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Chandrasekar S, Tiwari R, Ganesan K, Singhal M. Double microvascular free flap reconstruction for bilateral lower extremity injury in a paediatric patient. BMJ Case Rep 2024; 17:e257181. [PMID: 38272514 PMCID: PMC10826477 DOI: 10.1136/bcr-2023-257181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024] Open
Abstract
Many challenges have been described by microsurgeons in paediatric free flaps. With the advancement in microsurgical expertise, it is now possible to achieve excellent results. We present a case of a female child with car-tyre friction injury of bilateral feet with associated extradural haemorrhage who underwent emergency bilateral anterolateral thigh flap. A secondary tendon reconstruction of the left foot was performed at 6 months. No complications were observed in the postoperative period after both procedures and good functional recovery was achieved at 1 year follow-up. The problems unique to this case were the presence of head injury and bilateral extremity injury in the paediatric patient. The technical details of planning, execution, difficulties and recommendations to minimise the risk in such cases are discussed. To the best of our knowledge, this is the only case report of bilateral lower limb paediatric emergency free flap with associated head injury.
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Affiliation(s)
- Shruthi Chandrasekar
- Plastic Surgery, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Raja Tiwari
- Plastic Surgery, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Karthick Ganesan
- Plastic, Reconstructive and Burns Surgery, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Maneesh Singhal
- Plastic, Reconstructive and Burns Surgery, All India Institute of Medical Sciences, New Delhi, Delhi, India
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Burns HR, Skochdopole AJ, Alfaro Zeledon R, Pederson WC. Pediatric Microsurgery and Free-Tissue Transfer. Semin Plast Surg 2023; 37:231-239. [PMID: 38098684 PMCID: PMC10718656 DOI: 10.1055/s-0043-1776698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Abstract
Advancements in microsurgery, along with increased microsurgical experience in pediatric patients, have made free-tissue transfer a reliable modality for pediatric bone and soft tissue reconstruction today. Free-tissue transfer is most commonly used in children for the coverage of large or complex defects resulting from traumatic, oncologic, or congenital etiologies. While flap success and complication rates between pediatric and adult populations are similar, special considerations must be taken into account within the pediatric population. In this article, we will describe common indications, technical nuances, and clinical considerations for the management of the pediatric free-tissue transfer patient.
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Affiliation(s)
- Heather R. Burns
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - Anna J. Skochdopole
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - Richardo Alfaro Zeledon
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - William C. Pederson
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
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Ha Y, Lee BH, Park JA, Kim YH. Reconstruction of soft tissue defect around knee with thoracodorsal artery perforator flap and muscle-sparing latissimus dorsi flap. Microsurgery 2023; 43:665-675. [PMID: 36789684 DOI: 10.1002/micr.31024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 12/15/2022] [Accepted: 02/02/2023] [Indexed: 02/16/2023]
Abstract
INTRODUCTION Around the knee reconstruction is challenging for reconstructive surgeons. Several methods have been proposed, including perforator and muscle flaps; however, all have advantages and disadvantages. As the success rate of free-flap surgery increases, reconstruction around the knee using this method is becoming increasingly popular. Nevertheless, there are no large-scale case reports in the previous literature using either a thoracodorsal artery perforator flap (latissimus dorsi (LD) perforator flap) or a muscle-sparing latissimus dorsi (msLD) flap for reconstruction around the knee. In this retrospective report, we describe our clinical experiences and present an algorithm regarding recipient vessel choice in free-flap reconstructive surgery of around the knee defects. PATIENT AND METHODS Fifty-six cases in which a flap from the lateral thoracic area was used to reconstruct an around the knee defect between January 2016 and March 2022 were reviewed. The patients were aged 18-87 years (mean, 52.13 years), and of the 56 patients, 36 were male and 20 were female. Injuries were caused by trauma, contracture, rheumatoid vasculitis, tumor, infection, burns, sunken deformity, and pressure sores. The 56 cases included 22 with a defect including the knee, 14 with a defect below the knee (7 of the primary below-knee amputation [BKA] and 7 of the secondary BKA), 9 involving the distal medial thigh, 8 involving the distal lateral thigh, 2 involving the popliteal area, and 1 involving the middle thigh. Most cases were reconstructed using a single LD perforator flap or msLD flap. Chimeric or supplementary flaps were used when extensive coverage or dead space obliteration was required. The average size of the defect area was 253.6 cm2 (range: 5 × 6-21 × 39 cm2 ). RESULTS In the cases, the recipient artery used included the following: descending genicular artery (23), superficial femoral artery (14), descending branch of the lateral circumflex femoral artery (14), anterior tibial artery (2), popliteal artery (2), and posterior tibial artery (1). The recipient vein included the greater saphenous vein (24), descending branch of the lateral circumflex femoral vein (14), superficial femoral vein (7), descending genicular vein (6), anterior tibial vein (2), popliteal vein (2), and posterior tibial vein (1). The average flap size was 281.8 cm2 (range: 4 × 8-35 × 19 cm2 ). All flaps survived; however, seven complications occurred, including 2 partial flap losses, 1 arterial insufficiency, 1 hematoma, 1 minor dehiscence, 1 donor-site graft loss, and 1 short BKA. Normal knee range of motion (121-140°) was observed in 34 patients and 16 showed varying degrees of limited range of motion. Motion was not observed in four patients who underwent knee fusion and could not be evaluated in two patients who underwent above-knee amputation. The mean follow-up duration was 24.6 months (range: 4-72 months). CONCLUSION The LD perforator flap is ideal for the reconstruction of around the knee defects because it enables a long pedicle, large flap, and chimeric design. The msLD flap is ideal because it enables strong stump support, dead-space obliteration, and infection control. Moreover, since the two flaps are distant from the knee, this method is advantageous in terms of postoperative rehabilitation and there is minimal donor-site morbidity due to the thin nature of the LD muscle. In addition, the flap can be elevated in three positions and the operation can be completed without positional changes in various recipient vessel locations. Based on our experience, we conclude that the LD flap has the potential to be used as widely as or in preference to the anterolateral thigh flap in the reconstruction of around the knee defects.
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Affiliation(s)
- Yooseok Ha
- Department of Plastic and Reconstructive Surgery, College of Medicine, Chungnam National University, Daejeon, Republic of Korea
| | - Bo Hyun Lee
- Department of Plastic and Reconstructive Surgery, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Ji Ah Park
- Design Lab of Technology Commercialization Center, Industry-University Cooperation, Foundation of Hanyang University, Seoul, Republic of Korea
| | - Youn Hwan Kim
- Department of Plastic and Reconstructive Surgery, College of Medicine, Hanyang University, Seoul, Republic of Korea
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Mundinger GS, Stalder MW, Lee J, Patterson CW, Sharma S, Womac DJ, Sopko NA, Swanson EW. Autologous Heterogeneous Skin Construct Closes Traumatic Lower Extremity Wounds in Pediatric Patients: A Retrospective Case Series. THE INTERNATIONAL JOURNAL OF LOWER EXTREMITY WOUNDS 2023; 22:103-112. [PMID: 33686885 PMCID: PMC9902981 DOI: 10.1177/1534734621992284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Lower extremity traumatic wounds pose unique challenges in pediatric patients, including vessel caliber, compliance with postoperative instructions, parental concerns about multiple operations, and long-term function. An autologous heterogeneous skin construct (AHSC) has demonstrated the ability to cover avascular structures and regenerate full-thickness functional skin. The objective of this study is to report our experience using AHSC in a cohort of pediatric trauma patients. This study is a noncontrolled, retrospective cohort analysis of all pediatric patients (<19 years of age) treated with AHSC for lower extremity traumatic wounds with at least one exposed deep structure (tendon, bone, and/or joint) at a single institution between May 1, 2018, and April 1, 2019. Seven patients with 10 traumatic wounds met inclusion criteria. The median follow-up time was 11.8 months. Five patients were male (71%); the median age was 7 years (range = 2-15 years). Average wound size was 105 cm2. All wounds achieved coverage of exposed structures and epithelial closure in a median of 13 and 69 days, respectively. There were no donor site complications and no reoperations required. All patients returned to normal activity, ambulate without limp, can wear shoes normally, and have normal tendon gliding. AHSC covered exposed structures and achieved closure within a single application in complex traumatic lower extremity wounds in a pediatric cohort.
