Abstract An animal experiment had been conducted for the purpose to find out the possibility of application of instantaneous sustained limited expansion (ISLE). A total of 54 skin defects in 9 pigs were obtained and were divided into two groups. One group of the pigs were subjected to instantaneous sustained limited expansion, the others, as the control group, just received the tension suture. At the same time the blood supply of the skin was measured by laser doppler flowmeter (LDF). It was showed that microcirculatory perfusion of the ISLE group was considerably better than that of the control. Inaddition, the correlation between the blood flow of the skin and the expanding pressure, as well as the pathologic changes of the skin were discussed.
ObjectiveTo explore the feasibility of using indocyanine green angiography in mapping the superficial temporal vessels and assisting design and harvesting of the superficial temporal artery based forehead flap. Methods A clinical data of 14 patients with facial soft tissue defects repaired with superficial temporal artery based forehead flaps between October 2015 and November 2022 was retrospectively analyzed. There were 9 males and 5 females with a median age of 9.5 years (range, 3-38 years). The forehead flaps were used to reconstruct facial soft tissue defects following excision of facial scar (8 cases) or congenital melanocyte nevus (6 cases). The size of defects ranged from 3 cm×2 cm to 24 cm×9 cm. Before operation, the indocyanine green angiography was used to map the superficial temporal artery and vein, and to analyze the relationship of the arteries and veins. The forehead flaps with unilateral superficial temporal fascia as the pedicle was transferred to repair the small facial defect in 2 cases. The facial pedicle contained the frontal branch of the superficial temporal artery and 2 cm of the superficial temporal fascia around the vessel, and the tiny accompanying vein of the frontal branch of the superficial temporal artery was used as the outflow of the flap. The forehead flaps with the skin pedicle including bilateral or unilateral superficial temporal fascia and the overlying skin was pre-expanded and transferred to repair the large facial defect in 12 cases. The skin pedicle contained the frontal branch of superficial temporal artery and one of main branches of superficial temporal vein. Among the 12 cases, the frontal branch of superficial temporal vein was used as the outflow in 4 cases, and the parietal branch was used as the outflow in 8 cases. The size of the flaps ranged from 3 cm×2 cm to 30 cm×13 cm. The skin pedicles were divided at 3 weeks after the flap transfer. ResultsIndocyanine green angiography could clearly showed the course and branching of the superficial temporal artery and vein. Individual differences existed in the location where the frontal branch of the superficial temporal artery entered the forehead. The superficial temporal vein had great variability and did not follow the artery. One patient had expander-related complication, which resulted in 3-cm flap necrosis. The necrotic tissue was debrided and repaired with skin grafting. The other flaps totally survived and the incisions healed by first intention. All patients were followed up 2-24 months, with a median of 11.5 months. The color, texture, and thickness of the flaps matched well with those of recipient sites. Hypertrophic scar was not observed in recipient or donor site. All patients were satisfied with the reconstructive outcomes. ConclusionIndocyanine green angiography can clearly visualize the course and the branches of the superficial temporal arteries and veins, which can help surgeons understand the position, distribution, and concomitant relationship of the superficial temporal vessels, and make a rational surgical plan of the forehead flap.
Objective To investigate the therapeutic effect of medial sural artery perforator flap in the repair of small and medium size skin and soft tissue defects in the ipsilateral lower extremities. Methods The clinical data of patients with small and medium area skin and soft tissue defects of lower limbs admitted to Restorative and Reconstructive Department, NO.1 Orthopedics Hospital of Chengdu between September 2021 and January 2023 was retrospectively analyzed. Basic information of patients was collected. The anatomical characteristics, application methods, and clinical results of the flap were recorded after operation, and the comprehensive efficacy evaluation table of the flap was used to evaluate the clinical efficacy at the last follow-up. Results A total of 13 patients were included. There were 12 males and 1 female. A total of 19 perforating branches of medial sural artery were found in the 13 cases, with an average of 1.46 perforating branches. The incision range of the flap was 5.5 cm×3.5 cm?13.5 cm×5.0 cm. Anterograde pedicle metastasis occurred in 3 cases and free transplantation occurred in 10 cases; mosaic flaps were used in 5 cases, lobed flaps in 1 case, and conventional perforator flaps in the remaining 7 cases. All the flaps survived successfully. All the 13 patients were followed up for 4-15 months, with an average of (10.38±3.64) months. The comprehensive score of flap efficacy was 77-92 points, with an average of (86.76±4.45) points. Among them, 5 cases were excellent, 8 cases were good, and the excellent and good rate was 100%. Conclusion The multifunctional features and flexible use of medial sural artery perforator flap increase the repair strategy of small and medium-sized wounds of the ipsilateral lower limbs, and can obtain better aesthetic repair results.
