Objective To investigate the surgical procedures and cl inical outcomes of the neurovascular free flap based on dorsal branch of digital artery of ring finger graft for repair of finger pulp defect. Methods From February 2006 to May 2009, 11 cases (11 fingers) of finger pulp defect with tendon and bone exposure were treated, including 8 males and 3 females with an average age of 29 years (range, 23-40 years). The defect locations were thumb in 2 cases, index finger in 5 cases, and middle finger in 4 cases. The defect size ranged from 1.0 cm × 1.0 cm to 2.5 cm × 2.0 cm. The time frominjury to operation was 1-9 hours. The flap size ranged from 1.5 cm × 1.5 cm to 3.0 cm × 2.5 cm. Five flaps carried the dorsal branch of digital nerve, 6 flaps carried nervi digitales dorsales. The flaps were cut from proximal radial dorsal ring finger in 4 cases and from promximal ulnar dorsal ring finger in 7 cases. Defect of donor site was repaired with full-thickness skin grafting. Results All flaps and grafted skins survived; wound and incision of donor site achieved heal ing by first intention Eleven patients were followed up 6 to 24 months with an average of 12 months. The other finger flaps had good texture and shape except for 1 flap with sl ightly bloated. The activities of finger distal interphalangeal joint were normal, the two-point discrimination of finger pulp was 7-12 mm. The extension and flexion activities of donor fingers were normal, the ringl ike thread scar left at the donor site. Conclusion It is an ideal method to use the neurovascular free flap based on dorsal branch of digital artery of ring finger graft for repair of finger pulp defect, which has the advantages of simple operation, good appearance, and functional recovery.
OBJECTIVE: To investigate the therapeutic effect of flap transplantation in repairing soft tissue defects of children. METHODS: From January 1997 to May 2002, 75 cases of different soft tissue defects (52 males and 23 females, with the age of 3-14 years) were repaired by axial and non-axial flaps transfer, and axial flaps transplantation by microvascular anastomosis. The flaps area ranged from 3 cm x 5 cm to 15 cm x 42 cm. Emergency operation was performed in 26 cases and secondary operation in 49 cases (infective wound such as osteomyelitis and plate extra-exposed of fracture). The defect regions included the forearm, back of the hand, thumb, index finger, leg and foot. The types of flap graft and application range included 39 cases of axial flaps transfer or transplantation (27 cases of along- or contra-transfer of transplantation and 12 cases of microvascular anastomosis). The non-axial flaps transfer were designed along- or contra-transfer near the wound area in 36 cases. The ratio of length to width was 2.5:1-3.5:1 in 27 cases, and larger than 3.5:1 in 9 cases. Adequate anesthesia method should be chosen according to the characteristics of children, non-traumatic operating during surgery and postoperative supervision and nursing of flaps should also be paid enough attention. RESULTS: After operation, blood circulation crisis occurred in 2 cases (1 case of artery failure and 1 case of vein failure). The flaps survived in 37 cases and partially survived in 1 case and necrosed in 1 case. The survival rate was 96.2%. The postoperative follow-up period was 3 to 60 months, the blood supply, elasticity and texture of flaps were good. The effect of repair was satisfactory. CONCLUSION: Different types of transplantation of blood-supply of flaps may repair the different types of soft tissue defects in children. Free flap transplantation is safe and beneficial in children, different defects of soft tissue were repaired by axial and non-axial flaps transfer, axial flaps transplantation by microvascular anastomosis. Non-traumatic operating and postoperative supervision and nursing of flaps should also be paid enough attention.