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Affiliation(s)
- Gerhard S. Mundinger
- Louisiana State University Health Sciences Center, New Orleans, LA, USA,Children’s Hospital of New Orleans, New Orleans, LA, USA,Gerhard S. Mundinger, Division of Plastic and Reconstructive Surgery, Department of Surgery, Louisiana State University Health Sciences Center, 433 Bolivar Street, New Orleans, LA 70112-2784, USA.
| | - Mark W. Stalder
- Louisiana State University Health Sciences Center, New Orleans, LA, USA,Children’s Hospital of New Orleans, New Orleans, LA, USA
| | - James Lee
- Tulane University, New Orleans, LA, USA
| | - Charles W. Patterson
- Louisiana State University Health Sciences Center, New Orleans, LA, USA,Children’s Hospital of New Orleans, New Orleans, LA, USA
| | - Silpa Sharma
- Children’s Hospital of New Orleans, New Orleans, LA, USA
| | - Daniel J. Womac
- Louisiana State University Health Sciences Center, New Orleans, LA, USA
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"Systematic Review and Guidelines for Perioperative Management of Pediatric Patients Undergoing Major Plastic Surgery Procedures, With a Focus on Free Tissue Transfer.". Plast Reconstr Surg 2022; 150:406e-415e. [PMID: 35674517 DOI: 10.1097/prs.0000000000009325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Microsurgical free tissue transfer has been successfully implemented for various reconstructive applications in children. The goal of this study was to identify the best available evidence on perioperative management of pediatric patients undergoing free tissue transfer, and use it to develop evidence-based care guidelines. METHODS A systematic review was conducted in Pubmed, Embase, Scopus, and Cochrane Library databases. Since a preliminary search of the pediatric microsurgical literature yielded scant data with low level of evidence (LOE), pediatric anesthesia guidelines for healthy children undergoing major surgeries were also included. Exclusion criteria included: vague descriptions of perioperative care, case reports, and studies of syndromic or chronically ill children. RESULTS 204 articles were identified, and 53 met inclusion criteria. Management approaches specific to the pediatric population were used to formulate recommendations. High quality data was found for anesthesia, analgesia, fluid administration / blood transfusion, and anticoagulation (LOE 1). Lower quality evidence was identified for patient temperature (LOE 3) and vasodilator use (LOE 4). Key recommendations include: administering sevoflurane for general anesthesia, implementing a multimodal analgesia strategy, limiting preoperative fasting, restricting blood transfusions until hemoglobin < 7 g/dl unless patient is symptomatic, and reserving chemical venous thromboembolism prophylaxis for high risk patients. CONCLUSIONS Pediatric-specific guidelines are important as they acknowledge physiologic differences in children, which may be overlooked when extrapolating from adult studies. These evidence-based recommendations are a key first step toward standardization of perioperative care of pediatric patients undergoing plastic surgical procedures, including free tissue transfer, to improve outcomes and minimize complications.
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Microsurgical Anterolateral Thigh Flap for Reconstruction of Extremity Soft Tissue Defects in Pediatric Patients. Ann Plast Surg 2022; 89:185-190. [PMID: 35703220 DOI: 10.1097/sap.0000000000003236] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The anterolateral thigh flap is one of the most widely used flaps because it has the advantages of less damage to the donor site, no sacrifice of main blood vessels, and abundant soft tissue. However, the application of anterolateral thigh flap in children is relatively rare because of small blood vessels and rapid physiological changes. The aim of this study was to explore the effectiveness and characteristics of free anterolateral thigh flaps for the reconstruction of extremity soft tissue defects in pediatric patients. PATIENTS AND METHODS This study included 26 pediatric patients, with an average age of 6.7 years (range, 2-13 years). There were 5 cases of upper limb defects and 21 cases of lower limb defects, all of which were accompanied by exposed bones or tendons. The causes of defects included traffic injury in 9 cases, mechanical injury in 7 cases, collision injury in 4 cases, spoke injury in 3 cases, cicatricial contracture in 2 cases, and fibroma in 1 case. All defects were reconstructed with free anterolateral thigh flaps. RESULTS Twenty-six anterolateral thigh flaps were harvested, including 15 fasciocutaneous flaps and 11 musculocutaneous flaps. The mean size of the flap was 73.4 cm2 (range, 4 × 3 to 24 × 8 cm). The donor sites were sutured directly in 19 cases and underwent split-thickness skin grafting in 7 cases. There were 3 cases of vascular crisis, 3 cases of flap edge necrosis, 3 cases of infection, 1 case of pressure ulcer, and 1 case of dehiscence after surgery. Eleven patients had scar hyperplasia in the donor site. A total of 34 reoperations were performed, including 14 flap debulking, 7 debridement, 4 skin graft, 3 vascular crisis re-exploration, and 6 other procedures. CONCLUSIONS Free anterolateral thigh flap was a safe and reliable option for reconstructing soft tissue defects of extremities in pediatric patients. Notably, the incidence of scar hyperplasia in the donor site and the possibility of reoperation in pediatric patients were higher than those in adult patients.
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Outcomes of grafted skin on the dorsum of the foot after car-tire friction injuries. Arch Plast Surg 2021; 48:678-684. [PMID: 34818716 PMCID: PMC8627940 DOI: 10.5999/aps.2021.00962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 08/10/2021] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND A car-tire friction injury on the dorsum of a child's foot often results in hypertrophic scarring of the wound margins. This study describes the clinical appearance of the injured areas and surgical complications that occurred during the follow-up period in a series of children with car-tire friction injuries who were treated with split-thickness skin grafts (STSGs). We describe the clinical features that we believe need to be highlighted when initially treating car-tire injuries in children. METHODS From May 2003 to June 2016, our retrospective study included 15 patients with car-tire injuries on the dorsum of the foot who were treated with surgical excision and STSG to cover the wound. RESULTS A total of 15 patients with car-tire injuries were treated. The average age was 6.26 years old. The average injury grade was 3.26. Two patients were treated using delayed repair, and 13 patients received STSG for initial management. Four patients experienced no complications, while 11 patients had hypertrophic scars and/or scar contracture after surgery. CONCLUSIONS A car-tire friction injury on the dorsum of a child's foot often results in hypertrophic scar formation or scar contracture even if proper management is undertaken. Since the occurrence of these complications in childhood can lead to a secondary deformity, it is important to properly treat car-tire friction wounds, inform patients and caregivers about potential complications, and ensure regular follow-up evaluations over a 12-month period following the initial surgery.
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Pedicled sural flaps versus free anterolateral thigh flaps in reconstruction of dorsal foot and ankle defects in children: a systematic review. Arch Plast Surg 2021; 48:410-416. [PMID: 34352954 PMCID: PMC8342255 DOI: 10.5999/aps.2020.00983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 04/09/2021] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND This systematic review compared free anterolateral thigh (ALT) flaps versus pedicled distally based sural artery (DBSA) flaps for reconstruction of soft tissue defects of dorsal foot and ankle in children. METHODS A systematic literature search was performed to identify cases where an ALT or DBSA was used to reconstruct the dorsal foot in children. A total of 19 articles were included in the systematic review. RESULTS Eighty-three patients underwent an ALT reconstruction and 138 patients underwent a DBSA reconstruction. Patients who had a DBSA were more likely to require grafting of the donor site (P<0.001). The size of ALT flaps was significantly larger than DBSA flaps (P=0.002). Subsequent flap thinning was required in 30% of patients after ALT and 12% of patients after DBSA reconstruction (P<0.001). Complications occurred in 11.6% of DBSA and 8.4% of ALT flaps (8.4%). CONCLUSIONS Both flaps are valid options in reconstructing pediatric foot and ankle defects. Each flap has advantages and disadvantages as discussed in this review article. In general for larger defects, an ALT flap was used. Flap choice should be based on the size of the defect.