Objective To investigate the effectiveness of Ilizarov technique in treatment of rigid congenital clubfoot in older children. Methods A clinical data of 55 patients (69 feet) with rigid congenital clubfoot (Diméglio grade Ⅳ) between September 2005 and September 2015 were retrospectively analyzed. There were 33 boys and 22 girls with an average age of 11 years (range, 6-14 years). There were 41 cases of unilateral clubfoot and 14 cases of bilateral clubfeet. The degree of foot deformity was rated as fair in 24 feet and as poor in 45 feet according to International Clubfoot Study Group (ICFSG) score before operation. Sixty-nine feet were treated by Ilizarov external fixator combined with limited soft tissue release, and 21 feet were combined with individualized V-shaped osteotomies. Results All patients were followed up 2-10 years ( mean, 4.2 years). The incisions healed well after operation. Five cases of needle tract infection occurred and were cured by local dressing change. The effectiveness was excellent in 39 feet, good in 21 feet, and fair in 9 feet according to ICFSG score, with the excellent and good rate of 87.0%. During the follow-up, X-ray films showed that no blood supply disorder or necrosis of talus, scaphoid, cuneiform, metatarsal, calcaneus, and cuboid occurred. No osteomyelitis occurred. Conclusion Ilizarov technique combined with limited soft tissue release or V-shaped osteotomy for the older children with rigid congenital clubfeet is safe and can obtain significant orthopedic effectiveness.
Objective To investigate the effectiveness of dorsal perforator flap of cross-finger proper digital artery in the treatment of finger soft tissue defect caused by high-pressure injection injury. MethodsBetween July 2011 and June 2020, 14 cases of finger soft tissue defect caused by high-pressure injection injury were repaired with dorsal perforator flap of cross-finger proper digital artery. All patients were male, with a mean age of 36 years (range, 22-56 years). The defects were located on the index finger in 8 cases, middle finger in 4 cases, and ring finger in 2 cases. The causes of injury include 8 cases of emulsion paint injection, 4 cases of oil paint injection, and 2 cases of cement injection. The time from injury to debridement was 2-8 hours, with a mean time of 4.5 hours. The soft tissue defects sized from 4.0 cm×1.2 cm to 6.0 cm×2.0 cm. The flaps sized from 4.5 cm×1.5 cm to 6.5 cm×2.5 cm. The donor site of the flap was repaired with skin graft. The pedicle was cut off at 3 weeks after operation, and followed by functional exercise. ResultsAll flaps and skin grafts at donor sites survived, and the wounds healed by first intention. Twelve patients were followed-up 16-38 months (mean, 22.6 months). The texture and appearance of all flaps were satisfactory. The color and texture of the flaps were similar to those of the surrounding tissues. The two-point discrimination of the flap was 10-12 mm, with a mean of 11.5 mm. There were different degrees of cold intolerance at the end of the affected fingers. At last follow-up, the finger function was evaluated according to the Upper Extremity Functional Evaluation Standard set up by Hand Surgery Branch of Chinese Medical Association, 3 cases were excellent, 8 cases were good, and 1 case was poor. Conclusion The dorsal perforator flap of cross-finger proper digital artery can effectively repair finger soft tissue defect caused by high-pressure injection injury. The operation was simple, and the appearance and function of the finger recover well.
ObjectiveTo explore the feasibility and effectiveness of bone transport technique for simultaneous repair of tibia defect and refractory soft tissue defect.
MethodsThirty-five patients with tibia bone defect combined with refractory soft tissue defect were treated between January 2010 and December 2014, and the clinical data were retrospectively analyzed. There were 21 males and 14 females with an average age of 29 years (range, 18-47 years). All patients had Gustilo type Ⅲ open tibial fractures, which were caused by traffic accident. Fracture located at the upper 1/3 of the tibia in 1 case, at the middle 1/3 of the tibia in 19 cases, and at the lower 1/3 of the tibia in 15 cases. All patients underwent external fixation after 4-10 hours of trauma, and tibial skin necrosis, infection, and purulent exudation were observed after 5-10 days of operation. The time from injury to admission was 21 days to 5 months (mean, 2 months). After debridement, the average length of tibia defect was 8 cm (range, 6-11 cm); the area of soft tissue defect was 6 cm×5 cm to 10 cm×8 cm. Orthofix external fixation was applied to tract the bone and soft.
