ObjectiveTo explore the clinical application of combined transverse upper gracilis flap and adductor magnus perforator flap in breast reconstruction of breast cancer patients after mastectomy.MethodsBetween August 2016 and February 2017, the combined transverse upper gracilis flap and adductor magnus perforator flap was used in 12 cases of breast cancer patients who received modified radical surgery for breast reconstruction. All patients were females with the age of 32 to 59 years (mean, 41.5 years). There were 7 cases in left side and 5 cases in right side. Eight cases were received breast reconstruction by one-stage operation and 4 cases by two-stage operation. In one-stage operation cases, pathological diagnosis includes invasive ductal carcinoma in 4 cases and invasive lobular carcinoma in 4 cases. The disease duration ranged from 2 to 9 months (mean, 4.5 months). In two-stage operation cases, the time interval between mastectomy and breast reconstruction ranged from 12 to 70 months (mean, 37.4 months). The length of flap was 20-28 cm, the width of flap was 5.5-7.5 cm, the thickness of flap was 2.5-4.5 cm. The length of gracilis flap pedicle was 6.5-9.2 cm, the length of adductor magnus perforator flap pedicle was 7.5-10.4 cm. The weight of flap was 295-615 g.ResultsThe ischemia time of flap ranged from 95 to 230 minutes (mean, 135 minutes). All flaps were successfully survived. All incisions of recipient donor sites healed by first intention. All patients were followed up 7-14 months (mean, 9.5 months). The reconstructed breasts’ shape, texture, and elasticity were good and no flap contracture deformation happened. Only linear scar left in the donor sites, but the function of thighs was not affected. No local recurrence happened during follow-up.ConclusionWith appropriate patient selection and surgical technique, the combined transverse upper gracilis flap and adductor magnus perforator flap can be a valuable option as an alternative method for autologous breast reconstruction.
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 investigate the feasibility and effectiveness of the latissimus dorsi myocutaneous flap in repair of large complex tissue defects of limb and the relaying posterior intercostal artery perforator flap in repair of donor defect after latissimus dorsi myocutaneous flap transfer.MethodsBetween January 2016 and May 2017, 9 patients with large complex tissue defects were treated. There were 8 males and 1 female with a median age of 33 years (range, 21-56 years). The injury caused by traffic accident in 8 cases, and the time from post-traumatic admission to flap repair was 1-3 weeks (mean, 13 days). The defect in 1 case was caused by the resection of medial vastus muscle fibrosarcoma. There were 5 cases of upper arm defects and 4 cases of thigh defects. The size of wounds ranged from 20 cm×12 cm to 36 cm×27 cm. There were biceps brachii defect in 2 cases, triceps brachii defect in 3 cases, biceps femoris defect in 2 cases, quadriceps femoris defect in 2 cases, humerus fracture in 2 cases, brachial artery injury in 2 cases, and arteria femoralis split defect combined with nervus peroneus communis and tibia nerve split defect in 1 case. The latissimus dorsi myocutaneous flaps were used to repair the wounds and reconstruct the muscle function. The size of the skin flaps ranged from 22 cm×13 cm to 39 cm×28 cm; the size of the muscle flaps ranged from 12 cm×3 cm to 18 cm×5 cm. The wounds were repaired with pedicle flaps and free flaps in upper limbs and lower limbs, respectively. The donor sites were repaired with posterior intercostal artery perforator flaps. The size of flaps ranged from 10 cm×5 cm to 17 cm×8 cm. The second donor sites were sutured directly.ResultsAll the flaps survived smoothly and the wounds and donor sites healed by first intention. All patients were followed up 10-19 months (mean, 13 months). At last follow-up, the flaps had good appearances and textures. The muscle strength recovered to grade 4 in 5 cases and to grade 3 in 4 cases. After latissimus dorsi myocutaneous flap transfer, the range of motion of shoulder joint was 40-90°, with an average of 70°. The two-point discrimination of latissimus dorsi myocutaneous flap was 9-15 mm (mean, 12.5 mm), and that of posterior intercostal artery perforator flap was 8-10 mm (mean, 9.2 mm). There were only residual linear scars at the second donor sites.ConclusionThe latissimus dorsi myocutaneous flap combined with posterior intercostal artery perforator flap for the large complex tissue defects and donor site can not only improve the appearance of donor and recipient sites, but also reconstruct muscle function, and reduce the incidence of donor complications.