OBJECTIVE: To evaluate clinical result of reconstructed thumb and finger with a free hallux nail flap(HNF) and frozen-phalanx-joint-tendon-sheath composite tissue allograft in 270 cases. METHODS: The patients were followed up with reexamination in the ambulant clinic, communication, X-ray photography, lab-examination, isotope 99mTc MDP and reoperation. The data were analyzed by statistics or proved by clinical observation, which were followed up for five years in average (ranging from five months to sixteen years). RESULTS: Enveloping the allogeneic finger composite tissue with self-HNF and pieces of phalanx of great toe, it could reconstruct a thumb or finger with good contour and nutrition. The excellent rate of opposition function of the reconstructed thumbs was 71.91%. The sense of the fingers recovered after 3 months to 8 months of operation. Two-point discrimination was 3 mm to 15 mm. The junction between implanted allo-phalanges and auto-phalanges could be hastened by implanted with vascularized autogenous phalanx pieces in the HNF. The isotope 99mTc MDP was used to take X-ray photography in 24 cases for four months to 9 years and seven months, which showed that the blood vessels grew into the allo-phalanges. However, the Charcot’s arthropathy of allogeneic joints and bony absorption still could be seen in some cases. That might be concerned with chronic abrasion of joint or chronic rejection of host to graft. CONCLUSION: The operation is fit for repairing the defect of thumb or finger in any degree. The implanted vascularized self-phalanx pieces can promote bone union, but it can not prevent the allogeneic joints from arthropathy or bone absorption
Objective To investigate the appl ication and cl inical result of flap in the repair of wounds with Achilles tendon exposure. Methods Between May 2006 and May 2010, 21 patients with Achilles tendon skin defects were treated with microsurgical reconstruction. There were 15 males and 6 females, aged 7-63 years with a median of 34 years. The defect causesincluded sport injury in 4 cases, wheel twist injury in 7 cases, crush injury in 5 cases, chronic ulcer in 3 cases, and Achilles tendon lengthening in 2 cases. The areas of wounds with Achilles tendon exposure ranged from 2 cm × 2 cm to 10 cm × 8 cm. After debridement, wounds were repaired with the medial malleolus fasciocutaneous flap (5 cases), sural neurocutaneous vascular flap (8 cases), foot lateral flap (2 cases), foot medial flap (2 cases), and peroneal artery perforator flap (4 cases). The size of the flaps ranged from 3 cm × 3 cm to 12 cm × 10 cm. The donor sites were either sutured directly or covered with intermediate spl it thickness skin grafts. The Achilles tendon rupture was sutured directly (2 cases) or reconstructed by the way of Abraham (2 cases). Results All flaps survived and wounds healed by first intention except 2 flaps with edge necrosis. Twenty-one patients were followed up 6-18 months (mean, 12 months). The flaps had good appearance and texture without abrasion or ulceration. The walking pattern was normal, and the two point discrimination was 10-20 mm with an average of 14 mm. The Ameritan Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale assessment revealed that 10 patients had an excellent result, 7 had a good result, 3 had a fair result, and 1 had a poor result with an excellent and good rate of 81.0%. Fourteen cases could l ift the heels with power; 5 cases could l ift the heels without power sl ightly; and 2 cases could not l ift the heels. Conclusion The wounds with Achilles tendon exposure should be repaired as soon as possible by appropriate flap according to the condition of wound.
Objective To investigate the application of free flaps in combinedtransplantation and its clinical outcome. Methods From January 1991 to December 2003, 56 cases of combined transplantation involving cutaneous or myocutaneous flaps were performed to repair extremely large soft tissue defects, large-sized skin and segmental bone defects and to simultaneously reconstruct the missing thumb andrepair the associated skin defects in the first web space.Of the 56 patients, 37 were males, 19 were females. Their ages ranged from 5 to 41, 27.6 in average.The transplants included latissimus dorsi myocutaneous flap, scapular flap, lateral femoral flap, big toe skin-nail flap, and fibula. To establish blood circulation in the transplants, the common vascular pedicle was anastomosed directly to the vessels in the recipient site in 35 cases but to the selected vessels in the healthy limb in 21through a cross-bridge procedure. Results With failure in 2 cases of combined transplantation of latissimus dorsi myocutaneous flap and vascularized fibula, all the transplants survived well. In the 32 cases of long bone defects with successful repair, the transplanted fibulas united with host bones 14.5 weeks after operation on the average. A mean follow-up of 28 (10-128) months revealed thatfunction in all cases was recovered, while one patient, who underwent a successful combined transplantation of latissimus dorsi myocutaneous flap and vascularized fibula, required amputation of the involved leg 3 years after repair because of the repeated ulcers in the toes. Conclusion The application of free flaps incombined transplantation can lead to an effective repair of complicated tissue defects of the limb and to a successful reconstruction of the associated missing thumb.
