ObjectiveTo explore the effectiveness of pedicled thoracoacromial artery perforator (TAAP) flap for pharyngocutaneous fistula repair after total laryngectomy and radiotherapy.
MethodsBetween February 2012 and January 2015, TAAP flap was used to repair pharyngocutaneous fistula after total laryngectomy and radiotherapy in 8 patients. The eight patients were male, aged from 46 to 72 years (mean, 51.8 years). The disease duration was 8-62 months (mean, 27.5 months). Fistula size ranged from 4.0 cm×2.5 cm to 6.0 cm×4.0 cm and the skin defect size ranged from 4.0 cm×3.0 cm to 6.0 cm×4.0 cm. The flap size ranged from 7.0 cm×4.0 cm×0.3 cm to 9.5 cm×6.0 cm×0.5 cm. The length of pedicle was (8.3±0.5)mm. The distance from pivot point of flap to central point of recipient site was (94.5±1.9) mm.
ResultsAll 8 flaps survived and all incisions healed smoothly. The hospitalization time was 7-14 days (mean, 9.6 days). The barium meal examination showed no fistula or stenosis. The patients were followed up 8-42 months (mean, 28.5 months). During follow-up, the neck appearance was good, and no fistulas or stenosis occurred. Only linear scars were observed at the donor sites, pectoralis major muscle function was normal in all patients.
ConclusionPharyngocutaneous fistula should be repaired as early as possible after total laryngectomy. TAAP flap is suitable for the reconstruction of pharyngocutaneous fistula after total laryngectomy.
Objective To investigate the anatomic variations of the perforator vessels of anterolateral thigh (ALT) flap and the clinical indications. Methods From March 1985 to August 2004, the anterolateral thigh flapgraft was performed in 112 patients. The clinical data were analyzed. There were 67 males and 45 females, aging from 5 to 65 years with an average of 38.5 years. According to recipient site condition, four methods of flap harvesting were as follows:① 78 received free fasciocutaneous flaps;② 22 received free adipofascial flaps;③ 5 received pedicled island fasciocutaneous flaps; ④ 7 received pedicled reverse-flow island fasciocutaneous flaps. Facial, neck, breast, extremityjoint, plantar, and perineum defects were repaired and the effectiveness and donor site morbidity were evaluated. Results The blood supply of ALT flap came from the descending branch or transverse branch of the lateral circumflex femoralartery. The skin vessels were found to be septocutaneous perforators in 33% of flaps and to be musculocutaneous perforators in 77% of flaps. Of 112 flaps, 107 survived completely, the survival rate was 95.6% with little donor site morbidity. Conclusion ALT flap is a versatile softtissue flap. If refined to perforator flap, it can achieve better results in reconstructing defect and minimizing donor-site morbidity.
Objective To investigate the accuracy of color Doppler ultrasound (CDU) and CT angiography (CTA) in the preoperative evaluation of perforator vessels in free posterior interosseous artery perforator (PIAP) flaps. Methods Between January 2020 and December 2023, 19 patients with hand skin and soft tissue defects caused by trauma were admitted. There were 11 males and 8 females, with a median age of 45 years (range, 26-54 years). The interval between injury and admission was 5-11 days (mean, 7.2 days). The skin and soft tissue defects were located on the dorsum of the hand in 8 cases and on the fingers in 11 cases. The size of defect ranged from 4.0 cm×2.5 cm to 7.5 cm×3.5 cm. After locating the perforator vessels through CDU and CTA before operation, the free PIAP flaps were designed to repair hand defects, with the size of 4.5 cm×3.0 cm-7.5 cm×4.0 cm. The defects of donor sites were directly sutured. The number and diameter of perforator vessels in the posterior interosseous artery detected by CDU and CTA were compared. The differences in localization of perforator vessels using CDU and CTA and their clinical effects were also compared to calculate the accuracy and recognition rate. During follow-up, the survival of the skin flap was observed, and the Vancouver scar scale (VSS) score was used to evaluate the healing of the donor site, while the visual analogue scale (VAS) score was used to evaluate the patient’s satisfaction with the appearance of the skin flap. Results The number and the diameter of PIAP vessels was 5.8±1.2 and (0.62±0.08) mm assessed by CDU and 5.2±1.0 and (0.60±0.07) mm by CTA, showing no significant difference between the two methods (P>0.05). The number, course, and distribution of perforator vessels of the PIAP vessels observed during operation were basically consistent with those detected by preoperative CDU and CTA. Compared with intraoperative observation results, the recognition rates of dominant perforating vessels by CDU and CTA were 95.0% (18/19) and 89.5% (17/19), respectively, and the accuracy rates were 100% (19/19) and 84.2% (16/19), with no significant difference between the two methods (P>0.05). All flaps survived after operation, and all wounds and incisions at donor sites healed by first intention. All patients were followed up 6-13 months (mean, 8.2 months). At last follow-up, the skin flaps had elasticity and soft texture, with the patient satisfaction VAS score of 9.2±0.8. The donor sites had no obvious scar hyperplasia with the VSS score of 11.7±0.9. Conclusion CDU and CTA accurately identify the dominant perforator vessels and provide reliable information for vessel localization, facilitating precise flap harvesting and minimizing donor site injury. However, CDU offers superior visualization of distal end of perforator vessels in the forearm compared to CTA.
