Versatility of Reverse Sural Fasciocutaneous Flap for Reconstruction of Distal Lower Limb Soft tissue Defects

Summary： In this study we present our experiences with the reverse sural fasciocutaneous flap to reconstruct the distal lower limb soft tissue defects caused by traumatic injuries. These flap graftings were carried out from Oct. 2010 to Dec. 2012 in our department. The series consisted of 36 patients, including 21 men and 15 women with an average age of 46.2 years （14-83 years） and with a medium followp period of 18 months （12-24 months）. Of all the cases of acute trauma, there were 10 eases of trauma of distal tibia, 9 cases of trauma of perimalleolus, and 17 cases of trauma of midfoot and forefoot. Related risk factors in the patients were diabetes （2 cases）, advanced age （〉65 years, 3 cases） and ciga- rette smoking （6 cases）. The reverse flow sural island flap irrigation depended on lower perforators of the peroneal artery. The fasciocutaneous pedicle was 3-4 cm in width and the anatomical structures consisted of the superficial and deep fascia, the sural nerve, short saphenous vein, superficial sural artery together with an islet of subcutaneous cellular tissue and skin. The most proximal border of the flap was only 1.5 cm away from the popliteal skin crease and the pivot point was 5-7 cm above the tip of the lateral malleolus. All the flaps survived. No arterial crisis occurred in any case. The venous congestion occurred in 2 cases and got better after raising the limbs and bloodletting. Only in an old man, 1.5 cm necrosis of distal margin of his flap occurred and finally healed after continuous dressing change. One-stage skin grafting was performed, and all the donor sites were sutured and successfully healed. It was concluded that the reverse sural fasciocutaneous flap is safe and reliable to extend to the proximal third even near the popliteal skin crease. We also concluded this flap can be safely and efficiently used to treat patients with large and far soft-tissue defects from the distal leg to the forefoot with more versatility and it is easier to reach the recipient sites.

Applied distally based peroneus brevis muscle flaps for coverage of the soft tissue defects over the lower one-third of the leg, ankle and foot

Objective To investigate a simple, valuable new method for coverage of the soft tissue defect over the lower one-third of the leg, ankle and the foot. Methods The distally based peroneus brevis muscle fkps were applied for coverage of the soft tissue defects over the lower one-third of the leg,the ankle and the foot. The muscle flaps were covered with split-thickness skin grafts. Results The distally based peroneus brevis muscle flaps were applied for coverage of the soft tissue defects over the lower one-third of the leg, the ankle and the foot in 16 cases. The larges area of the soft tissue defect was 5 cm × 7 cm. The smallest was 3 cm × 4 cm. Primary healing occured in 14 cases undergoing muscle flap construction, second-stage healing occured in 2 cases, no total flap necrosis occured in any cases. Conclusion ThisChina Medical Abstracts(Surgery) technigue is a simple and complication are lesser. The successful rates are higher. This muscle flap is suitable to the mudium or small soft tissue

Lower rotating point nutrient vessels of sural nerve flap with distant pedicled repairing soft tissue defect of foot and ankle

To explore lower rotating potint nutrient vessels of sural nerve flap with distant pedicled repairing the soft tissue defect of foot and ankle.Methods Lay a foundation of anatomic studying from february 2003 to March 2004,using lower rotating point nutrient vessels of sural nerve flap with distant pedicled repairing the soft tissue defect of foot and ankle in 11 cases.Cause of injuring:traffic accident 7 cases,crushing 1 case,saw injury 1 case,skin cancer 1 case,chronic ulcer 1 case.Areas:foot heel 6 cases,shank lower section 2 cases,heel tendon 2 cases,the distant back of the foot 1 case.Using the flap axis point was 1～3 cm above the pin of the external heel,average 2 cm.The scope of the flap was 6.0 cm×8.0 cm～12.0 cm～18.0 cm.Results All sural nerve flaps were alive.Of them,2 cases have distant part necrosis,accompanying with subcutaneous tissue,1 case heels after change dressings,another heels after skin grafting.All case can walk as usual,the flap was wear-resisting and keenly feel.Conclusion Lower rotating point nutrient vessels of sural nerve flap,donner area was fine,available area was large,skin in the pink,easy grafting,without main blood vessel damage,survival rate high,it is a good donner area in repairing around heel,foot and shank lower section.7 refs,1 tab.

