The prefabricated superficial temporal fascia flap in noma surgery

In a series of 15 patients with facial deformity due to noma, the authors report their experience with a prefabricated superficial temporal fascia (PTF) flap performed in an African hospital. The operative method has been simplified as compared with methods described by others. In the first stage, the temporal fascia is skin grafted and the wound is closed over the graft. After only 1 week, this prefabricated flap is harvested. One of 15 flaps was discarded because of damage to the vascular pedicle. Later this situation was prevented by including a rim of deep temporal fascia in the flap. All other 14 flaps, including four osteocutaneous flaps and one flap with double sided skin grafts, survived and healed without major complications at both the recipient and the donor site. The prefabricated temporal fascia flap is a pliable and well vascularized flap with a reasonably long vascular pedicle, which can be used successfully, even under suboptimal conditions. Received: 11 November 1999 / Accepted: 20 January 2000     

指背筋膜蒂岛状皮瓣修复同指指腹皮肤软组织缺损

目的 探讨一种新的筋膜蒂岛状皮瓣修复指腹皮肤软组织缺损的有效方法。方法 于指背形成筋膜蒂岛状皮瓣并移转至指腹创面。结果 临床已应用6例，皮瓣全部成活。结论 指背筋膜蒂岛状皮瓣可以安全、简便地修复同指指腹的创面。     

指背筋膜瓣或筋膜蒂岛状皮瓣的临床应用

目的 报道8例14指应用指背筋膜瓣或筋膜蒂岛状皮瓣修复手指皮肤缺损的临床治疗效果.方法 采用指背筋膜瓣方法修复3例3指,指背筋膜蒂岛状皮瓣移植5例11指,皮瓣面积：2.0 cm×2.0 cm～4.0 cm×3.0 cm.结果 术后皮瓣全部成活,皮瓣质地及外形好,患指伸指功能得到重建,功能恢复满意,供区功能基本无影响.结论 指背筋膜瓣或筋膜蒂岛状皮瓣是修复手指指背皮肤缺损的较好方法.     

吻合血管的阔筋膜瓣移植修复足部软组织缺损

目的总结吻合血管的阔筋膜瓣移植修复足部软组织缺损的临床应用结果。方法修复8例足部软组织缺损，阔筋膜瓣的血管蒂与受区的血管行端端吻合。结果阔筋膜瓣术后全部成活，取得了满意的临床效果。1例阔筋膜瓣术后发生远端尖部小片植皮坏死，经交换敷料逐渐自行愈合。供区没有发生明显的功能障碍。结论阔筋膜瓣以旋股外侧动脉降支为血供，血运丰富、血管解剖恒定、血管蒂长以及切取容易，而且较薄，适宜修复足部软组织缺损。     

The radial forearm flap without fascia and other refinements

The radial forearm flap is generally classified as a fasciocutaneous flap. The skin of the forearm is, however, supplied by branches from the radial artery which pierce the fascia of the forearm to course and branch subcutaneously. We have used the flap as a skin flap in 300 cases over 11 years. It is not necessary to take the fascia with the flap. Two other refinements of the forearm flap, also used over the past 11 years, are described. The venous drainage of the flap is simplified by utilising the usual anatomical confluence of deep and superficial veins at the elbow. Secondly, draping a large loop of pedicle in the neck during intraoral reconstruction enables a larger calibre vein to be used for the anastomosis, thus increasing its reliability.     

阔筋膜张肌球拍形岛状肌皮瓣

目的 探讨根据肌肉解剖形状和血管分布,将阔筋膜张肌皮瓣设计成上窄下宽,呈球拍形的岛状肌皮瓣的可行性。方法 应用阔筋膜张肌球拍形岛状肌皮瓣,修复中下腹壁大块软组织缺损4例。结果 3例全部成活,1例岛状肌皮瓣远端有小块皮肤坏死,经移植皮片而痊愈。结论 阔筋膜张肌球拍形岛状肌皮瓣是可行的,且皮瓣较窄 的上段似一个延长的蒂,使之移转灵活,而皮瓣供区的上侧面又可直接缝合,从而减少了用来修复皮瓣供区创面所需皮片的面积。     