Objective To evaluate 5 different kinds of perforator flaps for repairing soft-tissue defects and reconstructing the breast and tongue after the breast or the tongue resection.Methods From June 2005 to June 2006, 31 free or pedicled perforator flaps were used to repair the softtissue defects or reconstruct the organs in our hospital. The free anterolateral thigh flaps (ALT) were used in 16 cases to repair the soft-tissue defects in the head and neck after resection of malignant tumors, including malignant melanoma in 9, squamous carcinoma in 4, basaloma in 2 and malignant fibrous histocytoma in 1.Among them, 3 ALT flaps were used for reconstruction of the tongue after resection of the tongue (3/4); the maximum area of the flap was 26 cm×15 cm. The deep inferior epigastric perforator flaps (DIEP) were used in 10 cases, and the free transverse rectus abdominis myocutaneous flaps (FTRAM) were used in 2 cases to reconstruct the breast.Secondary reconstruction was performed in9 cases, immediate reconstruction with the skin-sparing mastectomy at the sametime was performed in 3 cases. The bilateral breast reconstruction was performed in 3 cases and the unilateral breast reconstruction was performed in 9 cases. The breast reconstruction was performed in 1 case using the superior gluteal artery perforator flap (SGAP) and the inferior gluteal artery perforator flap (IGAP), respectively. One case had an uncovered bone (6 cm × 4 cm) in the middle andlower parts of the right cnemis, which was repaired by the pedicled local posterior tibial artery perforator flap (PTA,15 cm × 5 cm). The donor sites were sutured directly in 27 cases, the ALT flap in 3 and PTA flap in 1 were covered by the epidermal skin graft. Results The follow-up for 3-6 months revealed that in the 31 cases (33 free flaps, 1 pedicled flap), only 1 had a total necrosis of the transferred ALT flap for the neck defect repair after resection of the neck tumor, which was caused by the venous insufficiency. There was nopartial necrosis in the remaining ALT flaps. There was a partial fat liquefaction in the DIEP flap, and a pain of abdomen in the FTRAM flap. The distal partial necrosis occurred in the pedicled PTA flap (2 cm×1 cm) in 1 case, as a result of the venous insufficiency, which was managed successfully using daily dressings. One SGAP and one IGAP survived. ConclusionAlthough the perforator dissection is difficult and the vascular anatomy is complicated, application of the perforator flaps to repair of the softtissue defects and reconstruction of the organs is still an important step forward becaue of the minimal donor site “cost” and the maximal efficacy.
Objective To provide a comprehensive review for development and existing problems of the perforator flaps. Methods The related home and abroad l iterature concerning perforator flaps was extensively reviewed. Results The perforator flaps are defined as the axial flaps nourished solely by small cutaneous perforating vessels (perforating arteriesand veins), which are exclusively composed of skin and subcutaneous fat. The perforator flaps have the advantages as follows: less injury at donor site, less damage to the contour of the donor site, good reconstruction and appearance of the reci pient site flexible design, and short time of postoperative recovery, which have been widely used in reconstructivesurgery. Conclusion The perforator flaps are the new development of the microsurgery, which usher an era of small axial flaps; However, the controversies of the definition, vascular classification, the nomenclature, and the cl inical appl ication of the perforator flaps still exist, which are therefore the hot spot for future study.