Management of soft tissue defects of the thumb

Hand surgery has undergone substantial changes in recent years,especially for reconstructive surgery techniques.We discuss the management of soft tissue defects of the thumb,discussing indications,and operative pearls and pitfalls.We cover non-operative treatment and local advancement flaps for small distal soft tissue defects and pedicled flaps for more significant defects.We also discuss composite vascularized free flaps such as second-toe neurocutaneous flaps and partial hallux transfer for compound defects or total amputations.This article aims to provide hand surgeons with an update on reconstructing an injured thumb.

Reconstruction of soft tissue defect of the extremity with the perforator flap from inguinal region

Background The perforator flap has become a very useful reconstructive means of soft tissue defect of extremities. The perforator flap from the inguinal region has advantages that include the ability to cover a large area with little donor site morbidity and provision of suitable thickness for reconstruction. Methods From July 1, 2005 to June 30, 2007, 10 patients with various types of soft tissue defect underwent reconstruction with 10 perforator flaps from the inguinal region. Six flaps were applied to the upper extremities and four flaps to the lower extremities. The dimensions of the transferred flaps ranged from 7-30 cm in length and 4-10 cm in width. Results The postoperative course of all 10 flaps was uneventful and all flaps survived. Distal small partial necrosis was observed in one case due to arterial insufficiency of the distal part of the flap. All patients were satisfied with the functional and esthetic resurfacing outcome. Conclusion Use of perforator flap from the inguinal region could overcome the disadvantages of the traditional free groin flap, and represents a safe and useful tool for coverage of soft tissue defects.

Efficacy and safety of external tissue expansion technique in the treatment of soft tissue defects:a systematic review and meta-analysis of outcomes and complication rates

Background:Currently,various external tissue expansion devices are becoming widely used.Considering the scarcity of relevant application standards,this systematic review was performed to explore the effectiveness and safety of external tissue expansion techniques for the reconstruction of soft tissue defects.Method:A systematic review and meta-analysis on the efficacy and safety of external tissue expansion technique was conducted.A comprehensive search was performed in the following electronic databases:PubMed/Medline,Embase,Cochrane Library(Wiley Online Library),andWeb of Science.Studies reporting patients with soft tissue defects under the treatment of external tissue expansion technique were included.Results:A total of 66 studies with 22 different types of external tissue expansion devices met the inclusion criteria.We performed a descriptive analysis of different kinds of devices.A single-arm meta-analysis was performed to evaluate the efficacy and safety of the external tissue expansion technique for different aetiologies.The pooled mean wound healing time among patients with defects after fasciotomy was 10.548 days[95%confidence interval(CI)=5.796-15.299].The pooled median wound healing times of patients with defects after excisional surgery,trauma,chronic ulcers and abdominal defects were 11.218 days(95%CI=6.183-16.253),11.561 days(95%CI=7.062-16.060),15.956 days(95%CI=11.916-19.996)and 12.853 days(95%CI=9.444-16.227),respectively.The pooled wound healing rates of patients with defects after fasciotomy,excisional surgery,trauma,chronic ulcers and abdominal defects were 93.8%(95%CI=87.1-98.2%),97.2%(95%CI=92.2-99.7%),97.0%(95%CI=91.2-99.8%),99.5%(95%CI=97.6-100%),and 96.8%(95%CI=79.2-100%),respectively.We performed a subgroup analysis in patients with diabetic ulcers and open abdominal wounds.The pooled median wound healing time of patients with diabetic ulcers was 11.730 days(95%CI=10.334-13.125).The pooled median wound healing time of patients with open abdomen defects was 48.810 days(95%CI=35.557-62.063)and the pooled successful healing rate was 68.8%(95%CI=45.9-88.1%).A total of 1686 patients were included,265(15.7%)of whom experienced complications.The most common complication was dehiscence(n=53,3.14%).Conclusions:Our systematic review is the first to demonstrate the efficacy and safety of external tissue expansion in the management of soft tissue defects.However,we must interpret the meta-analysis results with caution considering the limitations of this review.Large-scale randomized controlled trials and long-term follow-up studies are still needed to confirm the effectiveness and evaluate the quality of healing.