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Yu J, Luo Z, Wu P, Tang J. Novel Design of the Chimeric Deep Inferior Epigastric Artery Perforator Flap that Provides for Three-Dimensional Reconstruction of Composite Tissue Defects of the Heel in Children. Orthop Surg 2021; 13:216-224. [PMID: 33448701 PMCID: PMC7862167 DOI: 10.1111/os.12887] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 10/21/2020] [Accepted: 10/27/2020] [Indexed: 11/28/2022] Open
Abstract
Objective The aim of the present study was to report a novel design of the chimeric deep inferior epigastric artery perforator flap (DIEP) to achieve dead space filling, Achilles tendon bridging, and skin resurfacing simultaneously with minimal donor‐site morbidity. Methods From September 2012 to May 2016, a retrospective study was carried out on six pediatric patients with composite soft tissue defects of the heel that were repaired with the chimeric DIEP flap. The chimeric flap design included a flap of the anterior sheath of the rectus, a block of rectus muscle, and a large skin paddle. All the parts were supplied by a common artery. After harvesting the flap, all element parts were inserted at the corresponding sites in a tension‐free manner. With one set of vessel anastomoses at the recipient site, accurate repair with tendon reconstruction, dead space elimination, and wound covering were accomplished. The donor site incisions were closed initially. Data on patient age, medical history, injury severity, defect size, flap dimensions, recipient vessels, donor site closure, complications, and follow‐up were collected and reviewed. Results Five of the six chimeric DIEP flaps survived without complications. The remaining one case experienced partial necrosis of the skin paddle caused by venous congestion, which healed after routine dressing changes. Primary donor site closure was accomplished in all cases. The mean follow‐up was 18.6 months (range, 10–36 months). Five patients had satisfactory aesthetic and functional outcomes; one patient needed a secondary debulking procedure. Compared to the unaffected side, the affected side showed no obvious difference for ankle movement, tiptoe function, and patient gait during the follow‐up period. Good ankle function was observed in all patients. There was no donor site breakdown, with only a slightly noticeable linear scar. Conclusion The chimeric DIEP flap reduced the operative time, solved the problem of deficiency of recipient vessels, and attained satisfactory functional and aesthetic outcomes with low donor site morbidity. Therefore, it is a promising option for three‐dimensional reconstruction of composite defects with dead space and Achilles tendon defects as well as skin loss in children.
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Affiliation(s)
- Junyi Yu
- Department of Hand and Microsurgery, Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
| | - Zhenhua Luo
- Department of Hand and Microsurgery, Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
| | - Panfeng Wu
- Department of Hand and Microsurgery, Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
| | - Juyu Tang
- Department of Hand and Microsurgery, Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
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Chen L, Zhang Z, Li R, Liu Z, Liu Y. Reconstruction of extensive plantar forefoot defects with free anterolateral thigh flap. Medicine (Baltimore) 2020; 99:e20819. [PMID: 33327220 PMCID: PMC7738124 DOI: 10.1097/md.0000000000020819] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
PURPOSE The aim of the soft tissue reconstruction of plantar forefoot should yield weight-bearing function and aesthetic contour, which poses a significant challenge for reconstructive surgeons to provide an appropriate flap according to the "like for like" reconstructive principle. Local flaps and pedicled flaps have been described for the reconstruction of small- to medium-sized defects of plantar forefoot and achieved optimal results. However, reconstruction of extensive defects of plantar forefoot is rarely investigated. In this study, we present our experience using the free anterolateral thigh (ALT) flap in the reconstruction of extensive defects of plantar forefoot. METHODS Between November 2011 and April 2017, 9 patients were treated for extensive soft tissue defects in the plantar forefoot areas with ALT flaps. The mean age at the time of surgery was 39.3 years (range, 25-64 years). RESULTS The follow-up period ranged from 12 to 77 months, with a mean of 31 months. All flaps survived well, and the patients were satisfied with the aesthetic and functional results. The size of the flaps ranged from 63 to 455 cm, with a mean of 197.7 cm. Seven patients with no bony involvement began to gradually weight-bear at 3 weeks postoperatively. During the follow-up time, postoperative ulceration at the reconstructed weight-bearing areas was not encountered. CONCLUSION The ALT flap is a reliable option for treatment of extensive defects of plantar forefoot, resulting in an optimal functional and aesthetic outcome. Even when a total plantar loss exits, excellent results can be achieved.
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Elbatawy A, Elgammal M, Zayid T, Hamdy A, Ouf MO, Ismail H, Sholkamy K, Malik M, Zidan SM, Ayad W. Pediatric Microsurgery in the Reconstruction of Complex Posttraumatic Foot and Ankle Defects: A Long-Term Follow-Up with a Comprehensive Review of the Literature. J Reconstr Microsurg 2020; 37:193-200. [PMID: 32842159 DOI: 10.1055/s-0040-1714429] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Lower limb reconstruction is a well-recognized challenge to the trauma or plastic surgeon. Although techniques and outcomes in the adult population are well documented, they are less so in the pediatric population. Here, we present our experience in the management of posttraumatic foot and ankle defects with free tissue transfer in children. METHODS We performed a retrospective analysis of 40 pediatric patients between the ages of 3 and 16 from 2008 to 2016 who underwent foot and ankle soft tissue reconstruction. Any patient who underwent reconstruction for any reason other than trauma was excluded. Data were collected on operative time, free tissue transfer type, use of vein grafts, length of hospital stay, and postoperative morbidity. Also, a comprehensive systematic literature review was completed according to the PRISMA protocol for all previous reports of foot and ankle reconstruction in the young age group with free tissue transfer. RESULTS Of our 40 patients, 23 were males and 12 females, free tissue transfer was used to reconstruct primarily the dorsum (71%), heel (11%), medial (9%), and lateral (3%) aspect of the foot. The anterior tibial artery was the predominant recipient vessel for anastomosis (77%). Mean inpatient stay was 9 days and our complication rate was 20%, primarily of superficial infection treated with antibiotic therapy. The review of the literature articles is completely analyzed in detail. CONCLUSION The need for durable coverage of exposed joints, tendons, fractures, or hardware makes the free flap particularly well suited to trauma reconstruction of the foot and ankle. The lack of underlying vascular disease in this patient group allows for low complication rates. Our study evidences the safety and positive long-term outcomes of free tissue transfer for the reconstruction of huge sized-soft tissue defects of the foot and ankle in children.
