Soft tissue coverage using pedicled flap in combat zone: A case series

Background:Soft tissue reconstruction is typically conducted after evacuation from theater of operations.If circumstances do not allow timely evacuation,however,defect site may need to be reconstructed in the combat zone.Case presentation:A total of 41 patients with extremity soft tissue defect were treated using pedicled flaps by a single orthopedic surgeon during four deployments in Chad,Afghanistan and Mali between 2010 and 2017.The mean age was 25.6 years.A total of 46 injury sites in extremities required flap coverage:19 combat-related injuries(CRIs)and 27 non-combat related injuries(NCRIs).Twenty of the injury sites were infected.Overall,63 pedicled flap transfers were carried out:15 muscle flaps,35 local fasciocutaneous flaps and 13 distant fasciocutaneous flaps.The flap types used did not differ for CRIs or NCRIs.Mean follow-up was 71 days.Complications included deep infection(n=6),flap failure(n=1)and partial flap necrosis(n=1).Limb salvage rate was 92.7%(38/41).Conclusions:Soft tissue defect can be managed with simple pedicled flaps in theatre of operations if needed.Basic reconstructive procedures should be part of the training for military orthopedic surgeons.Trial registration:Retrospectively registered in January 2019(2019-0901-001).

The Pectoralis Major Myocutaneous Pedicled Flap Revisited

The pectoralis major myocutaneous pedicle flap (PMMF) is still being used by many surgeons and plays an important role in head and neck reconstruction. The purpose of this series was to review our 10 years’ experience with the PMMF in head and neck reconstruction. One hundred and two patients who underwent the PMMF technique were reviewed on the clinical records. Postoperative complications were classified into flap loss, hemorrhage, infection, fistula formation, wound dehiscence and donor site complication. Eighty two patients (80.4%) demonstrated no complication. Six patients among 102 patients (5.9%) demonstrated total or partial skin necroses. Three female patients were completely dissatisfied with the cosmetic appearance after the PMMF. One of them required a reconstructive surgery with the latissimusdorsi flap. Without surgical expertise in plastic surgical field, an ear-nose-throat or an oral surgeon can performed the PMMF technique provided the operator is well aware of serious and frequent complications of this “workhorse” procedure.

Preliminary study on the efficacy of lacrimal duct reconstruction with pedicled conjunctival flap in the treatment of severe lacrimal canalicular obstruction with conjunctivochalasis

AIM:To determine the efficacy and safety of pedicled conjunctival lacrimal duct reconstruction in the treatment of severe obstruction of superior and inferior lacrimal canaliculi with conjunctivochalasis.METHODS:This study was per formed as a retrospective analysis of patients who received conjunctival dacryocystorhinostomy with pedicled conjunctival flap reconstruction combined with tube intubation due to severe superior and inferior lacrimal canalicular obstruction with conjunctivochalasis from January 2019 to October 2019.The clinical data included the degree of preoperative epiphora and postoperative relief,preoperative examination of lacrimal duct computed tomography and ultrasound biomicroscopy,postoperative evaluation of lacrimal duct function by chloramphenicol taste and fluorescein dye disappearance test,etc.Syringing was carried out to determine the reconstruction and patency of the lacrimal duct.RESULTS:All 9 patients(9 eyes)had severe canalicular obstruction with conjunctivochalasis.The patients included 4 males and 5 females aged between 47–65y with an average age of 52.2±6.7y.At 3mo follow-up,the tube was removed and the patients were followed for a further 3mo.After tube removal,6 patients showed no epiphora.These patients also had positive chloramphenicol tastes and normal fluorescein dye disappearance test results.Two patientshad epiphora.Also,syringing showed partial patency of the reconstructed lacrimal duct.One patient had no improvement in epiphora with negative chloramphenicol taste and fluorescein dye disappearance test results and obstruction of the reconstructed lacrimal duct.The total effective rate of the operation was 8/9,with no serious complications.CONCLUSION:Pedicled conjunctival lacrimal duct reconstruction conjunctival dacryocystorhinostomy is safe and effective for superior and inferior canalicular obstruction with conjunctivochalasis.

