Objective To explore the method of the distal perforator-based gluteus maximus muscle V-Y flap to treat the sacral ulcer and to simplify the operative procedures.Methods From March 2002 to March 2005, 11 cases of sacral ulcer were repaired by distal perforatorbased gluteus maximus muscle flaps. The area of sacral ulcer ranged from 13 cm×11 cm to 18 cm×14 cm. Of 11 cases, 7 were female and 4 were male,whose age ranged from 21 to 69 years, and the disease course was 8 months to 3 years.A triangular flap was designed to create a V-Y advancement flap.The length of the base was made almost equal to the diameter of the defect.The apex of the tringle was located near the great trochanter. The medial part of the flap was elevated as a fasciocutaneous flap by dissecting the layer between the fascia and the muscle.The distal part ofthe flap was elevated by dissecting the layer between the gluteus maximus muscle and the fascia of the deeper muscle group.The flap was advanced to the defect. Results All the flaps survived. After a follow-up of 5 months to 3 years, the bilateral buttocks were symmetry and whose appearance was satisfactory. Except for 1 case dying of other disease, no recurrence of ulcer was observed.All the flaps survived. Conclusion The distal perforatorbased fasciocutaneous V-Y flap for treatment of sacral ulcers is a simple and reliable technique, which has several advantages over the conventional V-Y flap technique,such as excelent excursion,viable coverage with the fasciocutaneous component, high flap reliability, preservation of the contralateral buttock, and preservation of the gluteus maximus muscle function.
Objective To investigate the accuracy and reliability of augmented reality (AR) technique in locating the perforating vessels of the posterior tibial artery during the repair of soft tissue defects of the lower limbs with the posterior tibial artery perforator flap. Methods Between June 2019 and June 2022, the posterior tibial artery perforator flap was used to repair the skin and soft tissue defects around the ankle in 10 cases. There were 7 males and 3 females with an average age of 53.7 years (mean, 33-69 years). The injury was caused by traffic accident in 5 cases, bruising by heavy weight in 4 cases, and machine injury in 1 case. The size of wound ranged from 5 cm×3 cm to 14 cm×7 cm. The interval between injury and operation was 7-24 days (mean, 12.8 days). The CT angiography of lower limbs before operation was performed and the data was used to reconstruct the three-dimensional images of perforating vessels and bones with Mimics software. The above images were projected and superimposed on the surface of the affected limb using AR technology, and the skin flap was designed and resected with precise positioning. The size of the flap ranged from 6 cm×4 cm to 15 cm×8 cm. The donor site was sutured directly or repaired with skin graft. Results The 1-4 perforator branches of posterior tibial artery (mean, 3.4 perforator branches) in 10 patients were located by AR technique before operation. The location of perforator vessels during operation was basically consistent with that of AR before operation. The distance between the two locations ranged from 0 to 16 mm, with an average of 12.2 mm. The flap was successfully harvested and repaired according to the preoperative design. Nine flaps survived without vascular crisis. The local infection of skin graft occurred in 2 cases and the necrosis of the distal edge of the flap in 1 case, which healed after dressing change. The other skin grafts survived, and the incisions healed by first intention. All patients were followed up 6-12 months, with an average of 10.3 months. The flap was soft without obvious scar hyperplasia and contracture. At last follow-up, according to the American Orthopedic Foot and Ankle Association (AOFAS) score, the ankle function was excellent in 8 cases, good in 1 case, and poor in 1 case. Conclusion AR technique can be used to determine the location of perforator vessels in the preoperative planning of the posterior tibial artery perforator flap, which can reduce the risk of flap necrosis, and the operation is simple.