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Affiliation(s)
- Amr Elbatawy
- Plastic Surgery Department, Al Azhar University, Cairo, Egypt
| | | | - Tarek Zayid
- Plastic Surgery Department, Al Azhar University, Cairo, Egypt
| | | | | | - Hany Ismail
- Plastic Surgery Department, Al Azhar University, Cairo, Egypt
| | | | - Mohammad Malik
- Welsh Center for Plastic and Burn Surgery, Swansea Bay University NHS Trust, Swansea, United Kingdom
| | - Serag M Zidan
- Plastic Surgery Department, Al Azhar University, Cairo, Egypt
| | - Wael Ayad
- Plastic Surgery Department, Al Azhar University, Cairo, Egypt
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Liu S, Tan J, Tao S, Duan Y, Hu X, Li Z. Reconstruction of a Distal Foot Skin Defect Using an Intermediate Dorsal Neurocutaneous Flap. Orthop Surg 2020; 12:442-449. [PMID: 32048450 PMCID: PMC7189044 DOI: 10.1111/os.12623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 11/27/2019] [Accepted: 12/30/2019] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To present the use of an intermediate dorsal neurocutaneous flap for the reconstruction of defects on the distal foot. METHODS From September 2016 to October 2018, five patients (mean age at operation 33.8 years; range, 7-70 years; female/male = 2/3) with skin defects on one of their feet caused by road-traffic accidents, electrical injury, and syndactyly correction were retrospectively reviewed. The size of the defects ranged from 2.0 cm × 1.0 cm to 5.0 cm × 3.5 cm. All patients had undergone a reconstruction surgery using intermediate dorsal neurocutaneous flap. One patient underwent a syndactyly correction, and four patients first experienced aggressive debridement. The sizes of the flaps were between 5.0 cm × 2.0 cm and 6.0 cm × 4.0 cm. The function, appearance, and pain of the injured foot were assessed using the Chinese Manchester Foot Pain and Disability Index and visual analogue scale. RESULTS These five patients were systematically followed up for a mean of 15.8 months (range, 12-20 months). The donor sites were closed primarily in two cases, and skin grafts were performed in three cases. All the flaps survived with a success rate of 100%; the wounds healed well, and the color matches were excellent. Partial superficial flap necrosis occurred in one of five flaps, which was treated by dressing change using a hypertonic saline gauze. No significant problems were found at the donor site in any patient immediately afterwards or at follow-up. There were no problems in any patients associated with wearing shoes. Based on the Chinese Manchester Foot Pain and Disability Index, four patients were strongly satisfied and one was satisfied with the recovery of physical function; all the patients were strongly satisfied with the appearance of the injured foot; all five patients had an excellent score of pain intensity subscale. Except for one patient who reported mild pain, all the other patients reported no pain based on the visual analogue scale. Two typical cases are presented in this paper. CONCLUSIONS The intermediate dorsal neurocutaneous flap is an alternative and effective technique that can reliably cover minor- to medium-sized defects on the distal foot, toes, and web spaces. This surgical method leads to satisfactory functional recovery with minimal donor site morbidity, and no major vessels need to be sacrificed. This procedure offers an advisable option for orthopaedic surgeons to treat defects on the distal foot.
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Affiliation(s)
- Siyi Liu
- Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan City, Hubei Province, China
| | - Jinhai Tan
- Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan City, Hubei Province, China
| | - Shengxiang Tao
- Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan City, Hubei Province, China
| | - Yong Duan
- Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan City, Hubei Province, China
| | - Xiang Hu
- Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan City, Hubei Province, China
| | - Zonghuan Li
- Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan City, Hubei Province, China
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Sui X, Cao Z, Pang X, He J, Wu P, Zhou Z, Yu F, Tang JY. Reconstruction of moderate-sized soft tissue defects in foot and ankle in children: Free deep inferior epigastric artery perforator flap versus circumflex scapular artery perforator flap. J Plast Reconstr Aesthet Surg 2019; 72:1494-1502. [PMID: 31221596 DOI: 10.1016/j.bjps.2019.05.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 04/24/2019] [Accepted: 05/15/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND This retrospective study was conducted to compare the outcomes between the free deep inferior epigastric artery perforator (DIEP) flap and the circumflex scapular artery perforator (CSAP) flap in reconstruction of moderate-sized soft tissue defects in the foot and ankle of pediatric patients. PATIENTS AND METHODS From January 2004 to December 2016, 42 patients, ranging from 2 to 13 years old, underwent foot and ankle reconstruction, with a free DIEP flap in 21 cases and a free CSAP flap in the other 21cases. RESULTS All the flaps survived. No marked differences were observed in the demographics, flap size, recipient vessels, and overall early or late complication rate (p > 0.05). The CSAP group had a shorter operation time (134.3 ± 25 min vs. 202.4 ± 24.3 min, p < 0.05) and flap harvest time (29.7 ± 8.1 min vs. 52.2 ± 9.8 min, p < 0.05) than the DIEP group had. In long-term follow-up, the CSAP group showed a lower fat hyperplasia rate (14% vs. 52%, p < 0.05) and better cosmetic outcomes than the DIEP group did (p < 0.05). The functional outcomes had no marked differences (p > 0.05). CONCLUSIONS The DIEP flap and the CSAP flap are both good options for foot and ankle reconstruction of moderate-sized defects in pediatric patients. The CSAP flap has a shorter operation time and flap harvest time, a lower fat hyperplasia rate, and better long-term cosmetic outcomes than the DIEP flap does.
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Affiliation(s)
- Xinlei Sui
- Department of Hand and Microsurgery, Xiangya Hospital of Central South University, No. 87 Xiang Ya Road, Changsha, Hunan 410008, China
| | - Zheming Cao
- Department of Hand and Microsurgery, Xiangya Hospital of Central South University, No. 87 Xiang Ya Road, Changsha, Hunan 410008, China
| | - Xiaoyang Pang
- Department of Hand and Microsurgery, Xiangya Hospital of Central South University, No. 87 Xiang Ya Road, Changsha, Hunan 410008, China
| | - Jiqiang He
- Department of Hand and Microsurgery, Xiangya Hospital of Central South University, No. 87 Xiang Ya Road, Changsha, Hunan 410008, China
| | - Panfeng Wu
- Department of Hand and Microsurgery, Xiangya Hospital of Central South University, No. 87 Xiang Ya Road, Changsha, Hunan 410008, China
| | - Zhengbing Zhou
- Department of Hand and Microsurgery, Xiangya Hospital of Central South University, No. 87 Xiang Ya Road, Changsha, Hunan 410008, China
| | - Fang Yu
- Department of Hand and Microsurgery, Xiangya Hospital of Central South University, No. 87 Xiang Ya Road, Changsha, Hunan 410008, China
| | - Ju-Yu Tang
- Department of Hand and Microsurgery, Xiangya Hospital of Central South University, No. 87 Xiang Ya Road, Changsha, Hunan 410008, China.
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Claes KE, Roche NA, Opsomer D, De Wolf EJ, Sommeling CE, Van Landuyt K. Free flaps for lower limb soft tissue reconstruction in children: Systematic review. J Plast Reconstr Aesthet Surg 2019; 72:711-728. [PMID: 30898501 DOI: 10.1016/j.bjps.2019.02.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 02/07/2019] [Accepted: 02/12/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Since the first reports on microsurgery in children, there has been an evolution in the reconstruction of soft tissue defects as evidenced by a shift to free flaps as the first-line treatment. METHODS The primary objective of this systematic review was to compare the complication rate of free perforator/fasciocutaneous flaps with free muscular/myocutaneous flaps in pediatric lower limb soft tissue reconstructions. The secondary objective was to evaluate the frequency and severity of complications for both reconstructive options. A search was performed in the databases PubMed, Web of Science, Embase, Scopus, and Cochrane Library depending on predefined inclusion criteria. RESULTS The evolution to perforator flaps from muscular and myocutaneous flaps is reflected in this systematic review as demonstrated by the anterolateral thigh (ALT) flap, which is the most common reconstructive option with a very low complication rate (11.3%) and flap loss. The latissimus dorsi (LD) flap was the second most frequently reported reconstruction with a complication rate comparable with that of the thoracodorsal artery perforator (TDAP) flap (32% vs. 39%, respectively), but the former suffers few failures. The radial forearm (RFA) fasciocutaneous flap can be considered a good alternative for ALT and TDAP flaps with a very low complication rate (16%) and no flap loss. CONCLUSIONS The ALT flap is considered the best reconstructive method for pediatric lower limb soft tissue defects. More adequate prospective studies specifically concerning free flap reconstructions for lower limb defects in children are necessary in the future to provide guidelines for treatment and optimize outcomes in the long term.