Indications and Outcomes for Pedicled Pectoralis Major Myocutaneous Flaps at a Primary Microvascular Head and Neck Reconstructive Center

The pectoralis major musculocutaneous (PMMC) flap has been a useful technique for head and neck reconstruction since its first description by Ariyan in 1979. However, techniques in microvascular surgery have since evolved and recently free tissue transfer has played an important role in head and neck reconstruction. Although we use free flaps as the first choice for head and neck reconstruction, similar to many other institutions, some patients at our hospital have undergone reconstruction with PMMC flaps. We retrospectively analyzed the indications and outcomes of this reconstructive technique from our experience with 12 patients. The medical records of all patients who underwent PMMC flaps at Hokkaido Cancer Center from 2001 to 2010 were reviewed. Data concerning diagnosis, main indication, site of reconstruction, previous treatment, and postoperative complications were analyzed. Of the 12 PMMC flap surgeries performed, 3 were carried out as primary reconstructive procedures, whereas 9 were done as “salvage” procedures. Flap-related complications were observed in 6 cases. Partial flap loss developed in 4 patients, although there were no cases of total flap loss. There were 3 recurrent fistulae following reconstruction with PMMC flaps. The preoperative goals of performing PMMC flap surgery were met in 83% of our cases. The authors conclude that while free flap transfer is usually the first choice for head and neck reconstruction, PMMC flaps can produce acceptable results in certain situations.

Repair of oral mandibular defects with rib composite flap pedicled with internal thoracic

Objective To study feasibility and value of repair of oral mandibular defects with rib composite flap pedicled with internal thoracic vessels in basic level hospitals. Methods The clinical materials in 13 cases uith mandibular defects which were repaired with rib compos-

The relationship of tension and blood flow of the expanded pedicled fasciocutaneous flap in pig

Objective To evaluate the effect of wound closure tension on the blood flow of the expanded pedicled fasciocutaneous flap,so as to find the best tension for the blood supply of the flap.Methods 8 piglets,aged 9-12 months,were used.On

Applied anatomy of radial midforearm flap pedicled with intermuscular branch of radial artery

To provide anatomic basis for transposition of vascularized radial midforearm flap.Methods On 40 adult cadaveric upper limb specimens injected with red dye,the origin,course,branchs,diameters and anastomosis of intermuscular branch of radial artery and its cutaneous branch were observed.Results Originating from radial artery,intermuscular branch of radial artery descended along periosteum closely between pronator teres and supinator,the main stem was (4.8±1.0)cm in length and (1.2±0.2)mm in diameter.After its periosteal branches were sent off to distribute over middle and inferior shaft of radius,its cutaneous branch perforated from intermuscle and deep fascia and anastomosed with some other cutaneous branches in the forearm.Perforating point of the cutaneous branch was located (11.1±1.3)cm beneath lateral epicondyle of humerus,its diameter was about (0.6±0.1)mm.Conclusion Radial midforrarm flap pedicled with intermuscular branch of radial artery can be transferred to repair soft tissue defect of elbow,forearm or hand.7 refs.

Repairing small wounds around ankle by medial planta island flaps pedicled with anterior tibial artery perforator in front of inner malleolus

Objective To discuss the application of medial planta island flaps pedicled with anterior tibial artery perforator in front of inner malleolus for repairing small wounds around ankle Methods From Jan. 2005 to Jun. 2009,10 cases with small wounds around ankle

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.

Role of adipose-derived stromal cells in pedicle skin flap survival in experimental animal models

The use of skin flaps in reconstructive surgery is the first-line surgical treatment for the reconstruction of skin defects and is essentially considered the starting point of plastic surgery. Despite their excellent usability, their application includes general surgical risks or possible complications, the primary and most common is necrosis of the flap. To improve flap survival, researchers have used different methods, including the use of adiposederived stem cells, with significant positive results. In our research we will report the use of adipose-derived stem cells in pedicle skin flap survival based on current literature on various experimental models in animals.

Clinical outcomes with large macular holes using the tiled transplantation internal limiting membrane pedicle flap technique

AIM: To report the surgical technique and efficacy of the tiled transplantation internal limiting membrane(ILM) pedicle flap technique after vitrectomy for 33 patients with large macular hole(MH). METHODS: This study was a prospective noncontrolled interventional study. All patients were treated by vitrectomy, the tiled transplantation ILM pedicle flap and gas tamponade. All patients underwent visual acuity measurements and optical coherence tomography(OCT), during preoperative and the follow-up visits postoperative. RESULTS: Two high-myopic patient had flap dislocation during surgery. The thorough closure of MH following the tiled transplantation ILM pedicle flap technique was ultimately achieved in 31 patients observed by OCT imaging(93.94%) 1 wk after surgery. Visual acuity improved from 1.51±0.31(logMAR) preoperative to 0.92±0.30 6 mo after surgery(P=0.000). There were no significant changes in OCT finding during the follow-up period from 1 mo to 6 mo after surgery. CONCLUSION: The tiled transplantation ILM pedicle flap technique provides bridge for retinal gliosis to achieve successful closures of the large MHs, and the microenvironment of this technique is more similar to the normal physiological conditions.