Consecutive flap transfer for repairing massive soft tissue defects in the opisthenar with improved donor site closure

Objective：To explore a surgical model of utilizing consecutive free scapular flap and adjacent pedicled flap transfer for repairing massive soft tissue defects on the dorsum of the hand while minimizing the donor site morbidity.Methods：Six patients with massive soft tissue injuries on the opisthenar and forearm were treated with free scapular flaps.Afterwards,a pedicled flap adjacent to the donor site was transferred to cover the donor site defect by direct closure.Results：All six free scapular flaps survived without signs of infection.Three adjacent pedicled flaps presented minor signs of insufficient blood flow on the distal apex,which resolved after six weeks with only conservative therapy.All the incisions healed without other complications.At six-month follow-up,the patients regained full shoulder function.Conclusion：With the assistance of an adjacent pedicled flap,the scapular flap is a highly applicable approach in repairing massive soft tissue defects in the opisthenar.It can achieve positive outcomes in both reconstructive and aesthetic aspects.

Flap transplantation for treatment of pelvic fracture and defective hip

A case of flap transplantation for treatment of pelvic fracture and defective hip in the Third Affiliated Hospital of Inner Mongolia Medical University was collected and analyzed on the basis of diagnosis,physical examination and treatment.The patient was in serious condition with large necrotic area and prone to lead to various complications.The paper aims to share experience and provide references for similar cases amongst surgeons.

Application of vascular endothelial cells in stem cell medicine

Stem cell medicine is gaining momentum in the development of therapy for various end-stage diseases.The search for new seed cells and exploration of their application prospects are topics of interest in stem cell medicine.In recent years,vascular endothelial cells(VECs)have attracted wide attention from scholars.VECs,which form the inner lining of blood vessels,are critically involved in many physiological functions,including permeability,angiogenesis,blood pressure regulation,immunity,and pathological development,such as atherosclerosis and malignant tumors.VECs have significant therapeutic effects and broad application prospects in stem cell medicine for the treatment of various refractory diseases,including atherosclerosis,myocardial infarction,diabetic complications,hypertension,coronavirus disease 2019,and malignant tumors.On the one hand,VECs and their extracellular vesicles can be directly used for the treatment of these diseases.On the other hand,VECs can be used as therapeutic targets for some diseases.However,there are still some obstacles to the use of VECs in stem cell medicine.In this review,advances in the applications and challenges that come with the use of these cells are discussed.

Xenogeneic stem cell transplantation:Research progress and clinical prospects

Organ transplantation is the ultimate treatment for end-stage diseases such as heart and liver failure.However,the severe shortage of donor organs has limited the organ transplantation progress.Xenogeneic stem cell transplantation provides a new strategy to solve this problem.Researchers have shown that xenogeneic stem cell transplantation has significant therapeutic effects and broad application prospects in treating liver failure,myocardial infarction,advanced type 1 diabetes mellitus,myelosuppression,and other end-stage diseases by replacing the dysfunctional cells directly or improving the endogenous regenerative milieu.In this review,the sources,problems and solutions,and potential clinical applications of xenogeneic stem cell transplantation will be discussed.