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Affiliation(s)
- Karel Ey Claes
- Department of Plastic Surgery, Ghent University Hospital, C. Heymanslaan 10, 9000 Gent, Belgium.
| | - Nathalie A Roche
- Department of Plastic Surgery, Ghent University Hospital, C. Heymanslaan 10, 9000 Gent, Belgium
| | - Dries Opsomer
- Department of Plastic Surgery, Ghent University Hospital, C. Heymanslaan 10, 9000 Gent, Belgium
| | - Edward J De Wolf
- Department of Plastic Surgery, Ghent University Hospital, C. Heymanslaan 10, 9000 Gent, Belgium
| | - Casper E Sommeling
- Department of Plastic Surgery, Ghent University Hospital, C. Heymanslaan 10, 9000 Gent, Belgium
| | - Koenraad Van Landuyt
- Department of Plastic Surgery, Ghent University Hospital, C. Heymanslaan 10, 9000 Gent, Belgium
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Lee ZH, Daar DA, Stranix JT, Anzai L, Thanik VD, Saadeh PB, Levine JP. Risk factors for microvascular free flaps in pediatric lower extremity trauma. Microsurgery 2019; 40:44-50. [DOI: 10.1002/micr.30427] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 10/31/2018] [Accepted: 12/27/2018] [Indexed: 11/10/2022]
Affiliation(s)
- Z-Hye Lee
- Hansjörg Wyss Department of Plastic Surgery; New York University School of Medicine; New York New York
| | - David A. Daar
- Hansjörg Wyss Department of Plastic Surgery; New York University School of Medicine; New York New York
| | - John T. Stranix
- Department of Plastic Surgery; University of Virginia Health System; Charlottesville Virginia
| | - Lavinia Anzai
- Hansjörg Wyss Department of Plastic Surgery; New York University School of Medicine; New York New York
| | - Vishal D. Thanik
- Hansjörg Wyss Department of Plastic Surgery; New York University School of Medicine; New York New York
| | - Pierre B. Saadeh
- Hansjörg Wyss Department of Plastic Surgery; New York University School of Medicine; New York New York
| | - Jamie P. Levine
- Hansjörg Wyss Department of Plastic Surgery; New York University School of Medicine; New York New York
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Abstract
Free tissue transfer has become the standard in wound coverage and further refinements have given us newer flap donor sites or modifications of existing flaps to decrease morbidity; smaller vessels are being anastomosed, a direct spin-off following successful distal replantations. Younger children are presenting with traumatic defects similar to adults. Although there were apprehensions of free tissue transfer in children occasioned by smaller vessels, duration of procedure and concerns of growth following flap harvest, reports of small and large series have appeared in the literature with similar success. Pediatric-free tissue transfer is now an established entity. This article seeks to arrive at a consensus based on a review of the existing literature on free flaps for skin and soft-tissue coverage of lower limb trauma in children.
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Affiliation(s)
- R. Srikanth
- Department of Plastic and Reconstructive Surgery, Nizams Institute of Medical Sciences, Hyderabad, Telangana, India
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Starnes-Roubaud MJ, Hanasono MM, Kupferman ME, Liu J, Chang EI. Microsurgical Reconstruction Following Oncologic Resection in Pediatric Patients: A 15-Year Experience. Ann Surg Oncol 2017; 24:4009-4016. [PMID: 28884452 DOI: 10.1245/s10434-017-6061-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Free tissue transfer in the pediatric population is a challenging endeavor, even for experienced microsurgeons. Some surgeons argue these cases can be limited by vessel size and spasticity and should be undertaken only when absolutely necessary. We present a 15-year experience examining outcomes of free tissue transfer in pediatric oncologic patients. METHODS All free flaps performed at a single institution in pediatric patients (age range 3-17) between January 2000 and December 2014 were reviewed. RESULTS Overall, 102 patients (mean age 12.1 ± 4.0 years) were identified who underwent 109 free flaps. The most common flaps were the fibula free flap (46%) and the anterolateral thigh free flap (27%). 81 cases (74%) had malignant disease with 70 cases (64%) involving the head and neck region. 21 cases (19%) had preoperative radiation and 58 cases (53%) had preoperative chemotherapy. 5 cases had total flap loss (4.6%) and 17 cases (15.6%) had immediate post-operative complications, with wound infection (4.6%) being most common. 17 cases (15.6%) had long-term complications with delayed or non-union (4.6%) being most common. Survival rate was 91.7% at 1 year and 78.9% at 5 years. CONCLUSIONS Free tissue transfer is a reliable and appropriate choice in pediatric patients requiring soft tissue or bony reconstruction. Even in pediatric oncologic patients with preoperative chemotherapy or radiation, flap survival and outcomes are comparable to the adult population. Pediatric free tissue transfer should not be avoided but instead considered the gold standard for patients with complex defects, just as it is in the adult population.
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Affiliation(s)
| | - Matthew M Hanasono
- Department of Plastic Surgery, MD Anderson Cancer Center, The University of Texas, Houston, TX, USA
| | - Michael E Kupferman
- Department of Plastic Surgery, MD Anderson Cancer Center, The University of Texas, Houston, TX, USA
| | - Jun Liu
- Department of Plastic Surgery, MD Anderson Cancer Center, The University of Texas, Houston, TX, USA
| | - Edward I Chang
- Department of Plastic Surgery, MD Anderson Cancer Center, The University of Texas, Houston, TX, USA
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Merter A, Armangil M, Kaya B, Bilgin S. Immediate emergency free anterolateral thigh flap after car-tyre friction injury: A case report with eight years follow-up. Int J Surg Case Rep 2017; 38:102-106. [PMID: 28755614 PMCID: PMC5537393 DOI: 10.1016/j.ijscr.2017.06.066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 05/31/2017] [Accepted: 06/04/2017] [Indexed: 11/20/2022] Open
Abstract
The car-tyre friction injury has differences from other injuries. The components of injury which are burn, crushing, shearing, and degloving occur. Many treatment options can be performed for coverage of wound which are Vacuum Assisted Closure system (V.A.C), skin grafting, free flaps, local flaps and cross leg flap.
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Affiliation(s)
- Abdullah Merter
- Kahramanmaras Afsin State Hospital, Orthopedic Clinic, Turkey.