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 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 clinical application of the free peroneal artery perforator flap in soft tissue defect of foot and ankle.MethodsThe clinical data of 18 patients with soft tissue defects of foot and ankle who were repaired with free peroneal artery perforator flaps between March 2019 and March 2020 were retrospectively analyzed. Among them, there were 11 males and 7 females; the age ranged from 21 to 58 years, with an average age of 45 years. The defect was located in the ankle in 2 cases, in the hindfoot in 4 cases, in the midfoot in 5 cases, and in the forefoot in 7 cases. The causes of injury included 11 cases of traffic accident, 4 cases of machine injuries, 3 cases of infection and necrosis after internal fixation. The time from injury to flap repair was 12-48 days, with an average of 24 days. The range of wound was 3 cm×3 cm to 15 cm×8 cm, and the range of skin flap was 4 cm×3 cm to 16 cm×9 cm. The flap harvesting time, operation time, intraoperative blood loss, and complications were recorded; the flap survival and patient satisfaction were observed during follow-up; and the American Orthopaedic Foot and Ankle Society (AOFAS) foot function score was used to evaluate the foot function.ResultsThe flap harvesting time was 15-33 minutes (mean, 22 minutes); the operation time was 120-160 minutes (mean, 150 minutes); the intraoperative blood loss was 90-180 mL (mean, 120 mL). There were 3 cases of vascular crisis after operation, including 2 cases of arterial crisis, which survived after vascular exploration and vein graft repair; 1 case of venous crisis, partial necrosis of the skin flap, and skin grafting to cover the wound after repeated debridement. The remaining 15 skin flaps survived completely. All patients were followed up 6 months. The skin flaps were in good shape without obvious bloat. According to the AOFAS foot function score, 5 cases were excellent, 10 cases were good, and 3 cases were fair. The excellent and good rate was 83.3%.ConclusionThe free peroneal artery perforator flap is easy to harvest, the shape and size of the flap are easy to design, and it does not damage the main blood vessels of the limb. The appearance and function of the limbs are satisfactory after operation. It can be widely used in the repair of soft tissue defects of the foot and ankle.
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.
Objective To discuss the feasibil ity of repairing soft tissue defects of lower extremity with a distally based posterior tibial artery perforator cross-bridge flap or a distally based peroneal artery perforator cross-bridge flap. Methods Between August 2007 and February 2010, 15 patients with soft tissue defect of the legs or feet were treated. There were 14 males and 1 female with a mean age of 33.9 years (range, 25-48 years). The injury causes included traffic accident in 8 cases, crush injury by machine in 4 cases, and crush injury by heavy weights in 3 cases. There was a scar (22 cm × 8 cm atsize) left on the ankle after the skin graft in 1 patient (after 35 months of traffic accident). And in the other 14 patients, the defect locations were the ankle in 1 case, the upper part of the lower leg in 1 case, and the lower part of the lower leg in 12 cases; the defect sizes ranged from 8 cm × 6 cm to 26 cm × 15 cm; the mean interval from injury to admission was 14.8 days (range, 4-28 days). Defects were repaired with distally based posterior tibial artery perforator cross-bridge flaps in 9 cases and distally based peroneal artery perforator cross-bridge flaps in 6 cases, and the flap sizes ranged from 10 cm × 8 cm to 28 cm × 17 cm. The donor sites were sutured directly, but a spl it-thickness skin graft was used in the middle part. The pedicles of all flaps were cut at 5-6 weeks postoperatively. Results Distal mild congestion and partial necrosis at the edge of the skin flap occurred in 2 cases and were cured after dressing change, and the other flaps survived. After cutting the pedicles, all flaps survived, and wounds of recipient sites healed by first intention. Incisions of the donor sites healed by first intention, and skin graft survived. Fifteen patients were followed up 7-35 months with an average of 19.5 months. The color and texture of the flaps were similar to these of the reci pient site. According to American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score system, the mean score was 87.3 (range, 81-92). Conclusion A distally based posterior tibial artery perforator cross-bridge flap or a distally based peronealartery perforator cross-bridge flap is an optimal alternative for the reconstruction of the serious tissue defect of ontralateral leg or foot because of no microvascular anastomosis necessary, low vascular crisis risk, and high survival rate.
