保留或恢复了有用的功能。结论：急诊显微外科修复组织缺损是可行、安全和有效的。     

Indications and outcomes of free tissue transfer to the lower extremity in children: review

Thirty-four free tissue transfers for reconstruction of various tissue defects to the lower extremities were performed in 32 children over a 20-year period (1980 to 1999). Patient ages ranged from 3 to 19 years (mean: 10.8 years). Four donor sites were used: gracilis muscle, latissimus dorsi muscle, iliac crest osteocutaneous, and vascularized fibula. Fourteen patients had tissue defects related to trauma: nine received a gracilis flap; five received a latissimus dorsi flap. Five patients had tissue defects related to malignant tumor resection: three patients with Ewing's sarcoma received free fibulae; one patient with an osteogenic sarcoma received a gracilis flap, and another received an iliac crest osteocutaneous flap. Fifteen patients had congenital anomaly-related tissue defects: five with talipes equinovarus received gracilis flaps; ten with congenital tibial pseudoarthrosis received free fibulae. Vascular outcome was assessed based on the achievement of flap perfusion and post-surgical vascular revisions. Complete flap survival was achieved in 32 cases (85.3 percent); partial flap loss in three cases (8.82 percent); and complete flap loss in two cases (5.9 percent). Early revision surgery for the five partial or failed flaps consisted of debridement and split-thickness skin graft or flap removal. No patients required vascular take-backs or experienced vascular spasm. There were no systemic problems associated with the long and complex surgeries. Functional outcome was assessed based on ambulation, post-surgical complications, and whether the flap served its intended purpose. Ambulation was achieved in all cases. Functional surgical revisions were required in 32.4 percent of cases, and included scar revisions, flap debulking, bone grafts, and pin insertion. The most prevalent morbidity was persistent leg-length discrepancy (35.3 percent of cases). Only one successful flap was unable to meet its intended purpose, as a tibial pseudoarthrosis persisted, despite initial excision and a well-perfused reconstruction. Results show that free tissue transfer is safe and dependable for tissue defects of the lower extremity in children. From the authors' experience, free flaps used for the repair of defects from congenital tibial pseudoarthrosis have a high vascular success, but also require an extensive rehabilitation course, with only moderate functional success. There was no significant difference between flap surgeries performed immediately, intermediately, or late after trauma. These procedures have a wide range of indications and, despite the need for surgical revision and an extensive rehabilitation course, functional and vascular success can be achieved.     

Use of ultrasonography to evaluate muscle thickness and blood flow in free flaps

The purpose of this study was to investigate the common belief that a microvascular transfer of a non-innervated free muscle flap loses muscle bulk over time. Sixteen patients (latissimus dorsi = 8, rectus abdominis = 7, and gracilis muscle = 1) were evaluated an average of 41 months after free flap transfer. Latissimus dorsi and lower extremity flaps displayed significantly more swelling than the other flaps. Flap bulk was measured by ultrasound. The mean thickness of upper extremity flaps was 10.3 ± 1.8 mm (control muscles 11.8 ± 2.8), lower-extremity 14.5 ± 3.7 mm (control muscles 10.9 ± 0.7), latissimus dorsi 14.3 ± 2.2 mm (control muscles 10.3 ± 0.8, P = 0.018), and rectus abdominis 11.2 ± 1.2 mm (control muscles 12.4 ± 1.9). Color Doppler ultrasonography was used to detect the pedicles of the free flaps and also to measure the peak velocity of blood flow intramuscularly and in the pedicles. In the upper extremities (n = 5) the pedicles could be found in only 20% of cases whereas in the lower extremities (n = 11) 91% of pedicles were located. (P = 0.013). Peak flow within the free flaps was significantly higher in the lower extremity (50% of the peak flow of the common femoral artery) than in the upper extremity (5% of the peak flow of the common femoral artery, P = 0.013). This study demonstrated that non-innervated free muscle flaps in the extremities maintain the original muscle thickness, although lower extremity and latissimus dorsi flaps have a trend to be thicker. Most pedicles of free muscle flaps in the upper extremities could not be located by ultrasound. However, flaps in the lower extremities most often have patent pedicles and also more vigorous intramuscular blood flow. © 1995 Wiley-Liss, Inc.     