| | - Mehmet Armangil
- Ankara University, School of Medicine, Ibn-i Sina Hospital, Department of Orthopedics, Division of Hand Surgery, Turkey
| | - Burak Kaya
- Ankara University, School of Medicine, Cebeci Hospital, Department of Plastic and Reconstructive Surgery, Turkey
| | - Sinan Bilgin
- Ankara University, School of Medicine, Ibn-i Sina Hospital, Department of Orthopedics, Division of Hand Surgery, Turkey
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Microsurgical Reconstruction of Traumatic Lower Extremity Defects in the Pediatric Population. Plast Reconstr Surg 2017; 139:998-1004. [PMID: 28002282 DOI: 10.1097/prs.0000000000003156] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Few reports focus exclusively on microsurgical reconstruction of traumatic lower extremity defects in children. Hence, the authors felt it prudent to contribute to this area of clinical research. The authors hypothesized that reconstructive success would be comparable to success rates reported in adults, and that young age or concerns regarding vessel size or behavior do not negatively impact surgical outcome. METHODS A retrospective review of microsurgical lower extremity reconstruction cases at two academic medical centers was performed. All pediatric patients who underwent microsurgical reconstruction of traumatic lower extremity defects between 1997 and 2012 were included for analysis. RESULTS Forty flaps transferred in 40 patients with a mean age of 11.4 years (range, 1 to 17 years) were included for analysis. Muscle flaps were predominantly used [n = 23 (57.5 percent)]; however, there was a recent increase in use of fasciocutaneous flaps [n = 16 (40 percent)]. Postoperative complications were seen in 25 percent of patients, with a total flap loss rate of 5 percent. No donor-site complications were observed. The mean postoperative length of hospital stay was 12.9 days (range, 4 to 41 days), with patients returning to full weight-bearing after a mean of 2.6 months (range, 1 to 8 months). CONCLUSIONS Microsurgical reconstruction of traumatic lower extremity defects in the pediatric population is safe. Concerns related to patient age, vessel size, or vessel behavior (i.e., vasospasm) should not detract from offering free flap reconstruction, as they do not negatively impact outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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22
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Myung Y, Yim S, Kim BK. A comparison of axial circumference between superficial circumflex iliac artery perforator flap and other workhorse flaps in dorsal foot reconstruction. J Plast Surg Hand Surg 2017; 51:381-386. [PMID: 28152328 DOI: 10.1080/2000656x.2017.1279621] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Management and reconstruction of dorsal foot defects present various difficulties and challenges. The main purpose of this article is to discuss experiences of using superficial circumflex iliac perforator (SCIP) flap in various defects of the dorsal foot region. METHODS From August 2012 to February 2015, a total of 13 patients - nine males and four females - received a reconstruction operation for dorsal foot defects using SCIP flaps (the SCIP group). The defects were caused by trauma (n = 9), diabetes (n = 3), and malignancy (n = 1). The mean age was 43.07 years, which ranged between 19-70 years. Additionally, 19 other patients, who underwent reconstruction operation of the foot dorsum using ALT and TDAP flaps during the same study period, were recruited for comparison. The axial circumference of the operated foot and unoperated contralateral foot was measured, and the difference were compared between all patients, as well as between the two groups. RESULTS All of the flaps survived after the operation, but secondary procedures were performed in two cases due to partial skin necrosis. The mean follow-up period was 13 months. The mean axial circumference discrepancy of the SCIP group (12.08 ± 2.96 mm) was significantly lower compared with ALT (25.21 ± 3.16 mm) and TDAP (29.88 ± 1.55 mm) groups (p < 0.01). CONCLUSIONS The authors experienced good results with using the SCIP flap in dorsal foot reconstruction. Reconstruction with the SCIP flap can be a good surgical option, with better postoperative symmetry and minimal donor sequelae, compared to conventional workhorse flaps.
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Affiliation(s)
- Yujin Myung
- a Department of Plastic and Reconstructive Surgery , Seoul National University Bundang Hospital, Seoul National University College of Medicine , Seoul , South Korea
| | - Sangjun Yim
- a Department of Plastic and Reconstructive Surgery , Seoul National University Bundang Hospital, Seoul National University College of Medicine , Seoul , South Korea
| | - Baek-Kyu Kim
- a Department of Plastic and Reconstructive Surgery , Seoul National University Bundang Hospital, Seoul National University College of Medicine , Seoul , South Korea
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Lee SH, An SJ, Kim NR, Kim UJ, Kim JI. Reconstruction of Postburn Contracture of the Forefoot Using the Anterolateral Thigh Flap. Clin Orthop Surg 2016; 8:444-451. [PMID: 27904728 PMCID: PMC5114258 DOI: 10.4055/cios.2016.8.4.444] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 09/03/2016] [Indexed: 11/06/2022] Open
Abstract
Background Severe forefoot deformities, particularly those involving the dorsum of the foot, cause inconvenience in daily activities of living including moderate pain on the dorsal aspect of the contracted foot while walking and difficulty in wearing nonsupportive shoes due to toe contractures. This paper presents clinical results of reconstruction of severe forefoot deformity using the anterolateral thigh (ALT) free flap. Methods Severe forefoot deformities were reconstructed using ALT flaps in 7 patients (8 cases) between March 2012 and December 2015. The mean contracture duration was 28.6 years. Results All the flaps survived completely. The size of the flaps ranged from 8 cm × 5 cm to 19 cm × 8 cm. The mean follow-up period was 10 months (range, 7 to 15 months). There was no specific complication at both the recipient and donor sites. There was one case where the toe contracture could not be completely treated after surgery. All of the patients were able to wear shoes and walk without pain. Also, the patients were highly satisfied with cosmetic results. Conclusions The ALT flap may be considered ideal for the treatment of severe forefoot deformity.
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Affiliation(s)
- Sang Hyun Lee
- Department of Orthopedic Surgery, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Sung Jin An
- Department of Orthopedic Surgery, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Nu Ri Kim
- Department of Orthopedic Surgery, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Um Ji Kim
- Department of Orthopedic Surgery, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Jeung Il Kim
- Department of Orthopedic Surgery, Medical Research Institute, Pusan National University Hospital, Busan, Korea
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Kerfant N, Lentini A, Le Nen D, Henry AS, Ta P, Trimaille A, Hu W. [Pediatric lower extremity reconstruction]. ANN CHIR PLAST ESTH 2016; 61:536-542. [PMID: 27427445 DOI: 10.1016/j.anplas.2016.06.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 06/22/2016] [Indexed: 11/25/2022]
Abstract
Lower limb multi-tissular injuries are rare in children but require elaborate surgical care considering the child's growth potential, donor-site morbidity and the psychological consequences for the child and his family. This review outlines the various coverage options, from simple to more complex, developing their principles and their results. Technical features of wound repair of the lower limb in children will be detailed. An efficient and ambitious care can give excellent functional outcomes in children, even when extended, multi-tissue lesions members are involved.
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Affiliation(s)
- N Kerfant
- Service de chirurgie plastique, reconstructrice et esthétique, CHRU de Brest, boulevard Tanguy-Prigent, 29609 Brest cedex, France.
| | - A Lentini
- Service de chirurgie plastique, reconstructrice et esthétique, CHRU de Brest, boulevard Tanguy-Prigent, 29609 Brest cedex, France
| | - D Le Nen
- Service de chirurgie plastique, reconstructrice et esthétique, CHRU de Brest, boulevard Tanguy-Prigent, 29609 Brest cedex, France
| | - A-S Henry
- Service de chirurgie plastique, reconstructrice et esthétique, CHRU de Brest, boulevard Tanguy-Prigent, 29609 Brest cedex, France
| | - P Ta
- Service de chirurgie plastique, reconstructrice et esthétique, CHRU de Brest, boulevard Tanguy-Prigent, 29609 Brest cedex, France
| | - A Trimaille
- Service de chirurgie plastique, reconstructrice et esthétique, CHRU de Brest, boulevard Tanguy-Prigent, 29609 Brest cedex, France
| | - W Hu
- Service de chirurgie plastique, reconstructrice et esthétique, CHRU de Brest, boulevard Tanguy-Prigent, 29609 Brest cedex, France
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Zheng X, Zheng C, Wang B, Qiu Y, Zhang Z, Li H, Wang X. Reconstruction of complex soft-tissue defects in the extremities with chimeric anterolateral thigh perforator flap. Int J Surg 2015; 26:25-31. [PMID: 26739595 DOI: 10.1016/j.ijsu.2015.12.035] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2015] [Revised: 12/01/2015] [Accepted: 12/11/2015] [Indexed: 11/17/2022]
Abstract
INTRODUCTION The reconstruction of extensive three-dimensional defects in the extremities is a difficult challenge. Many attempts have been made to reconstruct such defects using the chimeric flap concept, enabling flaps with larger surface areas to be used while maintaining economical tissue use. The anterolateral thigh (ALT) chimeric flap is one of the most useful tools for the reconstruction of complex three-dimensional defects in the extremities. METHODS From January 2010 to March 2012, Twenty-two patients underwent extremity reconstruction using chimeric ALT perforator flaps, which consists of a skin component on its isolated perforator and a portion of the fascia and muscle flaps on the same pedicle from the descending branch of the lateral circumflex femoral artery (LCFA). The defects were in either a lower (n = 10) or an upper extremity (n = 12). The area of the soft tissue defects ranged from 43 × 35 cm to 19 × 9 cm (mean, 25 × 18 cm), containing extensive, irregular, ring-like soft tissue defects or degloving injuries. RESULTS The mean dimension of skin flap was 19.8 × 11.2 cm. The mean dimension of fascia flap was 8.9 × 7.1 cm. The mean dimension of muscle flap was 11.1 × 7.5 cm. No total flap loss occurred. One patient presented with venous thrombosis, and re-anastomosis and vein grafting were performed. Two cases exhibiting partial skin graft loss at the site at which the fascia flap was inset were treated via secondary skin grafts. During a follow-up period of 18 months-30 months, patients were satisfied with the functional and aesthetic outcome. No serious donor-site complications occurred. DISCUSSION Chimeric anterolateral thigh perforator flap can be one of the best choice for reconstruction of complex soft-tissue defects in the extremities. CONCLUSIONS The various tissue components and maximal freedom offered by chimeric tissue flaps associated with the same descending branch of the LCFA provide versatile coverage of large, complex, and irregular soft-tissue defects in the extremities.