Based on skin elasticity and mobility, V-Y advancement flaps are designed to repair wounds. Traditional V-Y flaps have been limited due to short advancing distance. With the development of perforator flaps and the application of microsurgical techniques, V-Y advancement flaps are gradually transiting from traditional random flaps to axial flaps containing well-known vessels or perforator arteries. The advancing distance of V-Y advancement flaps is significantly increased, and the design forms are gradually flexible and diversified. V-Y advancement flaps are widely used in clinical practice and can be used to repair wounds in almost all parts of the body. This article reviews the clinical application progress of V-Y advancement flaps to further promote its clinical application.
Objective To explore the effect of the intensive CT on the deep inferior epigastric perforator (DIEP) flap design strategy. Methods From June 2007 to March 2008, 7 patients received reconstructive operation of the vertical DIEP flap, among whom there were 5 females with congenital absence of vagina and 2 males with peno-scrotal Paget’s disease,aged 18-62 years old. Before the operation, the intensive CT scans were appl ied to all the petients in search for DIEP. The flaps were designed according to the radiological findings. The scrotum and penis defects were reconstructed in 2 cases and vaginal reconstruction was performed in 5 cases. The flap dimension ranged from 15 cm × 7 cm to 22 cm × 5 cm. The donor site was closed directly. Results A total of 10 ideal perforating branches of all the 7 DIEP flaps were found before the operation, with the diameter of over 1.5 mm. Of the 7 flaps, 4 had 1 perforating branch and the other 3 had 2 perforating branches. All 7 flaps survived completely. The incisions of 6 patients obtained heal ing by first intention. Only 1 patient with Paget’s disease had erosion at the scrotum incision and partial necrosis 7 days after the operation, and then healed after discontinuous dressing change. The incisions at the donor site obtained heal ing by first intension. Two patients complained about draw-off at the lower abdomen on the operated side, which was basically rel ieved at 7 days after the operation. All patients were followed up for 1 to 10 months (4.5 months on average). No operation-related compl ication was observed after operation. Six patients were satisfied with the reconstructive results. Only 1 patient was dissatisfied with the buried pennies and requested a revision. Conclusion The intensive CT scans play an important role in the DIEP flap design. It can not only make the flap safer, but also decrease operation time and improve efficiency.
ObjectiveTo study the digital anatomy and application value of the thoracic dorsal artery based on CT angiography (CTA).
MethodsBetween September 2012 and June 2014, aorta CTA images were chosen from 10 cases (20 sides) undergoing aorta CTA. By using Mimics 17.0 software for three dimensional (3D) reconstruction of image post-processing, the digital vascular anatomical information were obtained after observing and measuring the origin of the thoracic dorsal artery, the number of perforators, type, inner diameter, and pedicle length; and the body surface location of perforator vessel was determined, and then the thoracic dorsal artery perforators tissue flap harvesting was simulated.
Results3D reconstruction images showed that the thoracic dorsal artery originated from subscapular artery, 76 perforator vessels were found, including 32 perforators (42.1%) from the medial branch of the thoracic dorsal artery and 44 perforators (57.9%) from the lateral branch of the thoracic dorsal artery, of which 69 were intramuscular perforators (90.8%) and 7 were direct skin artery (9.2%). The inner diameter of the thoracic dorsal artery was (1.69±0.23) mm, and its pedicle length was (2.12±0.64) cm. The first lateral perforator of the thoracic dorsal artery located at (1.65±0.42) cm above the horizontal line of the inferior angle of scapula and at (1.68±0.31) cm lateral to vertical line of the inferior angle of scapula. The first medial perforator located at (1.43 ±0.28) cm above the horizontal line of the inferior angle of scapula and at (1.41±0.28) cm lateral to vertical line of the inferior angle of scapula. The thoracic dorsal artery perforators flap harvesting was successfully simulated.
ConclusionCTA is a more intuitive method to study the thoracic dorsal artery in vivo, it can clearly display 3D information of the main blood supply artery course and distribution after flap reconstruction, so it can effectively and accurately guide the design of the flap.