ObjectiveTo explore the application value of digital subtraction angiography (DSA) in repairing foot and ankle wounds with posterior tibial arterial perforator flaps. MethodsBetween January 2010 and May 2014, 12 cases of foot and ankle wounds were repaired using posterior tibial arterial perforator flaps. There were 7 males and 5 females with an average age of 36 years (range, 22-54 years). The causes were machine injury in 2 cases, falling injury in 3 cases, and traffic accident injury in 7 cases. The disease duration ranged from 7 to 45 days (mean, 16 days). The size of wound ranged from 6 cm×4 cm to 10 cm×5 cm. Preoperative DSA was performed to observe the orientation and distribution of the posterior tibial arterial perforator and the relationship between perforator vessels. Correspondently, the flaps were designed and harvested. The size of flap ranged from 7 cm×5 cm to 11 cm×6 cm. The donor sites were repaired with skin grafts. ResultsPosterior tibial arterial perforator vessels send out ascending branches and descending branches while going down in the superficial layer. All branches were connected to form vertical chain-form anastamosis, and its orientation was consistent with limb vertical axis. According to DSA results, the flaps were designed and harvested easily. All flaps survived after operation. Meanwhile, wounds healed by first intention. All skin grafts at donor site survived. All patients were followed up 6 months. The flaps had good appearance, color, and texture. No ulcer was found. Affected feet had normal walking function. ConclusionThe size, distribution, and chain-form anastamosis condition of the posterior tibial arterial perforator vessels can be accurately observed by DSA, which provides imaging evidence for harvesting posterior tibial arterial perforator flaps and improves the success rate for repairing foot and ankle wounds.
ObjectiveTo explore the effectiveness of free lobed perforator flaps in repairing of complex wounds of limbs. Methods Between January 2018 and January 2021, 10 patients with complex wounds of limbs were admitted. There were 7 males and 3 females, aged from 32 to 64 years, with an average age of 45 years. There were 4 cases of traffic accident injuries, 3 cases of machine strangulation injuries, 1 case of machine crush injury, and 2 cases of heavy object crush injuries. There were 5 cases of upper limb wounds and 5 cases of lower limb wounds. The size of wounds ranged from 11 cm×10 cm to 25 cm×18 cm. The wounds were repaired with tri-lobed flaps of the descending branch of the lateral femoral circumflex artery in 7 cases, four-lobed flaps in 2 cases, and with tri-lobed flaps of the descending branch of the lateral femoral circumflex artery combined with oblique branch in 1 case. The size of flaps ranged from 12.0 cm×10.5 cm to 28.0 cm×12.0 cm. The donor sites were sutured directly in 9 cases and repaired with superficial iliac circumflex artery perforator flap in 1 case. ResultsSinus formed at the edge of the flap in 1 patient, which healed after dressing change and drainage; other flaps survived well, and the wounds healed by first intention. The skin flap at donor site survived, and the incisions healed by first intention. All patients were followed up 6-24 months (mean, 11 months). All flaps had good appearance and function, and linear scars were left at the donor site without obvious complications. ConclusionFree lobed perforator flap is an alternative method to repair complex wounds of limbs with high safety, good effectiveness, and less complications.
Objective To explore the feasibility and effectiveness of radial collateral artery polyfoliate perforator flap in repair of resurfacing soft tissue defect of hand. Methods Between September 2017 and September 2018, the radial collateral artery polyfoliate perforator flaps were transplanted to repair 5 cases of two adjacent wounds of hand and wide or irregular wounds. All patients were male, aged from 27 to 52 years, with an average of 42.5 years. The time from injury to admission was 4 hours to 3 weeks, with an average of 7.3 days. Causes of injury included traffic accident in 2 cases, crushing injury in 2 cases, and paint injection injury in 1 case. The wounds were located at the dorsum of hand in 3 cases, the dorsum of finger in 1 case, and the thumb and thumb web in 1 case. The area of wound ranged from 8 cm×6 cm to 10 cm×8 cm. The area of skin flap ranged from 6.0 cm×3.0 cm to 11.0 cm×4.5 cm, all of which carried the posterior cutaneous nerve of the arm, and the donor site was closed directly. Results All flaps survived and healed by first intention. All patients were followed up 3-11 months (mean, 6.5 months). The patients were satisfied with the appearance of hands. The flaps were not bulky, and the color and texture were similar to the hand. There was only linear scar in the donor site, no radial nerve injury occurred, and elbow joint function was not affected. One patient underwent finger-splitting and skin flap thinning at 6 months after operation. Conclusion The radial collateral artery polyfoliate perforator flap is a good method for repairing two adjacent wounds and wide or irregular wounds of hand.