Quadrilobed superior gluteal artery perforator flap for sacrococcygeal defects

Background Perforator flaps are used extensively in repairing soft tissue defects. Superior gluteal artery perforator flaps are used for repairing sacral defects, but the tension required for direct closure of the donor area after harvesting of relatively large flaps carries a risk of postoperative dehiscence. This research was to investigate a modified superior gluteal artery perforator flap for repairing sacrococcygeal soft tissue defects. Methods From June 2003 to April 2010, we used our newly designed superior gluteal artery perforator flap for repair of sacrococcygeal soft tissue defects in 10 patients （study group）. The wound and donor areas were measured, and the flaps were designed accordingly. Wound healing was assessed over a follow-up period of 6-38 months. From January 1998 to February 2003, twelve patients with sacrococcygeal pressure sores were treated with traditional methods, VY advancement flaps or oblong flaps, as control group. Results After debridement, the soft tissue defects ranged from 12 cm× 10 cm to 26 cm× 22 cm （mean 16.3 cm× 13.5 cm）. Four patients were treated using right-sided flaps ranging from 15 cm × 11 cm to 25 cm × 20 cm （mean 18.2 cm × 14 cm）. Four patients were treated using left-sided flaps, and two were treated using both right- and left-sided flaps. Suction drains were removed on postoperative Days 3-21 （mean 5.9） and sutures were removed on postoperative Days 12-14. Each flap included 1-2 perforators for each of the donor and recipient sites. Donor sites were closed directly. All flaps survived. In eight patients, the wounds healed after single-stage surgery. After further debridement, the wounds of the remaining two patients were considered healed on postoperative Days 26 and 33, respectively. The rate of first intention in the study group （80%, 8/10） significantly increased than that of control group （（25%, 3/12）, X2=4.583, P=0.032）. Follow-up examinations found that the flaps had a soft texture without ulceration. In the two patients without paraplegia, the range of motion of the hip joints was not affected. Conclusion The use of the quadrilobed superior gluteal artery perforator flap can overcome the disadvantages of traditional perforator flaps and represents an improved approach for repairing soft tissue defects in the sacrococcygeal region.

Superiorly based perforator plus fl ap for inguinal defects

Aim:Inguinal block dissections for metastasis to inguinal lymph nodes and occasionally trauma are always associated with soft tissue loss over the groin region.A clinical study was undertaken to demonstrate the ability to utilize a superiorly-based perforatorflap with reliable vascularity and less donor site morbidity to cover defects in the inguinal region.Methods:A prospective study was performed on 7 patients with inguinal soft tissue defects managed in our institution from January 2013 to September 2013.During the study period,a“superiorly-based perforator plusflap”was used for soft tissue coverage over the femoral vessels in the inguinal region.Hyperbaric oxygen therapy was administered postoperatively.The postoperative period,hospital course,and follow-up after radiotherapy was documented in patients with inguinal block dissection.Results:Seven patients presented with soft tissue defects in the inguinal region.Five of the defects were secondary to prior surgery,and 2 were secondary to trauma.A superiorly-based perforator plusflap was performed in all patients.The defect sizes ranged from 9 cm×4 cm to 17 cm×8 cm.Theflap dimensions ranged from 12 cm×5 cm to 20 cm×10 cm.No secondary procedures were necessary following surgery.Postoperatively,there was no evidence of partial or totalflap loss.Noflap revisions were required,and no complications were experienced at either the donor or recipient site following radiotherapy.Patients were followed-up for 10-18 months.Conclusion:Inguinal defects require stable soft tissue coverage to withstand radiotherapy following inguinal block dissection surgery,and are susceptible to wound complications.The superiorly-based perforator plusflap technique is simple,requires little operative time,and is a reliableflap for coverage of the femoral vessels and inguinal region with improved tolerance to postoperative radiotherapy.

Supermicrosurgical reconstruction of knee defect using superior medial genicular perforator as a recipient vessel

A 24-year-old male presented after being involved in a motorcycle accident and was found to have soft tissue defects of the knee with exposure of patella.Due to the severe injury from the popliteal fossa to the posterior aspects of the lower leg,repair with a free flap from anterolateral thigh perforator was planned instead of local calf muscle flap.Preoperative angiography was performed,and it showed that superior medial genicular perforator was patent compared with unreliable filling of the superior lateral genicular perforator.The soft tissue defect was repaired using the superior medial genicular perforator as the recipient vessel.This was performed by creating perforator to perforator anastomosis(supermicrosurgery).The flap survived successfully,and the patient was able to ambulate in a few weeks without serious complications.This case indicates that superior medial genicular perforator can be used as the recipient vessel for covering the soft tissue defects of the knee caused by blunt injury.