Objective To summarize the clinical effects of the repairing methods for deep wounds of the foot and ankle. Methods From March 2002 to June 2006, 49 patients with skin and deep tissue defects of the foot and ankle underwent the repairing treatment. Of them, 36 were males and 13 were females, aged 16 to 67 years( 39 years on average). The causes of injuries included mangled injury in 24 cases, high fall injury in 9 cases, cut injury in 7 cases, malignant soft tissue tumor in 5 cases, decubital ulcer in 2 cases, and electric burn in 2 cases. Of the 49 cases, 19 were in left side and 30 in right side. The defect size of skin ranged from 3 cm×2 cm to 20 cm×15 cm and deep tissue injuries were accompanied by defects of tendon and ligament in 24 cases, by damage of joint in 12 cases, and by bone defect in 9 cases, and 35 of them had infections, and 2 of them had diabetes of stage 2. The time between the injury and surgery ranged from 4 hours to 1 year.The wounds were repaired separately by local flap(3 cm×3 cm to 6 cm×4 cm) in 15 cases, local island flap(8 cm×5 cm to 12 cm×7 cm) in 25 cases, free flap(15 cm×11 cm to 24 cm×17 cm) in 4 cases, and cross leg flap(5 cm×4 cm to 8 cm×6 cm) in 5 cases. In 24 cases of defects of tendon and ligament, 15 underwent the reconstruction in one-stage operations,9 in two-satge operation.In 9 cases accompanied by bone defect, twostage bone grafting (12-64 g) was given after wound healed. Results All of the 49 flaps survived. Fortysix healed by the first intention and 3 with distal edge necrosis healed after skin grafting. Two patients with sinus formation healed after 68 months of dressing change. All the cases were followed up 6 months to 3 years, and all the flaps were well developed, the functions of the foot and ankle were satisfactory. Conclusion It can get an excellent result of appearance and function recovery repairing deep wounds of the foot and ankle with proper flaps in earlier time.
Objective To explore the application of the improved operative technique and clinical results of sural nerve nutritional vessel axial flap repairing the soft tissue defects of the lower leg,the ankle and the foot. Methods From January 1999 to Novenber 2004,the modified flaps were applied in 22 cases of soft tissue defect on the basis of anatomy of the intermusclar septum perforating branches of peroneal artery and the sural nerve nutritional vessel.There were 14 males and 8 females. Their ages ranged from 5 to 54 years.According to the position and size of the soft tissue defects, the sural nerve nutritional vessel flap pedicled with the perforating branch of the peroneal artery in the lower leg were desingned and obtained to repair the soft tissue defects of the lower leg,the ankle and the foot.The flap size ranged from 13cm×12cm to 30cm×20cm. The vessel pedicle of perforating branches ranged from 1.7cm to 3cm.The distribution of the vessel pedicle of perforating branches ranged from4.5cm to 8cm on the lateral malleolus.The diameters of vessel ranged from 1mm to 1.2mm. Results The flap pedicle with the terminal branch of the peroneal artery was used in 13 cases, the other branches were used in 9 cases. Among of 22 cases,the sural nerve were anastomosed with the acceptor sensory nerve in 4 cases. The skin sense were satisfactory after 1 year of operationnd 2-point discrimination was 10-13mm. All flaps survived completely in 22 cases. The outline andfunction were satisfactory during 6-18 months follow-up. Conclusion The blood supply of this flap is reliable. Flap elevation is easy. The size of flap is large enough to repair skin defects of the lower leg, the ankle and the foot.