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Affiliation(s)
- Xiaoju Zheng
- Department of Hand and Podiatric Microsurgery, Xian Fengcheng Hospital, Xian, PR China
| | - Canbin Zheng
- Department of Microsurgery, Orthopedic Trauma and Hand Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, PR China.
| | - Baoshan Wang
- Department of Hand and Podiatric Microsurgery, Xian Fengcheng Hospital, Xian, PR China
| | - Yongfeng Qiu
- Department of Hand and Podiatric Microsurgery, Xian Fengcheng Hospital, Xian, PR China; The First Affiliated Hospital of Shaanxi University of Chinese Medicine, Xianyang, PR China
| | - Zhong Zhang
- Department of Hand and Podiatric Microsurgery, Xian Fengcheng Hospital, Xian, PR China
| | - Haijun Li
- Department of Hand and Podiatric Microsurgery, Xian Fengcheng Hospital, Xian, PR China
| | - Xinhong Wang
- Department of Hand and Podiatric Microsurgery, Xian Fengcheng Hospital, Xian, PR China
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Kim YH, Kim KH, Sung KY, Kim JT, Kim SW. Toe resurfacing with a thin thoracodorsal artery perforator flap. Microsurgery 2015; 37:312-318. [PMID: 26612346 DOI: 10.1002/micr.30007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 08/19/2015] [Accepted: 10/29/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND In toe reconstruction, amputation procedures are much more common than salvage procedures. However, toe resurfacing, rather than amputation, provides superior functional and aesthetic results. In this study, we report the clinical outcomes of toe resurfacing using a thin thoracodorsal artery perforator flap. PATIENTS AND METHODS Between January 2004 and June 2013, a total of 15 patients underwent toe resurfacing using thoracodorsal artery perforator flaps. Thin flaps were harvested by discarding the deep adipose layer. Twelve cases involved a great toe defect, three, a second toe defect, three, a third toe defect, and one, a fourth toe defect. Patient ages ranged from 19 to 82 years (mean, 42.9 years). The mechanism of injury varied, including crushing injury, degloving injury, and diabetic foot infection. RESULTS The size of thoracodorsal artery perforator flap ranged from 4 × 3 to 20 × 8 cm2 and the thickness of the flap ranged from 4 to 9 mm (mean, 6.5 mm). All flap survived completely without complications. The mean follow-up period was 18.8 months (range, 12-60 months). Only one patient with rheumatoid arthritis had mild gait disturbance. All patients were satisfied with the aesthetic and functional results. CONCLUSION Toe resurfacing with thin thoracodorsal artery perforator flaps appears to be a safer and more reliable option than amputation for preserving their function. © 2015 Wiley Periodicals, Inc. Microsurgery 37:312-318, 2017.
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Affiliation(s)
- Youn Hwan Kim
- Department of Plastic and Reconstructive Surgery, College of Medicine, Hanyang University, Seoul, Korea
| | - Ki Ho Kim
- Department of Plastic and Reconstructive Surgery, College of Medicine, Hanyang University, Seoul, Korea
| | - Kun-Yong Sung
- Department of Plastic and Reconstructive Surgery, Kangwon National University Hospital, Republic of Korea
| | - Jeong Tae Kim
- Department of Plastic and Reconstructive Surgery, College of Medicine, Hanyang University, Seoul, Korea
| | - Sang Wha Kim
- Department of Plastic and Reconstructive Surgery, College of Medicine, Seoul National University, Seoul National University Hospital, Seoul, Korea
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Iida T, Yamamoto T, Yoshimatsu H, Abe N, Tsuchiya M, Nemoto N, Watanabe S. Supermicrosurgical free sensate superficial circumflex iliac artery perforator flap for reconstruction of a soft tissue defect of the ankle in a 1-year-old child. Microsurgery 2015; 36:254-8. [DOI: 10.1002/micr.22525] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 09/23/2015] [Accepted: 10/13/2015] [Indexed: 11/09/2022]
Affiliation(s)
- Takuya Iida
- Department of Plastic and Reconstructive Surgery; University of Tokyo; 7-3-1 Hongo Tokyo 1138655 Japan
| | - Takumi Yamamoto
- Department of Plastic and Reconstructive Surgery; University of Tokyo; 7-3-1 Hongo Tokyo 1138655 Japan
| | - Hidehiko Yoshimatsu
- Department of Plastic and Reconstructive Surgery; University of Tokyo; 7-3-1 Hongo Tokyo 1138655 Japan
| | - Naho Abe
- Division of Plastic Surgery; Department of Surgery; Saitama Children's Medical Center; 200 Magome, Iwatsuki-Ku Saitama 3398551 Japan
| | - Masato Tsuchiya
- Division of Plastic Surgery; Department of Surgery; Saitama Children's Medical Center; 200 Magome, Iwatsuki-Ku Saitama 3398551 Japan
| | - Naho Nemoto
- Division of Orthopedic Surgery; Department of Surgery; Saitama Children's Medical Center; 200 Magome, Iwatsuki-Ku Saitama 3398551 Japan
| | - Shoji Watanabe
- Division of Plastic Surgery; Department of Surgery; Saitama Children's Medical Center; 200 Magome, Iwatsuki-Ku Saitama 3398551 Japan
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Jabir S, Sheikh F, Fitzgerald O’Connor E, Griffiths M, Niranjan N. A systematic review of the applications of free tissue transfer for paediatric lower limb salvage following trauma. J Plast Surg Hand Surg 2015; 49:251-259. [DOI: 10.3109/2000656x.2015.1047781] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Lee G, Jeong E. Coverage of defect over toes after failure of microsurgical replantation with medial sural artery perforator flap: A case report. Microsurgery 2015; 36:161-4. [PMID: 25867277 DOI: 10.1002/micr.22415] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Revised: 03/18/2015] [Accepted: 03/25/2015] [Indexed: 11/11/2022]
Abstract
In this report, we present a case of toe reconstruction with a medial sural artery perforator free flap after failure of replantation. A 35-year-old male suffered a crush injury from a heavy object falling over the left 1st, 2nd, and 3rd toes and underwent microsurgical replantation of the toes at an outside facility. Over the next 2 weeks, ischemic necrosis of all the toes developed. This condition was very frustrating for the patient who had very high expectations of preserving the toes, and also for the surgeon to determine the optimal method to reconstruct the distal foot and toes. After debridement of non-viable tissues, the defect over the toes was resurfaced using a medial sural artery perforator free flap and full thickness skin graft. Subsequently, several minor operations, including interdigitation, excision of neuromas, and defatting procedure were performed to complete his reconstruction. Eighteen months later, the patient had very aesthetically pleasing and fully functional toes. A medial sural artery perforator free flap may be used to repair the soft tissue defect on the toes after failed replantation, and provides sufficient skin.