背阔肌肌皮瓣移植急诊修复肢体软组织缺损

１９９１年４月～１９９４年８月，急诊治疗１０例肢体大面积损伤伴骨骨各、肌腱裸露患者，采用带血管蒂背阔肌肌皮瓣移位修复１例，游离背阔肌肌皮瓣移植修复６例，游离双侧背阔肌肌皮瓣组合移植修复３例。移植肌皮瓣完全成活６例，远端皮肤部分坏死３例，大部分皮肤坏死１例，但肌瓣均全部成活。有２例发生轻微感染，换药后愈合。介绍了手术方法，讨论了手术适应证及急诊修复创面的优点等。     

部分背阔肌皮瓣游离移植修复前臂背侧组织缺损并重建伸指功能

目的 报告应用部分背阔肌皮瓣游离移植修复前臂背侧复合组织缺损,并重建伸指功能的手术方法.方法 对11例因外伤致前臂背侧大面积复合组织缺损的患者,采用保留内侧部分背阔肌及胸背神经内侧支的部分背阔肌皮瓣游离移植修复,将皮瓣中胸背神经近端与受区桡神经深支或指总伸肌肌支缝合,背阔肌远端腱膜修复2～4指指总伸肌.皮瓣切取面积为21 cm×9 cm-27 cm×13 cm.结果 术后11例肌皮瓣全部存活,3例因皮瓣臃肿再次行皮瓣、肌皮瓣修整术,2例指伸肌腱松弛再次行肌腱紧缩术.术后2例失访,9例获得6个月至3年的随访,其中指伸肌力恢复至Ⅲ级2例、Ⅳ级6例、V级1例,肢体功能大部分恢复且外形满意.按中华医学会手外科学会上肢功能评定标准评定:优2例,良5例,可2例;优良率为77.8%.结论 应用游离部分背阔肌皮瓣修复前臂背侧复合组织缺损并重建伸指功能可取得较好的临床疗效,同时供区保留了部分背阔肌的功能.     

Latissimus dorsi flap coverage of soft tissue defect following below-knee amputation: emphasis on flap design and recipient vessels

High-energy trauma to the lower extremity often results in amputation of the limb. For maximal preservation of limb length during amputation, free tissue transfer is often necessary. In this study, we report our experience of stump coverage using latissimus dorsi musculocutaneous flaps with an emphasis on flap design and recipient vessels. Between January 2005 and September 2010, twelve patients with severe traumatic injuries to the lower leg underwent below-knee amputations with stump coverage using latissimus dorsi free flaps. The primary and secondary cases were approached differently regarding the flap design and recipient vessels. All flaps survived completely. There were 8 primary cases and 4 secondary cases. In the primary cases, the anterior tibial artery was used as the recipient vessel in 6 cases, and in 2 cases, the descending geniculate artery was used. In the secondary cases, the descending geniculate artery was used in all cases. There were two cases of ulceration on the grafted non-weight-bearing site, but after the usage of collagen–elastin artificial dermis, no ulcerations were seen. The latissimus dorsi musculocutaneous flap is the most feasible option for coverage of amputation stumps. In flap design, the width of the skin paddle must match the anteroposterior diameter of the defect at the stump. The latissimus dorsi muscle must sufficiently wrap the bony stump for padding. We recommend using the anterior tibial artery as a recipient vessel in primary cases, and the descending geniculate artery in secondary cases.     

Treatment of radiation necrosis of skin, muscle and bone in oncology

Following the wide excision of radiation necrosis, the treatment of these lesions has been transformed by the use of the myocutaneous flap technique. The most widely used, flaps are latissimus dorsi flaps for chest wall, subclavicular defects, pectoralis major flaps for defects of the neck and lower part of the face, fascia lata flaps to treat lesions of the groin and lower abdominal wall, gracilis flaps for perineal defects, gluteus maximus flaps for the ischial and sacral region. Due to their good blood supply and their thickness, they can be used to repair large defects and they ensure very good protection against infection. Omentum can be useful when a myocutaneous flap cannot be performed or in association with this flap. Good cosmetic results can be obtained with free myocutaneous flaps for lesions located on the head or on the limbs. Such flaps require micro vascular anastomoses.     

Emergency free tissue transfer

The authors report the use of acute free flaps in head, upper and lower limb injuries. The series includes 9 clinical cases, 2 latissimus dorsi muscle and 2 fasciocutaneous radial forearm flaps for coverage and 1 flow-through cephalic antebrachial dermal venous flap for coverage and venous drainage and 4 flow-through fasciocutaneous radial mid-forearm flaps for coverage and revascularisation of the ischaemia extremities. There were no postoperative infections and no failures, confirming the reliability of this concept.     