Pedicle complex tissue flap transfer for reconstruction of duplicated thumbs with unequal size

BACKGROUND Thumb polydactyly is one of the most common congenital hand deformities,and the Bilhaut-Cloquet procedure or a modified one is often used.However,controversy remains over the rare instances in which both thumbs are not of similar length or far apart in distance.AIM To evaluate the clinical outcomes of pedicle complex tissue flap transfer in the treatment of duplicated thumbs with unequal size.METHODS From January 2014 to December 2020,15 patients underwent duplicated thumb reconstruction by pedicle complex tissue flap transfer at our hand surgery center.The technique was used when it was necessary to combine different tissues from both severed and preserved thumbs that were not of similar length or far apart in distance.Subjective parents’evaluations and functional outcomes(ALURRA and TATA criteria)were obtained.The alignment deviation,instability,range of motion(percent of opposite thumb)of the interphalangeal and metacarpophalangeal joints,and the aesthetic aspects,including circumference,length,nail size,and nail deformity,were used to assess the clinical outcomes.RESULTS The average age of patients at the time of surgery was 13 mo,and the mean final follow-up occurred at 42 mo.An appropriate volume with a stable joint and good appearance was obtained in 14 reconstructed thumbs.An unstable interphalangeal joint occurred in one thumb.The flexion-extension arc at the metacarpophalangeal joint was good,while that at the interphalangeal joint was poor.Most of the parents were satisfied with the cosmetic and functional results of the reconstructed thumbs.The mean ALURRA score was 21.8(range:20-24),and the Tada score was 6.9(range:5-8).Compared with the non-operated side,the length of the operated thumb was approximately 95%,the girth was 89%,and the nail width was 82.9%.The mean ranges of motion were 62.1%of that of the unaffected thumb in the interphalangeal joint and 78.3%in the metacarpophalangeal joint.CONCLUSION Harvesting a pedicle flap from a severed thumb is a safe and reliable procedure.Defects of the preserved thumb,such as the skin,nail,and bone,can be effectively restored using the complex tissue flap.

Subcutaneous pedicle Limberg flap for repairing skin defects in the face

Objective:To investigate the effect of a subcutaneous pedicle Limberg flap for the reconstruction of medium-sized skin defects in the face following skin tumor or scar excision. Methods: From August 2002 to June 2004,the subcutaneous pedicle Limberg flap was designed to repair facial skin defects in 17 patients(19 flaps),and the size of the lesions ranged from 2.0 cm×1.9 cm to 5.0 cm×4.5 cm.The operation was performed under general anesthesia in 2 children,and under local anesthesia in the remaining 15 patients. Results: All flaps survived with primary healing postoperatively.With a follow-up from 1 to 22 months,neither short-term nor long-term postoperative complications such as flap necrosis,hematoma,infection,visible dog-ear and trap door deformity were found,and functionally and cosmetically satisfactory outcomes were achieved. Conclusion: This subcutaneous pedicle Limberg flap provides a competitive repair alternative for the treatment of medium-sized skin defects in the face.

Subcutaneous island pedicle flap for aesthetic reconstruction of the face

Objective:To investigate the outcomes of subcutaneous island pedicle flap for reconstruction of the medium-sized facial skin defects. Methods: Eighty nine cases of facial defects within one cosmetic unit following removal of skin tumors or scars were reconstructed with advancement or transposition island pedicle flaps. Patient records and postoperative photographs were reviewed retrospectively. Both patients and other surgeons were asked to assess outcome variables. Results: All flaps survived with primary healing postoperatively. Patients and surgeons judged excellent or good overall outcomes in 95. 5% and 92. 7% of all evaluated cases, respectively. Conclusion: The subcutaneous island pedicle flap may be an extremely versatile and reliable method for aesthetic reconstruction of medium-sized facial defects in the patients of all time of life.

Application of vacuum sealing drainage in skin graft of calf pedicle island flap donor-site

Objective: To explore the clinical effect of vacuum sealing drainage on free dermatoplasty in the donor-site of calf pedicled island flap. Method: From January 2016 to January 2018, a total of 70 patients undergoing reconstruction of skin and soft tissue defects in ankles and legs with calf pedicle island flap in Foshan Traditional Chinese Medicine Hospital were selected into our research. Selected patients were divided into VSD group and pressure dressing group according to the order of surgery. The VSD group was treated with free skin grafting and vacuum sealing drainage after separation of donor-site flap. The pressure dressing group was treated with free skin grafting and traditional pressure dressing technology after the separation of donor-site flap. Visual acuity simulation scores (VAS) were observed and recorded on the 1st, 7th, and 14th day after surgery. The unpacking time, skin graft healing time, skin graft survival rate, infection rate and incidence of subcutaneous hematoma were compared between the two groups. Results: The VAS scores on the 7th and 14th day after surgery in the VSD group were lower than those in the pressure dressing group. The unpacking time and skin graft healing time of the VSD group were shorter than those of the pressure dressing group. The survival rate of skin graft in VSD group was higher than that in the pressure dressing group. The infection rate and the incidence of subcutaneous hematoma in the VSD group were lower than those in the pressure dressing group. Conclusion: Vacuum sealing drainage is beneficial to promote the healing of free skin grafts in the donor site of the calf pedicle island flap, relieve pain, reduce adverse reactions, safe and effective, and worthy of clinical promotion.