Objective To investigate the operative technique and the effectiveness of perforator flaps for the treatment of elderly patients with ischia-sacral ulcers. Methods Between January 2005 and June 2010, 29 elderly patients with ischia-sacral ulcers were treated. There were 16 males and 13 females, aged from 61 to 75 years (mean, 68 years), including 11 cases of degree III and 18 cases of degree IV according to the standard of the National Pressure Ulcer Advisory Panel(NPUAP). The disease duration was from 5 months to 10 years (median, 5.5 years). The size of ulcers ranged from 7 cm × 6 cm to 12 cm × 10 cm. Of them, 8 cases were companied by cerebral vascular disorders, 6 cases by Alzheimer disease, 11 cases by paraplegia, and 4 cases by others. The flap size ranged from 8 cm × 6 cm to 14 cm × 12 cm. The donor sites were sutured directly. Results Distal flap necrosis occurred in 3 cases (10.3%) 2 days after operation and healed after symptomatic treatment, and the remaining flaps survived and wound healed by first intention with first intention rate of 89.7%. The incisions of donor sites healed primarily. Two cases (6.9%) had infection 1 week after operation and 1 case (3.4%) had wound dehiscence 10 days after operation. Twenty-seven patients were followed up 6 months to 5 years (mean, 3 years). Two cases recurred at 1 and 3 years after operation, respectively. One died of infection, and the other healed by debridement and suture. The flaps of other patients had good texture, color, and elasticity. Conclusion As long as the indications are controlled strictly, good effectiveness can be achieved in the treatment of elderly patients with ischia-sacral ulcers by using perforator flaps.
Objective To explore the characteristics and clinical application of the anterolateral thigh flap pedicled with the oblique branch in the intramuscular of lateral circumflex femoral artery. Methods The clinical data of 25 patients with skin and soft tissue defects of extremities admitted between December 2020 and April 2021 were retrospectively analyzed, including 16 males and 9 females, aged 14-75 years, with the median age of 43 years. The defect site included 13 cases of hand, 2 cases of forearm, 2 cases of calf, and 8 cases of foot and ankle. The wound area ranged from 6 cm×4 cm to 35 cm×22 cm. Twenty-four patients with trauma were admitted to hospital immediately after injury, and 1 patient with diabetic foot infection was transferred to the hospital after ineffective treatment in other hospital. Flap surgery was performed from 0 to 56 days (median, 22 days) after admission. A total of 26 thigh flaps were harvested in 25 patients, with unilateral flaps in size of 7 cm×5 cm to 40 cm×10 cm. The type, caliber, and location of the perforating branch were recorded during the operation, and the anatomical characteristics of the oblique branch of the intramuscular trunk were mainly observed. The flap harvesting time was recorded; the flap survival and wound healing time were observed; at last follow-up, XIAO Feipeng et al. flap comprehensive efficacy evaluation table was used to evaluate the effectiveness of flap repair from three aspects of donor site, recipient site, and subjective satisfaction of doctors and patients. Results After the oblique branch in intramuscular of lateral circumflex femoral artery was sent out, it ran 2-3 cm obliquely laterally and inferiorly in the intermuscular septum and then entered the vastus lateralis muscle, and sent out perforating branches to nourish the skin. A total of 61 perforating branches were marked in 26 thighs of 25 patients before operation, and 70 perforating branches were found during operation, including 9 transverse branches, 29 descending branches, and 32 oblique branches, all of the oblique branches were musculocutaneous perforators. All 25 patients were followed up 6-10 months, with an average of 8 months. The time of unilateral thigh flap harvesting ranged from 13 to 90 minutes, with an average of 48 minutes. One patient with diabetes developed disturbance of blood supply and complete necrosis of the flap at 1 month after operation, and then the flap was repaired with skin graft; 1 case developed arterial crisis after operation, which survived after timely exploration; and the rest of the flaps survived smoothly. The wound healing time of the recipient site ranged from 10 to 44 days, with an average of 19 days, and the donor site of the thigh healed by first intention. At last follow-up, the color and texture of the flap was good and the sensation recovered to S1-S2. Only linear scar was left in the donor site, no scar contracture, pain, and other discomfort occurred, and no other serious complications occurred. Evaluated by flap comprehensive efficacy evaluation table, the score was 74-93, with an average of 88, of which 10 cases were excellent, 13 cases were good, and 2 cases were fair, with an excellent and good rate of 92%. Conclusion The intramuscular trunk oblique branch is not uncommon, and its trunk course and perforators distribution are regular. To improve the understanding of this type of oblique branch and adopt appropriate methods during operation can improve the success rate of skin flap extraction.