The distally planned lateral arm flap in hand reconstruction

The lateral arm flap is a versatile free flap with straightforward dissection and low donor site morbidity. However, it presents some drawbacks: the vascular pedicle is relatively short (2-6 cm), and the flap is rather thick. Further surgery is often needed to decrease flap volume. An anastomotic network between the posterior collateral radial artery and the recurrent radial artery allows the skin paddle to be safety located over the epicondylar region and proximal forearm. This modification increases pedicle length up to 100% and limits the amount of subcutaneous fat. A series of eight consecutive distally planned lateral arm flaps used for hand reconstruction is presented. The medical records and operative notes were reviewed. Six patients were reviewed. The minimum follow-up was six months. Flap size ranged from 11 x 5.5 cm to 23 x 7 cm (average 15 x 6 cm), pedicle length ranged from 8 to 10 cm (average 9 cm), no venous grafts were needed for the microanastomosis. The mean flap harvesting time was 50 minutes. All donor sites were closed primarily. All flaps survived totally despite postoperative arterial thrombosis in one case that was salvaged by a skin graft over the surviving fascia. To date, no further surgery was needed to debulk the flaps. The donor site scar was enlarged in one patient. Elbow mobility was unaffected by surgery. Patient self-assessment of appearance of both reconstruction and donor site showed a high satisfaction rate. The distally planned lateral arm flap presents decreased bulk and a longer pedicle than the classical lateral arm flap with no added technical difficulties.     

颞肌筋膜瓣与全厚皮片移植修复下睑凹陷性畸形

目的 探讨颞筋膜瓣或颞肌筋膜瓣与自体全厚皮片移植，在下睑凹陷性瘢痕畸形修复中的应用效果。方法 设计以颞浅动脉为蒂的颞筋膜瓣，对伴眶下壁骨缺损者同时行以颞浅、深动脉为蒂的颞肌筋膜瓣，并取耳后全厚皮片移植联合矫正下睑凹陷性畸形。结果 8例患者，术后组织瓣及皮片成活良好，凹陷处填充效果满意。随访6个月至1年，睑外翻矫正，瘢痕不显，颞部供区毛发生长良好。结论 应用颞筋膜瓣或颞肌筋膜瓣与全厚皮片移植，联合矫正下睑凹陷性畸形的方法，具有操作简便。且无明显的供区损害的特点，是修复下睑凹陷性瘢痕畸形较理想的方法。     

吻合血管的阔筋膜瓣移植修复手指软组织缺损

目的 总结吻合血管的阔筋膜瓣移植修复手指软组织缺损的临床应用结果.方法 修复8例手指软组织缺损,行一期阔筋膜瓣移植加中厚网状游离植皮,供区直接缝合,阔筋膜瓣的血管蒂与受区的血管行端端吻合.结果 1例术后发生远端小片植皮坏死,经更换敷料逐渐自行愈合.7例术后经过顺利,全部成活,取得了满意的治疗效果.结论 该筋膜瓣以旋股外侧动脉降支为血供,血运丰富、血管解剖恒定、血管蒂长易于切取,而且较薄,适宜修复手指软组织缺损.     

阔筋膜瓣移植修复手背软组织缺损

目的:采用吻合血管的阔筋膜瓣移植修复手背软组织缺损,观察其临床应用效果。方法:修复12例(男8例,女4例)手背软组织缺损;右手7例,左手5例;年龄16~46岁(平均30岁)。缺损范围4 cm×6 cm~8 cm×15 cm,切取阔筋膜瓣范围5.0 cm×7.5 cm~8 cm×16 cm。行Ⅰ期中厚网状游离植皮,供区直接缝合,阔筋膜瓣的血管蒂与受区的血管行端端吻合。结果:1例术后发生远端尖部小片植皮坏死,经更换敷料逐渐自行愈合。11例术后经过顺利,全部成活,取得了满意的临床效果。结论:该筋膜瓣以旋股外侧动脉降支为血供,血运丰富,血管解剖恒定,血管蒂长以及切取容易,而且较薄,适宜修复手背软组织缺损。     

Reconstruction of distal phalanx defect with microsurgical fascia latae flaps combined with rib and skin graft]

OBJECTIVE: To evaluate the clinical application of microsurgical fascia latae flaps combined with rib and skin graft for reconstruction of the distal phalanx defect. METHODS: The phalanx wounds were sutured together like syndactyly. The autologeous rib was revised to repair the bone defect of distal phalanx. The fascia latae flap was used to cover the bone exposure with microvascular anastomoses and resurfaced by a meshed split-thickness skin graft. RESULTS: 5 cases were treated successfully. The fascia latae flaps were all survived with only skin graft necrosis at the distal end in one case. It was healed spontaneously. CONCLUSIONS: The fascia latae flap is nourished by the desending branch of the lateral circumflex femoral artery. The flaps has a good blood supply and can be easily obtained with a long vascular pedicle. The flap is ideal for the reconstruction of distal phalanx defect when combined with autologeous rib implant and skin graft.     