Treatment of large defect of abdominal wall after tumors resection by transposition of tissue flaps with pedicle

Objective To report evaluat of division region of abdominal wall large defect after tumors resection and repair methods by tissue flaps with pedicle. Methods Form October 1992 to September 2001, 8 cases large abdominal wall defect after malignant tumors resection(10 × 10 cm-32 cm×32 cm) were reviewed. The defectcontributed:Ⅰ region, 2 cases; twin-Ⅱ region, 2; Ⅲ region, 2; Ⅰ and Ⅱ region of one side, 1 and total abdominal wall,one case, The tissue flaps of transposition included: gracilis myocutaneous flaps, 4; retus abdominal myocutaneous flaps, 2; external abdominal obligue musculo-fascia flaps, 2; latissimus dorsi muscle, tensor fasciae latae muscle and retus femoris muscle flaps each, 1. One patient used MycroMesh also. Results In the course of peroperation, the incisions of 8 cases healed in first time; total tissue flaps survived and all pateints started exercise left the bed in 3 weeks. All 8 patients were followed up average of 2 years and 5 months: the success rate of reconstruction

Repair of facial skin defect with a skin flap of SMAS pedicle

To report a method of repair facial skin defects with a skin flap of SMAS pedicle.Methods According to the size of defect of skin,design a skin flap with SMAS pedicle for repair of defect.Results The method has been successfully applied for skin defects of eyelid and lip in 14 cases with satisfied results.The area of the largest flap was 5 cm×3 cm.Conclusion Repairing facial defects such as eyelid skin defect or lip skin defect with skin flap of SMAS pedicle is a very good method.The flap has a good blood supporting and satisfactory color and flexibility.5 refs,6 figs.

One-stage urethroplasty with circumferential vascular pedicle preputial island flap for perineal hypospadias

Objective To report the treatment of perineal hypospadias with one - stage urethroplaty with circumferential vascular pedicle preputial island flap. Methods A circumferential incision was made proximal to the cprona and the urethral plate to correct chordee. A U - shaped skin incision was then made surrounding the meatus。

Flap reconstruction of the knee: A review of current concepts and a proposed algorithm

A literature search focusing on flap knee reconstruction revealed much controversy regarding the optimal management of around the knee defects. Muscle flaps are the preferred option, mainly in infected wounds. Perforator flaps have recently been introduced in knee coverage with significant advantages due to low donor morbidity and long pedicles with wide arc of rotation. In the case of free flap the choice of recipient vessels is the key point to the reconstruction. Taking the published experience into account, a reconstructive algorithm is proposed according to the size and location of the wound, the presence of infection and/or 3-dimensional defect.

Salvage anastomosis in free PAP-flap breast reconstruction:What about free flap neovascularization?

Since the emergence of microsurgery in reconstructive surgery, free flaps have become a key tool in the management of patients with breast cancer. One such flap is the profunda artery perforator(PAP) flap. To date,there is no scientific consensus on whether voluminous free flaps remain dependent on their vascular pedicle throughout their lifespan. Therefore, the pedicle should always be carefully protected during revision surgery.In this article, we review the case of a middle-aged woman who suffered a pedicle transection needing reanastomosis during revision surgery six months after free-flap breast reconstruction. A 52-year-old woman who noticed a firm nodule in her right breast and armpit was referred to our department for surgical management. The Caucasian woman presented with no significant medical history or symptoms at the first consultation. Ultrasound-guided biopsy confirmed an invasive grade Ⅲ lobular carcinoma. Following staging,the patient underwent neoadjuvant chemotherapy before a right mastectomy with a complete homolateral axillary lymph node dissection and postoperative radiotherapy. One year after completing radiotherapy, free flap reconstruction with a PAP flap was performed, and six months later, revision surgery was required to enhance the volume of the reconstructed breast with a tissue expander and later an implant. Unfortunately,pedicle transection occurred during revision surgery, causing complete devascularization of the flap, which was confirmed by intraoperative Indocyanine Green imaging. The authors elected to perform salvage reanastomosis during the surgery. In keeping with the author’s 23-year experience with free flaps, the vascular pedicle should always be preserved in voluminous free flaps, as neovascularization alone may not ensure whole flap survival. The authors suggest always attempting re-anastomosis if vessels are compromised during revision surgery.