Objective To investigate the effectiveness of perforator propeller flap of lower limb in the treatment of foot and ankle defect in children. Methods The clinical data of 28 children with foot and ankle defect treated with perforator propeller flap of lower limb between January 2018 and January 2021 were retrospectively analyzed. There were 18 boys and 10 girls with an average age of 7.3 years (range, 6-14 years). There were 8 cases of traffic accident injury and 20 cases of chronic infection wound. The disease duration was 2-4 months, with an average of 2.8 months. After thorough debridement, the residual wound size ranged from 5 cm×4 cm to 9 cm×5 cm. Repairing was performed after 7-28 days of the infection in control. According to the location, size, and shape of the wound, the perforating vessels were located by ultrasonic Doppler, and the perforator propeller flap (area ranged from 6 cm×5 cm to 11 cm×6 cm) was designed and harvested to repair the wound. Flap transfer combined with free split-thickness skin graft covered the wound in 2 cases. The donor site was sutured directly (22 cases) or repaired with skin graft (6 cases). Results Twenty-six flaps survived, of which 20 cases were in primary healing, and 6 cases had epidermal necrosis at the end of small paddle, which healed after dressing change. Necrosis occurred in 2 cases due to venous crisis which healed after anterolateral femoral flap free transplantation. Primary wound healing was achieved in donor site. All 28 children were followed up 6-24 months (mean, 10.5 months). The texture, shape, and motor function of the lower limb was satisfactory. At last follow-up, the American Orthopaedic Foot and Ankle Association (AOFAS) score was 89.8±8.0, which was significantly different from the preoperative score (79.6±10.4) (t=−11.205, P<0.001); 20 cases were excellent, 6 cases were good, and 2 cases were poor, and the excellent and good rate was 92.8%. ConclusionThe perforator propeller flap of lower limb in children has its own characteristics. It is a reliable method to repair the foot and ankle defect in children.
Objective To study the hemodynamic characteristics of concealed perforator flap in mini-pigs by ultrasonic Doppler technique. Methods Seven 7-month-old mini-pigs, weighing 20-25 kg, were included in the study. The saphenous artery perforator flap (group A, n=4), saphenous artery concealed perforator flap (group B, n=5), and saphenous artery concealed perforator flap combined with sarcolemma (group C, n=5) models were established randomly on both hind limbs of pigs. The pigs and flap survival conditions were observed after operation. The percentage of flap survival area was calculated by Photoshop CS5 software at 5 days after operation. Ultrasonic Doppler technique was performed on the flaps before operation and at immediate, 3 days, and 5 days after operation to record the hemodynamic changes of the flaps. The hemodynamic indicators of saphenous artery (inner diameter, peak systoli velocity, resistance index, and blood flow) and saphenous vein (inner diameter, maximum velocity, and blood flow) were recorded. Results At 1 day after operation, 1 pig died of infection, and the rest survived until the experiment was completed. Finally, the 3 flaps of group A, 4 of group B, and 5 of group C were included in the study. The flaps of the 3 groups all showed swelling after operation, which was most significant at 3 days. At 3 days after operation, the flaps in group B showed partial bruising and necrosis. At 5 days after operation, the flaps in groups A and C were basically alive, and the necrosis area of flap in group B increased further. The percentage of flap survival area in groups A, B, and C were 99.7%±0.5%, 74.8%±26.4%, and 100%, respectively. The percentage of flap was significantly lower in group B than in groups A and C (P<0.05). There was no significant difference between groups A and C (P>0.05). There were significant differences in the hemodynamic indicators of saphenous artery and vein between different time points in 3 groups (P<0.05). There was no significant difference in each indicator between groups at each time point (P>0.05). Conclusion Both the saphenous artery concealed perforator flap and the flap combined with sarcolemma have stable blood flow, but the survival area of the latter was better than the former.