Artificial periosteum in bone defect repair--A review

Periosteum is a thin membrane that encases the surfaces of most bones.It is composed of an outer fibrous layer contains longitudinally oriented cells and collagen fibers and an inner cambial layer that consists of multipotent mesenchymal stem cells（MSCs）and osteogenic progenitor cells.Periosteum has a function of regulating cell and collagen arrangement,which is important to the integrity,modelling and remodelling of bone,particularly during bone defect repair.Apart from autograft and allograft,artificial periosteum,or tissue-engineered periosteum mimicking native periosteum in structure or function,made up of small intestinal submucosa,acellular dermis,induced membrane,cell sheets,and polymeric scaffolds,and so on,has been developed to be used in bone defect repair.In this review,we classify the artificial periosteum into three approaches based on the material source,that is,native tissues,scaffoldfree cell sheets and scaffold-cell composites.Mechanisms,methods and efficacy of each approach are provided.Existing obstacles and enabling technologies for future directions are also discussed.

Free peroneal perforator-based sural neurofasciocutaneous flaps for reconstruction of hand and forearm

Background Sural neurofasciocutaneous flap has been popularly used as an excellent option for the coverage of soft tissue defects in the lower third of leg, ankle and foot, but its free transplantation has been rarely reported. The objective of our work was to investigate the operative technique and clinical results of repairing the soft tissue defects of hand and forearm with free peroneal perforator-based sural neurofasciocutaneous flap. Methods Between May 2006 and March 2007, 10 patients including 7 men and 3 women were treated. Their ages ranged from 22 to 51 years. They presented to emergency with large soft tissue defects of 16 cm × 7 cm to 24 cm × 10 cm in size in hand and forearm after injured by motor vehicle accidents （2 cases） or crushed by machine （8 cases）. Thorough debridements and primary treatments to associated tendon ruptures or bone fractures were performed on emergency. And free peroneal perforator-based sural neurofasciocutaneous flaps were transplanted when the wound areas were stable at 5 to 7 days after emergency treatment. The flaps were designed along the axis of the sural nerve according to the shape and size of the soft tissue defects, with the peroneal perforator above the lateral malleolus as the pedicle and along with a part of the peroneal artery for vascular anastomosis. Then the flaps were harvested to repair the recipient sites with the peroneal artery anastomosed to the radial （or ulnar） artery and the peroneal veins to one of the radial （or ulnar） veins and the cephalic vein respectively. The flap sizes ranged from 18 cm × 8 cm to 25 cm × 12 cm. The donor areas were closed by skin grafts. Results All of the 10 flaps survived after surgeries. Marginal necrosis occurred in only 2 cases. The skin grafts survived entirely in the donor sites, and no obvious influence on the donor legs was observed. All of the transplanted flaps presented favourable contours and good functions at 9 to 12 months＇ follow-up. Conclusions Peroneal perforator-based sural neurofasciocutaneous flap has favourable appearance, constant vascular pedicle, reliable blood supply, large size of elevation, and minimal influence on the donor site. The free transplantation of this flap offers a satisfactory alternative for repairing the large soft tissue defects of forearm and hand.

The forehead flap:a valuable option in resource depleted environment

Aim:Reconstruction of orofacial soft tissue defect is often challenging and this is more difficult in resource challenged environment.This retrospective study highlights our experience with the use of forehead flap to overcome some of the challenges of orofacial reconstruction in a resource depleted environment.Methods:A 23-year retrospective analysis of all patients who had orofacial defect reconstruction using forehead flap in our department was undertaken.Information was sourced from patient’s case notes and operating theatre records.Data was analyzed using Statistical Package for Social Sciences(SPSS)version 16(SPSS Inc.,Chicago,IL,USA)and Microsoft Excel 2007(Microsoft,Redmond,WA,USA).Results:A total of 43 patients were managed within the period reviewed and consisted of 31(72.1%)males and 12(27.9%)females.Trauma 24(55.8%)accounted for most defect and the lip was the commonest site of defect.Complete forehead flap was used in 31(72.1%)of cases and when timing of defect repair is considered,delayed reconstruction was the preferred method.Postoperative complications was observed in 8(18.6%)patients and consisted of failed flap in 2(25.0%)patients,tumor recurrence in reconstructed site in 2(25.0%)patients and tumor occurrence in forehead flap donor site in 1(12.5%)patient.Conclusion:The forehead flap remains a reliable option in orofacial soft tissue defect reconstruction.It is easy to raise and can provide coverage for wide defects as far as the paramandibular and submandibular regions.Moreover,it does not require patient repositioning.