Reconstructive surgery of roller injuries of the hand.

Eleven patients with roller injuries to the upper extremity are described. Nine were treated initially; two were referred for treatment within 3 weeks after injury. Six patients were injured by kneading machines in bakeries, two by hot dry-cleaning mangles, two by industrial rolling machines, and one by a transmission belt which acted as a roller. The tissue damage depends on (1) the space between the rollers, (2) the speed of the rollers, (3) the hardness of the rollers, (4) the temperature of the rollers, and (5) how violently the patient attempts to withdraw the entrapped part. Lesions may be closed, consisting of a compression of the soft tissues, which may result in skin necrosis, or a tearing and separation of the skin and soft tissues away from the deep fascia (more common on the dorsal surface of the hand), or destruction of skin and deep tissue because of burns. Closed injuries usually respond to conservative care, although decompression sometimes is necessary. Experience gained from treating these 11 patients indicates that the inexperienced surgeon often tries to replace distally based flaps. Such flaps usually die and predispose to deep infection. If the condition of the wound permits, primary skin grafts should be applied; but if the bed is of poor quality, skin grafting can be delayed for several days. If it is necessary to protect exposed deep structures, they should be covered with immediate pedicle flaps. It is better to use skin from an uninjured area for a free skin graft than to use the avulsed skin as a graft. Distant flaps should be used if secondary reconstruction is anticipated. In circumferential skin loss, a combination of pedicle skin and free skin grafts is better than encircling the part with a pedicle flap. The thumb and radial fingers should be preserved, but the ulnar fingers are expendible in severe injuries. By amputating parts of fingers, reconstruction often is simplified.     

上臂内侧皮瓣血管的解剖学研究

目的:本研究旨在通过对上臂内侧皮瓣深筋膜浅层以上血管的解剖学研究,为临床应用上臂内侧扩张皮瓣提供理论指导。方法:新鲜成人上肢标本10侧,左右各半,乳胶灌注血管。四倍放大镜下由浅入深进行解剖,观察浅筋膜层内血管的吻合情况、吻合支的数量及皮动脉穿出深筋膜的位置。结果:上臂内侧自深筋膜浅层平面发出的皮动脉8～9支,各皮动脉于深筋膜浅层内发出分支沿纵行方向相互吻合。上臂皮瓣的中轴部位即内侧肌间隔区域吻合支最为丰富,其次为上臂内侧偏后部分。每侧肢体均有2～5支明显的贯串上臂全长的吻合支,多位于皮瓣的中部及偏后侧部位。皮动脉穿出点集中在臂内侧肌间隔区域,最远分支距肘横纹(3.47±1.50)cm,近端分支距腋窝横皱襞距离(1.64±1.22)cm。结论:上臂内侧皮瓣血供介于轴型皮瓣与任意型皮瓣之间,切取时长宽比例超过任意型皮瓣。皮瓣为双向供血,无论以近端为蒂还是以远端为蒂切取皮瓣均是安全的。以内侧肌间隔为轴线,沿深筋膜浅层设计顺行或逆行皮瓣血供均可靠,切取皮瓣安全,如需扩大切取皮瓣,向后扩展延伸比向前扩展血供更可靠。皮瓣制作时蒂部尽可能置于肌间隔区域,蒂宽约4cm。以近端为蒂时,扩张器剥离腔隙近端距腋窝横皱襞需超过3cm,远端为蒂时,扩张器剥离腔隙远端距肘横纹需超过5cm。     

Optimization of microsurgery: improved coverage of the latissimus dorsi vascular pedicle with vascularized serratus fascia

The latissimus dorsi free flap is a workhorse for extremity reconstruction. One of its benefits is a long vascular pedicle that spans the zone of injury. However, it may be difficult to adequately cover this pedicle. Direct closure may be too tight, and skin grafting over the pedicle risks exposure if graft take is poor. We report a technique in which the serratus branch of the thoracodorsal artery and its overlying fascia are harvested en bloc with the thoracodorsal artery and latissimus muscle. This provides 2 flaps on a common pedicle that can easily be rotated to allow positioning and insetting. We successfully used this technique in the reconstruction of both upper and lower extremities. The serratus fascia provides excellent padded covering and is a good bed for skin grafting. The versatility of this hybrid flap will allow its use in a range of complex reconstructive procedures.     