Objective To compare the effects of flap delay and vascular endothelial growth factor (VEGF) on the viability of the rat dorsal flap. Methods Thirty rats were divided into 3 groups: saline group, flap delay group and VEGF group. The rats in flap delay group underwent flap delay by keeping bipedicle untouched, and the cranial pedicle was cut 7 days later. The rats in VEGF group were given VEGF solution locally when the flaps were elevated in the operation. The ratsin saline group were given saline solution in the same way. Five days after thesingle pedicle flaps were performed, the flap survival rate was measured. Theflap tissues were collected to measure and analyze the microvascular density, diameter and sectional area by immunochemical method. Results The flap survival rate of flap delay group was similar to that of VEGF group andthere is no statistically significant difference(Pgt;0.05). The vascular diameter of flap delay group was much larger than that of saline group and VEGF group, showing statistically significant difference (Plt;0.05). The vascular density of VEGF group was much higher than that of saline group and flap delay group, showing statistically significant difference (Plt;0.05). The vascular sectional area of flap delay group was similar to that of VEGF group(Pgt;0.05). Conclusion The change in the flap after flap delayis manifested as obvious dilatation of microvessels, while the change in the flap after the injection of VEGF is manifested as obvious vascular proliferation. Both flap delay and VEGF can increase the vascular sectional area and the viability of the flap, but the mechanism is different.
Objective To investigate the surgical methods and cl inical results of reconstructing soft tissue defects in dorsum of forefoot with distally based saphenous neurocutaneous flap of lower rotating point. Methods From January 2005 to August 2007, 6 cases of soft tissue defects in dorsum of forefoot, including 4 males and 2 females aged 28-53 years, were treated with the distally based saphenous neurocutaneous flaps of lower rotating point. The soft tissue defect was in left foot in 2 cases and in right foot in 4 cases. Five cases of soft tissue defects were caused by crush, and 1 case was caused by traffic accident. Tendons and bones were exposed in all cases. The defects after debridement were 7.0 cm × 5.0 cm to 9.0 cm × 5.5 cm in size. Emergency operation was performed in 2 cases and selective operation in 4 cases. Rotating point of the flaps was from 1 to 3 cm above medial malleolus. The size of the flaps ranged from 8.0 cm × 6.0 cm to 13.0 cm × 6.5 cm. Neuroanastomosis was performed in 2 cases of the flaps. Skin defects in donor site were repaired with thickness skin graft. Results Four cases of the transferred flaps survived completely and the other 2 cases began to swell and emerge water bl ister from the distant end of the flap after operation, which resulted in distal superficial necrosis of flaps, heal ing was achieved after change dressings and skin grafted. Skin graft in donor site survived completely in all cases. All cases were followed up from 6 to 18 months. The color and texture and thickness of theflaps were similar to reci pient site. Pain sensation and warmth sensation of the 2 flaps whose cutaneous nerve were anastomosed recovered completely, two point discrimination were 8 mm and 9 mm respectively. Sensation and warmth sensation of the 4 flaps whose cutaneous nerve were not anastomosed recovered partly. All patients returned to their normal walking and running activities and no ulceration occurred. No donor site morbidity was encountered. Conclusion Blood supply of the distally based saphenous neurocutaneous flap of lower rotating point is sufficient, the flap is especially useful for repair of soft tissue defects in dorsum of forefoot.
OBJECTIVE: To evaluate the effect of vascular endothelial growth factor(VEGF) 165 or basic fibroblast growth factor (bFGF), which was slowly-released in fibrin glue patch, on expanded prefabricated flaps in rabbits to facilitate the neoangiogenesis process. METHODS: A total of 53 rabbits were divided randomly into 6 groups. The central auricular vascular bundle of the ear was implanted into the expanded prefabricated flap as the pedicle. Fibrin glue, sandwiched between the expander and the implanted vessels, was adopted for topical delivering and slow-releasing of VEGF(625 ng) or bFGF(2880U). After 14 days, the island flap with the implanted vascular bundles as the pedicle was elevated, sutured back to its original position and then harvested more 3 days later. Neoangiogenesis was measured by digital recording of survival area, laser Doppler flowmetry, PCNA immunohistochemistry, TUNEL, ink and PbO infusions. RESULTS: When compared with the other groups, flap survival improved; neoangiogenesis of flaps increased, together with the blood flow enhanced in the groups applied growth factors. The reduced cellular apoptosis and the increased proliferation were also observed. CONCLUSION: VEGF or bFGF slowly-released by fibrin glue shows the potential to facilitate neoangiogenesis and accelerate maturation of the expanded prefabricated flap.