Objective To evaluate the effectiveness of anterolateral thigh polyfoliate perforator flap plus pedicle with one foliate flap for repairing extremities soft tissue defect. Methods Between January 2014 and January 2017, 24 patients with extremities soft tissue defects were treated by anterolateral thigh polyfoliate perforator flap plus pedicle with one foliate flap. There were 15 males and 9 females, with a median age of 33.5 years (range, 5-64 years). Wounds located in upper limb in 8 cases, complicated with radial styloid fracture in 1 case, extensor tendon exposure in 3 cases, and brachioradialis muscle tendon exposed in 1 case. Wounds located in lower extremity in 16 cases, complicated with calcaneal or metatarsal, phalangeal fractures in 4 cases, Achilles tendon departure in 1 case, toe long extensor tendon and flexor digitorum longus tendon exposed in 8 cases. The wound area ranged from 8 cm×5 cm to 18 cm×12 cm. According to wound size, anterolateral thigh perforators were detected by conventional ultrasound Doppler (2-5 perforators). The irregular wounds were decomposed into multiple parts and the leaf number (2-4 leaves) of polyfoliate flap depended on the part number of the wound. The flap area ranged from 9 cm×6 cm to 20 cm×14 cm, and the largest area of single leaf was 24 cm×6 cm. The vascular pedicle length ranged from 7 cm to 12 cm. The foliate flap area with protecting pedicle ranged from 5 cm×3 cm to 7 cm×5 cm. Results All the flaps survived, and no vascular crisis occurred. All the patients were followed up 2-28 months (mean, 9 months). Sinus occurred in 1 case of calcaneal fracture after flap repair, and the sinus was healed after 3 months by conventional dressing. All the flaps were thin and had a good texture. Healing of soft tissue was found in 5 patients with fracture. The wrist and ankle plantar flexion and dorsiflexion function of recipient site were normal in all patients. Conclusion It is safe and reliable to repair the extremities soft tissue defect with anterolateral thigh polyfoliate perforator flap plus pedicle with one foliate flap. And it is one of the ways to reduce the vascular crisis of the anterolateral thigh free perforator flap.
ObjectiveTo investigate the effect of pharmacologic delay with pioglitazone, a peroxisome proliferator-activated receptor γ (PPAR-γ) agonist, on extended perforator flap survival in a rat model. MethodsSeventy male Sprague Dawley rats, weighing 250-300 g, were randomly divided into control group (n=35) and experimental group (n=35). A three-territory flap was made, including two choke zones. Pioglitazone was dissolved in 1.5 mL saline. Oral doses of pioglitazone[10 mg/(kg·d)] was given by gavaged for 5 days in the experimental group, while the same volume of saline was given in the control group at same time point. After 7 days, the flap survival area was measured and angiographic diagnosis was made. The tissue samples were harvested from choke zone Ⅱ for histological study and vascular endothelial growth factor (VEGF) expression detection by immunohistochemical staining. The content of nitric oxide (NO) in choke zones I and Ⅱ was measured at immediate, 1, 3, 5, and 7 days after operation. ResultsThe flap general change of 2 groups was similar. Varying degrees of necrosis occurred with the extension of time in 2 groups. At 7 days after operation, the flap survival rate was 87.73%±3.25% in the experimental group and 76.07%±2.92% in the control group, showing a significant difference (t=-10.338, P=0.000). The number of true anastomosis in choke zones I and Ⅱ was 5.40±1.14 and 3.00±0.71 in the experimental group, and was 3.20±0.84 and 0.80±0.84 in the control group respectively, showing significant differences between the 2 groups (t=-3.479, P=0.008;t=-4.491, P=0.002). The microvessel density and the expression of VEGF in choke zone Ⅱ of experimental group were (33.16±7.73)/mm2 and 4 368.80±458.23, respectively, which were significantly higher than those of control group[(23.29±5.91)/mm2 and 2 241.24±554.43] (t=5.073, P=0.000;t=-14.789, P=0.000). The content of NO in the experimental group were significantly higher than those in the control group at other time points (P<0.05) except for at immediate after operation. ConclusionPharmacologic delay with pioglitazone can improve extended perforator flap viability through increasing ischemia-induced angiogenesis and choke vessels vasodilation in rat models.
Objective To evaluate a new alternative method for thereconstruction of vagina with deep inferior epigastric perforator(DIEP) flap. Methods From January 2004 to May 2005, DIEP flaps were used for vaginal reconstruction in 5 patients(19 to 40 years), including 4 cases of congenital vaginal agenesis and 1 case of vaginal tumor. Before operation, the perforators were detected by theDoppler and the flaps based on the perforators ranged from 10 cm×9 cm to 12 cm×11 cm. DIEP flaps were elevated and then transferred to reconstruct the vagina. Results Deep inferior epigastric perforator flaps were used in 5 patients. Only 1 patient developed haematoma in the posterior aspect of thereconstructed vagina, but the flap was viable. The wounds healed secondarily after conservative therapy. All the flaps survived completely. No complication occurred at donor site of abdominal wall. Conclusion Despite technical difficulties in elevatingthe deep inferior epigastric perforator flap, the flap is a good choice for vaginal reconstruction.