Customized reconstruction with the free anterolateral thigh perforator flap

From April of 2003 through September of 2006, 70 free anterolateral thigh (ALT) flaps were transferred for reconstructing soft-tissue defects. The overall success rate was 96%. Among 70 free ALT flaps, 11 were elevated as cutaneous ALT septocutaneous vessel flaps. Fifty-seven were harvested as cutaneous ALT myocutaneous "true" perforator flaps. Two flaps were used as fasciocutaneous perforator flaps based on independent skin vessels. Fifty-four ALT flaps were used for lower extremity reconstruction, 11 flaps were used for upper extremity reconstruction, 3 flaps were used for trunk reconstruction, and 1 flap was used for head and neck reconstruction. Total flap failure occurred in 3 patients (4.28% of the flaps), and partial failure occurred in 5 patients (7.14% of the flaps). The three flaps that failed completely were reconstructed with a free radial forearm flap, a latissimus dorsi flap and skin grafting, respectively. Among the five flaps that failed partially, three were reconstructed with skin grafting, one with a sural flap, and one with primary closure. The free ALT flap has become the workhorse for covering defects in most clinical situations in our center. It is a reliable flap with consistent anatomy and a long, constant pedicle diameter. Its versatility, in which thickness and volume can be adjusted, leads to a perfect match for customized reconstruction of complex defects.     

应用瓦合式游离背阔肌肌皮瓣修复面中部肿瘤切除术后洞穿性缺损

目的：探讨应用瓦合式游离背阔肌肌皮瓣修复面中部皮肤恶性肿瘤切除术后洞穿性缺损的方法。方法：对下睑、内眦等面中部复发肿瘤进行扩大根治切除。对于切除肿瘤后形成的洞穿性缺损,应用瓦合式游离背阔肌肌皮瓣进行修复。结果：应用瓦合式游离背阔肌肌皮瓣修复面中部皮肤恶性肿瘤切除术后洞穿性缺损9例,肌皮瓣全部成活,外形良好。术后半年复查未见局部复发。3例患者于术后半年接受皮瓣去脂术。结论：应用瓦合式游离背阔肌肌皮瓣修复面中部皮肤恶性肿瘤切除术后洞穿性缺损成功率高,可达到功能和外形同时修复的效果。     

手部复杂组织缺损的急诊显微外科修复

目的 探讨应用显微外科技术急诊一期修复手部复杂组织缺损的手术方法及临床效果，方法 自2000年1月至2005年8月，对手部复杂组织缺损的49例，应用再植、再造、游离皮瓣或组合皮瓣技术进行急诊一期修复重建，其中手部小组织块再植与再造21例，再植组合吻合血管的皮瓣移植15例，再植同时进行再造并组合皮瓣移植8例，多指组合再造联合皮瓣移植5例。吻合血管的游离皮瓣移植包括股前外侧皮瓣、背阔肌皮瓣、足背皮瓣、足内侧皮瓣及足底内侧皮瓣等。结果 除1例冉植手指坏死外，其余皮瓣及再植与再造手指全部成活。创口一期愈合45例，二期愈合4例。随访6个月～3年，手部功能及修复部位外形恢复良好，按中华医学会手外科学会上肢部分功能评定试用标准，优良率为85．7％．结论 应用显做外科技术修复手部复杂组织缺损具有疗程短、功能效果好的优点，根据缺损部位、范围以及术者的技术水平，在急诊再植与再造的同时组合不同的显微外科皮瓣或组织瓣进行一期修复，可获得理想的临床效果。     

Free-tissue transfer in plastic surgery (emergencies excluded). Apropos of a 10-year experience]

Over a period of ten years the authors have performed 176 elective free tissue transfers. Flaps used were 99 latissimus dorsi, 46 chinese forearm flaps, 12 fibula, 6 toes, 5 omentum, 4 parascapular, and 4 others flaps. Recipient sites were lower limbs in 106 cases, head and neck in 50 cases, forearm and hand in 13 cases, thorax, abdomen, and buttocks in 7 cases. The overall failure rate was 5.7 per cent. Analysis of these failures taught us some original principles. Among these principles, the risk of vascular thrombosis is very important when a venous graft is performed on one end of the artery of a low blood flow flap such as chinese forearm or fibular flaps when the other end of this artery is ligated. When such a graft is done we think that the best way to avoid thrombosis is to suture the other end of the flap artery to a recipient vessel which can be even the distal end of the flap vein itself. Pretransfer expansion of a latissimus dorsi flap was successfully performed in 4 cases. Migrating semi-free flap method, in which the vascular pedicle of a flap is temporarily sutured to recipient vessels located far from the defect, was performed in 12 cases, in most cases on lower limbs where this method constitutes a modern variant of the cross-leg. Folded free-flap method, in which a flap is folded on itself during some days before excision of the recipient site, was performed in 14 cases. Analysis of this series also allowed us to review in detail our usual strategic principles for vascular anastomoses in the head and lower limbs.     