ResultsAll 35 patients were followed up 12-22 months (mean, 16 months). The average time of bony healing was 15 months (range, 9-20 months), and no obvious force line offset was found. Osteotomy segment was extended from 6 to 11 cm (mean, 8 cm); after treatment, the external fixation support was retained for 2 to 10 months (mean, 5 months). No blood vessel and nerve injuries were found during treatment, and no osteomyelitis and refracture happened after operation. The skin and soft tissue defects healed, and the healing time was 1 to 3 months (mean, 1.3 months). Different degrees of infection occurred in 5 cases, and was cured after dressing change. According to Johner-Wruhs' evaluation criteria after external fixator was removed, the results were excellent in 26 cases, good in 5 cases, and moderate in 4 cases, with an excellent and good rate of 88.6%.
ConclusionBone transport technique can simultaneously repair tibia bone defect and soft tissue defect by continuous bone and soft tissue traction.
Objective To investigate the effectiveness of the lower abdominal conjoined flap with bilateral superficial inferior epigastric arteries (SIEA) for repairing the large soft tissue defects on the foot and ankle. Methods The clinical data of 18 patients with large soft tissue defects on foot and ankle treated between October 2017 and January 2020 were retrospectively analyzed, including 12 males and 6 females; the age ranged from 25 to 62 years, with a median age of 35 years. The causes of injury included machine injury in 9 cases, traffic accident injury in 5 cases, cutting injury in 2 cases, and electric injury in 2 cases. All wounds were accompanied by exposure of blood vessels, tendons, bones, and joints. Wound located at ankle in 8 cases, dorsum of foot in 6 cases, and sole in 4 cases. In the emergency department, complete debridement (the defect area after debridement was 15 cm×10 cm to 25 cm×16 cm) and vacuum sealing drainage on the wound was performed. The time from debridement to flap repair was 3-10 days, with an average of 5 days. According to the defect location and scope, the lower abdominal conjoined flap with bilateral SIEA was prepared. The size of the flap ranged from 15 cm×10 cm to 25 cm×16 cm. The length of vascular pedicle was 4.5-7.5 cm, with an average of 6.0 cm; the thickness of the flap was 0.5-1.2 cm, with an average of 0.8 cm. The abdominal donor site was closed in one-stage. Results One flap was altered as the conjoined flap with the bilateral superficial circumflex iliac artery because of the absence of the SIEA in one side. Except for 1 case of skin flap with distal necrosis, the flap healed after two-stage skin grafting repair; the rest skin flaps survived, and the wounds of the donor and recipient sites all healed by first intention. All patients were followed up 12-28 months, with an average of 16 months. The skin flap had a satisfactory appearance and soft texture, without abnormal hair growth or obvious pigmentation. Only linear scars were left at the donor site, and no complication such as abdominal hernia occurred. The foot and ankle function was satisfactory. At last follow-up, the American Orthopaedic Foot and Ankle Society (AOFAS) scores were rated as excellent in 16 cases and good in 2 cases. Conclusion The lower abdominal conjoined flap with bilateral SIEA is an ideal flap for repairing large defects of foot and ankle with less morbidity scarcely, which ascribed to its ease of dissection, adjustable thinness, and concealed donor site, as well as the flexible perforator match.
ObjectiveTo investigate the effectiveness of Masquelet technique combined with flap transplantation in treatment of infectious bone and soft tissue defects of the lower leg.MethodsBetween January 2013 and January 2017, 35 cases of infectious bone and soft tissue defects of lower leg were treated with Masquelet technique combined with flap transplantation. There were 21 males and 14 females, with an average of 31.5 years (mean, 25-55 years). All patients were tibial fractures caused by trauma and the infections occurred after debridement or internal fixation. The time from injury to admission was 1 to 6 months, with an average of 3.2 months. Defect located at the proximal leg in 11 cases, the middle leg in 11 cases, and the distal leg in 13 cases. The length of tibia defect after debridement ranged from 5.6 to 11.2 cm, with an average of 7.1 cm. The size of soft tissue defect ranged from 14.2 cm×6.9 cm to 17.3 cm×8.7 cm. Bacterial culture of purulent secretion of wound was positive in 18 cases. After debridement, the bone cement was used to fill the bone defect and the flap transplantation was used to repair the wound. The bone cement was taken out at 8 to 12 weeks after the one-stage operation, and the bone defect was repaired with autogenous iliac bone or combined with artificial bone.ResultsThree cases had necrosis at the distal edge of the flap after one-stage operation, and survived after dressing change. The other flaps survived successfully, and the wounds healed by first intention. All incisions healed by first intention after two-stage operation. All patients were followed up 24-32 months, with an average of 27 months. The color of the flap was similar to that of the surrounding normal tissue, and its texture was good. X-ray reexamination showed that all bone defects healed after 6-8 months, with an average of 6.7 months. At 9 months after two-stage operation, according to the revised Edwards tibial fracture evaluation standard, 19 cases were excellent, 14 cases were good, and 2 cases were poor, the excellent and good rate was 94.3%. The American Orthopedic Ankle Association (AOFAS) score was 60-98, with an average of 81.3. And 21 cases were excellent, 11 were good, and 3 were fair, with an excellent and good rate of 91.4%.ConclusionMasquelet technique combined with flap transplantation is an effective treatment for infectious bone and soft tissue defects of lower leg.