Ulnar versus radial forearm flap in head and neck reconstruction: an experimental and clinical study.

BACKGROUND: To consider the pros and cons of the microvascular ulnar forearm flap compared with its radial counterpart, this study compares the use of these two flaps for head and neck reconstruction. METHODS: In 75 patients, 51 ulnar and 24 radial forearm flaps were used. Both groups were compared regarding flap dissection, suitability of the flap for the recipient region, complication rate, and secondary morbidity in the donor region. Furthermore, in 40 healthy volunteers, the thickness of the subcutaneous tissue layer was measured by use of ultrasonography. RESULTS: Flap survival rate, respectively wound healing, in the recipient region showed no differences. Clinical and experimental results demonstrated a thinner subcutaneous layer in the ulnar aspect of the forearm. Compared with its radial equivalent, closure of the ulnar donor side by skin grafting resulted in a significantly lower complication rate. CONCLUSIONS: The ulnar forearm flap is favored because of the less hairy skin of the ulnar forearm region, the thinner layer of subcutaneous tissues, and the more conveniently located donor area. The ulnar forearm pedicle is long compared with alternative transplants but shorter than the radial equivalent.     

改良桡动脉穿支皮瓣在修复额面部组织缺损中的应用

目的 探讨改良桡动脉穿支皮瓣在修复额面部中小面积缺损中的临床应用.方法 以桡动脉腕上皮支动脉和桡动脉伴行静脉为蒂.通过筋膜蒂营养的前臂近端桡侧皮瓣(最大面积10 cm×5 cm),游离移植修复额面部肿瘤切除后的组织缺损10例.结果 修复额部缺损6例,面颊都缺损4例,术后皮瓣全部存活,经随访6～12个月后行皮瓣修薄整形术.10例病例经8～18个月随访,平均随访11.3个月,其中7例于术后6～9个月进行二次整形.所有病例皮瓣柔软,瘢痕不明显,皮色与面颊部基本接近,皮瓣两点分辨率在20～40mm.结论 改良的前臂桡动脉穿支皮瓣是修复额面部中小面积缺损的主要方法之一.     

吻合血管的阔筋膜瓣游离移植及皮片修复手部创伤性缺损

目的　考察应用吻合血管的阔筋膜瓣游离移植 ,联合皮片修复手部软组织缺损的临床效果。方法　共行手术 8例 ,切取的阔筋膜瓣最大 6cm× 1 6cm ,最小 3cm× 8cm。结果　移植的阔筋膜瓣和皮片全部成活 ,取得了预期的效果。结论　以旋股外侧动脉降支为血管蒂的阔筋膜瓣 ,血管解剖恒定 ,蒂长 ,切取容易 ,且瓣较薄 ,适宜修复手部软组织缺损     

A Comparison of Full and Split Thickness Skin Grafts in Radial Forearm Donor Sites

To formally evaluate the functional and aesthetic outcomes between full versus split thickness skin graft coverage of radial forearm free flap donor sites. A retrospective chart review of 47 patients who underwent pedicled or free radial forearm free flap reconstruction from May 1997 to August 2004 was performed. Comparisons were made between patients who had donor site coverage with split thickness skin grafts (STSG) or full thickness skin grafts (FTSG). There was no statistically significant difference between the STSG and FTSG in the number of post-operative dressings, incidence of tendon exposure, time to healing at the skin graft donor site, and time to healing at the skin graft recipient site. The questionnaire data showed there was a trend toward higher scores with the radial forearm scar aesthetics and satisfaction in the FTSG group. Full thickness skin graft coverage of radial forearm free flap donor site is superior to split thickness skin graft coverage in terms of aesthetic outcome, and has no statistically significant difference in terms of tendon exposure, time to healing at the skin graft donor site, time to healing at the skin graft recipient site, or post operative pain.     

Application of free tissue transfers to the foot

During the past five years we have used three sources of free tissue transfers in 26 patients to reconstruct defects of the ankle and dorsum, hind, mid- and forefoot, defects poorly or unamenable to traditional reconstructive methods. These included free muscle transfers covered with a skin graft, temporoparietal fascia also covered with a graft, and radial forearm skin or fascia. In addition, six complex defects were reconstructed with composite tissue free transfers, usually tendinocutaneous flaps. There was one partial flap loss. All were successful in both healing the defect and in providing functional restoration, except in the forefoot. From an analysis of these cases, we have developed indications for various transfers based on the functional needs of the area involved and donor site requirements.