Composite scapular flap for reconstruction of complex humeral tissue loss: a case report

We report a case of complex reconstruction after traumatic loss of bone and muscle of the upper third of the humerus. A composite flap using the lateral border of the scapula and the pediculated latissimus dorsi muscle was used. The latissimus dorsi flap covered the bony reconstruction and enabled elbow flexion. Outcome was very satisfactory at three years follow-up. The lateral border of the scapula is rarely used for bony reconstruction of the humerus. Free composite flaps with the lateral portion of the scapula and the latissimus dorsi muscle have been used to reconstruct tissue loss of the lower limb. We were unable to find another published case where this composite pediculated flap was used for the upper limb.     

应用带少许肌袖的背阔肌肌皮瓣修复下肢软组织缺损

目的探讨应用带少许肌袖的背阔肌肌皮瓣移植修复下肢软组织缺损的临床效果。方法2000年6月～2006年12月,应用带少许肌袖的背阔肌肌皮瓣移植修复8例下肢软组织缺损患者。男6例,女2例;年龄25～69岁。其中创面位于足跟3例,足背2例,胫前2例,右小腿鳞癌1例。软组织缺损范围10cm×7cm～18cm×12cm,皮瓣切取范围15cm×8cm～22cm×15cm。结果术后6例皮瓣成活;1例术后2h出现皮瓣血管危象,经探查重新吻合静脉,植皮后成活;1例胫前创面因骨髓炎感染,经引流后皮瓣成活。创面及供区均期愈合。8例患者获随访3～12个月。皮瓣外形满意,无臃肿。供区功能不受影响。结论应用带少许肌袖的背阔肌肌皮瓣移植是修复大面积肢体软组织缺损较为理想方法之一。     

Reconstruction of soft tissue and bone defects in lower extremity with free flaps

This article reports our experiences treating soft tissue and bone defects in the lower extremity with free flaps. One of the most common causes for lower extremity wounds are high-energy injuries. These kinds of injuries contain soft tissue and bone defects beyond neurovascular complications. The rate of infection and nonunion is very high in these injuries. Between 1988 and 1996, we applied 33 flaps to 28 patients. The numbers and kinds of the free flaps are as follows: 12 latissimus dorsi, nine radial forearm, seven lateral arm, three vascularised fibula grafts with skin, one gracilis, and one medial plantar flap. Three free flaps were lost (12%). The success rate is 88%. The advantage of free flaps is that they allow the reconstruction of the large defects in one-session operations. Thus, they decrease the rate of infection and increase that of nonunion. The patient returns to his active life at an earlier stage. © 1998 Wiley-Liss, Inc. MICROSURGERY 18:176–181 1998     

Primary maxillary reconstruction after cancer excision

Eleven patients who underwent primary maxillary reconstruction following cancer excision are presented. Low partial and high partial maxillectomies are recognised, as are the more radical excisions. Skin grafts, a temporalis muscle flap, free radial forearm flaps, single paddle, double paddle and triple paddle latissimus dorsi free flaps and a latissimus serratus, rib composite flap have been utilised. Oncological aspects and secondary reconstructive problems are detailed. Six patients have survived; three have died of recurrent disease and two of myocardial infarction some time after surgery.     

Versatility of the pedicled thoracodorsal artery perforator (TDAP) flap in soft tissue reconstruction

For the last decades, the latissimus dorsi skin-muscle flap has contributed to the efficient reconstruction of the loss of skin cover (especially in breast surgery) and in long-distance tissue defects. Unfortunately, the nonuse of such an important muscle as the latissimus dorsi for the patient, as well as the resulting thickness of the flap after reconstruction, has turned it into a second choice flap. However, this flap is still indicated in the reconstruction of areas which need a great amount of cutaneous and muscular tissue. The appearance of the perforator flaps and, specifically, thoracodorsal artery perforator (TDAP) flap, has meant a radical change in relation to lower morbidity of the donor site, thus highly ranking the use of these flaps in the reconstruction for similar defects. The aim of this publication is to present our experience with the pedicled TDAP flap in a series of 17 different cases. Of those, there were 14 cases of mammary reconstruction after sparing surgery, 2 cases of axillary reconstruction following severe recurrent hidradenitis, and a case of extensive substance loss in a patient's upper limb following a severe crush injury.