Objective To explore the feasibility of peroneal perforating chimeric tissue flap in repairing the composite defects of calf and heel based on lower limb angiography, and the clinical effect. Methods The digital subtraction angiography images of lower limbs of 50 patients met the selection criteria between May 2011 and October 2014 were used as the research object to observe the course of peroneal artery and its perforating vessels. Based on the observation results, between April 2015 and October 2020, the peroneal perforating chimeric tissue flap was designed to repair 7 cases of composite defects of the calf and heel. There were 5 males and 2 females with an average age of 38 years (range, 25-55 years). The causes of injury included traffic accident in 4 cases, falling from height in 2 cases, and machine strangulation in 1 case. There were 5 cases of calf skin defect and tibial defect. The size of skin defect ranged from 5 cm×3 cm to 11 cm×7 cm, and the length of bone defect was 5-8 cm. There were 2 cases of heel skin defect and calcaneal defect. The sizes of skin defects were 5.0 cm×4.0 cm and 7.5 cm×6.5 cm, and the bone defects were 3.0 cm×2.6 cm and 4.0 cm× 3.0 cm. For the calf defect, the size of skin flap ranged from 6 cm×4 cm to 12 cm×8 cm, and the length of the fibula was the same as that of the tibial defect. For the heel defect, the sizes of the skin flaps were 8.5 cm×5.5 cm and 13.0 cm×5.0 cm, and the lengths of the fibulae were 10 cm and 12 cm. Free transplantation was performed in 5 cases and pedicle transplantation in 2 cases. The wound at donor site was repaired with skin grafting or sutured directly. Results The peroneal artery ran close to the fibula 7.25-8.40 cm below the fibula head and send out 5-7 perforating vessels, with an average of 6.5 vessels. Perforating vessels mainly appeared in four places, which were (9.75±0.91), (13.21±0.74), (18.15±1.22), and (21.40±0.75) cm below the fibular head, with the occurrence rates of 94%, 90%, 96%, and 88%, respectively. Clinical application of 7 cases of peroneal perforating chimeric tissue flap all survived, all wounds healed by first intention. The skin graft at donor site survived and the incision healed by first intention. All patients were followed up 6-36 months, with an average of 12 months. Peroneal perforator chimeric tissue flap had good shape and soft texture. X-ray films showed that the bone graft healed well, and the healing time was 6-11 months (mean, 7 months). No obvious bone resorption was observed during follow-up. Five patients had no pain when walking, and 1 had mild pain with claudication. Postoperative heel ulcers formed in 1 case and healed after wearing custom plantar pressure dispersing shoes. At 6 months after operation, 2 patients were rated as grade Ⅳ and 5 patients as grade Ⅴ according to Holden walking function score. ConclusionThe peroneal perforating vessel distribution is constant and the peroneal perforating chimeric tissue flap is safe and reliable for repairing the composite defects of calf and heel.
Objective To investigate the effectiveness of posterior lateral perforator flap in lower limb combined with free fibula for maxillary tissue defect repair. Methods Between December 2018 and December 2023, 16 patients with the maxillary malignant tumors were admitted. There were 10 males and 6 females, with an average age of 64.3 years (range, 54-75 years). There were 7 cases of maxillary gingival cancer, 5 cases of hard palate cancer, and 4 cases of maxillary sinus cancer. According to the 2017 American Joint Committee on Cancer (AJCC) TNM stage, there were 8 cases of stage Ⅲ, 6 cases of stage Ⅳa, and 2 cases of stage Ⅳb. After resection of the lesion, the remaining maxillary defects were classified into class Ⅱa in 3 cases, class Ⅱb in 5 cases, and class Ⅲb in 8 cases according to Brown’s classification. The size of soft tissue defects ranged from 4 cm×3 cm to 8 cm×6 cm. The posterior lateral perforator flap in lower limb in size of 5 cm×4 cm-9 cm×7 cm were harvested to repair soft tissue defects, and free fibula in length of 6-11 cm were used to repair bone defects. The donor sites of the lower limb were sutured directly (6 cases) or repaired with free skin grafting (10 cases). Six patients with positive lymph node pathology were treated with radiotherapy after operation. At 6 and 12 months after operation, the self-assessment was performed by the University of Washington Quality of Survival Questionnaire Form (QUW-4) in five dimensions (facial appearance, swallowing function, chewing function, speech function, and mouth opening), and swallowing function was evaluated by using the Kubota water swallowing test. Results Postoperative pathological examination showed that all patients were squamous cell carcinoma. One patient who was treated with radiotherapy developed osteomyelitis and 1 patient developed venous crisis of skin flap. The rest of the flaps and all skin grafts survived, and the wounds healed by first intention. All patients were followed up 1-5 years (mean, 2.8 years). Two patients died of local recurrence of the tumor at the 4th and 5th years after operation, respectively. Except for the chewing function score and total score at 6 months after operation, which showed significant differences compared to preoperative scores (P<0.05), there was no significant difference in other QUW-4 scale scores between different time points (P>0.05). The patients’ swallowing function evaluated by Kubota water swallowing test reached normal in 4 cases, suspicious in 9 cases, and abnormal in 3 cases at 6 months after operation, and 10, 6, and 0 cases at 12 months after operation, respectively. The swallowing function at 12 months was significantly better than that at 6 months (Z=–2.382, P=0.017). Conclusion The posterior lateral perforator flap in the lower limb combined with free fibula to repair maxillary tissue defects can repair soft and hard tissue defects at the same time, so that the patient’s facial appearance, swallowing function, chewing function, speech function, and mouth opening are satisfactorily restored and the mid-term effectiveness is good.