Objective To investigate the effectiveness of the deep inferior epigastric perforator (DIEP) flap for extreme defects around the knee. Methods Between June 2017 and December 2018, 15 patients with the extreme defects around the knee were admitted. There were 9 males and 6 females with a median age of 36 years (range, 23-51 years). The etiology was the traffic accident in 7 cases, tumor in 5 cases, and burn in 3 cases. The injured location was left knee in 8 cases and right knee in 7 cases. The size of soft tissue defects ranged from 15 cm×10 cm to 30 cm×20 cm, and all defects complicated with exposure of blood vessels, nerves, tendons, and other tissues. Transverse DIEP flaps with 1-2 vascular pedicles were prepared according to the size of the defect, including 6 cases of single-pedicle flaps and 9 cases of double-pedicle conjoined flaps. According to the depth of the defect, 10 cases of skin flaps were thinned under microscope. The size of the DIEP flaps ranged from 16 cm×10 cm to 32 cm×20 cm; the average thickness was 1.5 cm (range, 0.8-1.8 cm); the average pedicle length was 7.5 cm (range, 5.0-9.0 cm). The donor site was directly sutured. Results One single-pedicle flap developed distal necrosis after operation, and healed after skin grafting; the other skin flaps survived, and the wounds at the donor and recipient sites healed by first intention. All patients were followed up 16-28 months (mean, 24 months). The shape and texture of the flap were satisfactory, and there was no abnormal hair growth or obvious pigmentation. There was only linear scar at the donor site and no complication such as abdominal hernia. The appearance and function of the knee were satisfactory. No recurred tumor was observed, and the scar contracture was released. At last follow-up, 13 cases were excellent and 2 cases were good, according to the Knee Society Score (KSS) criteria. Conclusion The DIEP flap is an ideal alternative for repairing the extreme defects around knee, with a concealed donor site, easy dissection, flexible design, as well as less complication.
ObjectiveTo investigate the treatment outcome of applying venous Flow-through flap in the replantation of severed finger with circularity soft tissue defect and vascular defect.
MethodsBetween January 2010 and December 2012,11 cases (11 fingers) of severed finger with circularity soft tissue defect and vascular defect underwent replantation with venous Flow-through flaps.There were 8 males and 3 females,aged 18-42 years (mean,24.6 years).The cause of injury was squeeze injury in 6 cases,crush injury in 3 cases,and strangulation in 2 cases.Combined injuries included nerve defect in 3 cases (1.0,2.0,and 3.5 cm in length),and tendon defect in 2 cases (2.0 and 6.5 cm in length); cyclic skin and soft tissue defect was 3.0-4.5 cm in width,was 1/2-1 finger circumference in length,and was 2.0 cm×1.0 cm to 7.0 cm×4.5 cm in size.Six cases had complete circular defect (both finger artery and vein defects),and 5 cases had incomplete circular defect (only finger artery defect),and vascular defect was 1.0-4.5 cm in length.The time from injury to operation was 1.5-4.5 hours.
ResultsVenous crisis occurred in 1 case at 2 days after operation,was cured after vein graft; flap edge necrosis was observed in 2 cases and was cured after dressing change and skin grafting respectively; flap edema and blister occurred in 2 cases and relieved spontaneously.The other 6 flaps and replanted fingers survived completely,with primary healing of incision.Ten cases were followed up 12-18 months (mean,15.5 months).Only a linear scar was seen at the donor sites,with no functional limitation.The flaps had similar color and texture to adjacent skin.The two-point discrimination was 6.5-13.0 mm (mean,8.6 mm).According to replanted finger function scoring system of Society of Hand Surgery of Chinese Medical Association,the results were excellent in 6 cases,good in 3 cases,and poor in 1 case at last follow-up,and the excellent and good rate was 90%.
ConclusionVenous Flow-through flap can repair both vascular defect and soft tissue defect,so it has good outcome in increasing the survival rate of replanted finger for severed finger replantation with circularity soft tissue defect and vascular defect.