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Affiliation(s)
- Gordon Lee
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Palo Alto, CA
| | - Euicheol Jeong
- Department of Plastic Surgery, SMG-SNU Boramae Medical Center, Seoul, Korea
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Kim SW, Youn DH, Hwang KT, Sung IH, Kim JT, Kim YH. Reconstruction of the lateral malleolus and calcaneus region using free thoracodorsal artery perforator flaps. Microsurgery 2015; 36:198-205. [PMID: 25732603 DOI: 10.1002/micr.22389] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Revised: 01/19/2015] [Accepted: 01/22/2015] [Indexed: 11/06/2022]
Abstract
Reconstruction of the lateral malleolus or calcaneus region is challenging because of poor vascularity, minimal presence of soft tissue, and difficulties with flap positioning during and after the operation. In many cases, local flaps are limited in terms of size, durability, and vascularity. Free tissue transfer can be useful for complicated wounds. We report here on the results of the reconstruction in this region using free thoracodorsal artery perforator flaps. Between October 2010 and October 2013, 16 cases of lateral malleolus or calcaneus defects were reconstructed using free thoracodorsal artery perforator flaps. The defects varied from 2 × 5 cm(2) to 12 × 16 cm(2), and the flaps from 3 × 5 cm(2) to 10 × 15 cm(2). Two cases were reconstructed using chimeric-pattern flaps. Only the superficial adipose layers were harvested for all the flaps, without further thinning or debulking process. Five cases with complications occurred, including three cases of partial necrosis of the flap and two cases of venous congestion caused by thrombosis and compression of the venous pedicle, and one flap was totally lost. The mean follow-up duration was 11.8 months. All the patients were able to wear shoes. All but one were able to walk. The thoracodorsal artery perforator flap can be made super-thin, allowing patients to wear shoes, and it can be harvested in a chimeric-pattern for complex defects. Therefore, it may represent a viable alternative choice for the reconstruction of the lateral malleolus and calcaneus region.
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Affiliation(s)
- Sang Wha Kim
- Department of Plastic and Reconstructive Surgery, The Catholic University of Korea, Seoul, Korea
| | - Dong Hyun Youn
- Department of Plastic and Reconstructive Surgery, College of Medicine, Hanyang University, Seoul, Korea
| | - Kyu Tae Hwang
- Department of Orthopedic Surgery, College of Medicine, Hanyang University, Seoul, Korea
| | - Il Hoon Sung
- Department of Orthopedic Surgery, College of Medicine, Hanyang University, Seoul, Korea
| | - Jeong Tae Kim
- Department of Plastic and Reconstructive Surgery, College of Medicine, Hanyang University, Seoul, Korea
| | - Youn Hwan Kim
- Department of Plastic and Reconstructive Surgery, College of Medicine, Hanyang University, Seoul, Korea.,Department of Plastic and Reconstructive Surgery, Seoul National University Hospital, Seoul, Korea
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Busnardo FF, Coltro PS, Olivan MV, Faes JC, Lavor E, Ferreira MC, Rodrigues AJ, Gemperli R. Anatomical comparison among the anterolateral thigh, the parascapular, and the lateral arm flaps. Microsurgery 2014; 35:387-92. [DOI: 10.1002/micr.22357] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Revised: 11/05/2014] [Accepted: 11/10/2014] [Indexed: 11/11/2022]
Affiliation(s)
- Fábio F. Busnardo
- Division of Plastic Surgery and the Cancer Institute of São Paulo; University of São Paulo School of Medicine; São Paulo Brazil
| | - Pedro S. Coltro
- Division of Plastic Surgery and the Cancer Institute of São Paulo; University of São Paulo School of Medicine; São Paulo Brazil
| | - Marcelo V. Olivan
- Division of Plastic Surgery and the Cancer Institute of São Paulo; University of São Paulo School of Medicine; São Paulo Brazil
| | - Jose C. Faes
- Division of Plastic Surgery and the Cancer Institute of São Paulo; University of São Paulo School of Medicine; São Paulo Brazil
| | - Elizeu Lavor
- Division of Plastic Surgery and the Cancer Institute of São Paulo; University of São Paulo School of Medicine; São Paulo Brazil
| | - Marcus C. Ferreira
- Division of Plastic Surgery and the Cancer Institute of São Paulo; University of São Paulo School of Medicine; São Paulo Brazil
| | - Aldo J. Rodrigues
- Division of Plastic Surgery and the Cancer Institute of São Paulo; University of São Paulo School of Medicine; São Paulo Brazil
| | - Rolf Gemperli
- Division of Plastic Surgery and the Cancer Institute of São Paulo; University of São Paulo School of Medicine; São Paulo Brazil
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Ozkan O, Ozkan O, Cinpolat A, Bektas G. Reconstruction of distal lower extremities defect using the free peroneal artery perforator vessel based flap. Microsurgery 2014; 34:629-32. [DOI: 10.1002/micr.22290] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2014] [Revised: 05/24/2014] [Accepted: 06/24/2014] [Indexed: 12/12/2022]
Affiliation(s)
- Omer Ozkan
- Akdeniz University School of Medicine; Department of Plastic; Reconstructive and Aesthetic Surgery; Antalya Turkey
| | - Ozlenen Ozkan
- Akdeniz University School of Medicine; Department of Plastic; Reconstructive and Aesthetic Surgery; Antalya Turkey
| | - Ani Cinpolat
- Akdeniz University School of Medicine; Department of Plastic; Reconstructive and Aesthetic Surgery; Antalya Turkey
| | - Gamze Bektas
- Akdeniz University School of Medicine; Department of Plastic; Reconstructive and Aesthetic Surgery; Antalya Turkey
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Visconti G, Salgarello M, Visconti E, Cipriani A, Cina A, Bonomo L. Anatomy of anteromedial thigh perforators: CT-angiography study. Microsurgery 2014; 35:196-203. [PMID: 25043682 DOI: 10.1002/micr.22292] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Revised: 06/20/2014] [Accepted: 06/24/2014] [Indexed: 11/09/2022]
Abstract
The anatomy of perforator for anteromedial thigh (AMT) flap is a very much-debated issue. In this article, we report AMT perforator vascular anatomy by CT-Angiography (CTA) evaluation of 68 consecutive healthy thighs. Perforators emergence, caliber, length, course, and source vessel in the central three fifth of the thigh were studied by a virtual coordinate system. A mean 4.94 ± 1.75 perforators per thigh (average length, 2.6 ± 0.99 cm) from superficial femoral artery (SFA) were found, emerging medial and lateral to sartorius muscle. A mean 0.4 ± 0.74 perforators per thigh (average length, 2.45 ± 0.97 cm) branched from rectus femoris artery, of which 80% were emerging lateral to sartorius muscle. A mean 0.62 ± 0.91 perforators per thigh (average length, 3.1 ± 1.23 cm) branched from an unnamed branch of SFA, of which 88% were emerging lateral to the sartorius muscle. Perforators' calibre was inferior to 1-5 mm in 177 perforators (51.6%), between 1.5 and 2 mm in 159 (46.7%), and over 2 mm in 7 (2%). The findings from this study show that AMT region is plenty of reliable perforators with overlapping fascial emergence but branching from three different source arteries.
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Affiliation(s)
- Giuseppe Visconti
- Department of Plastic and Reconstructive Surgery, Università Cattolica del "Sacro Cuore", University Hospital "A. Gemelli", Largo A. Gemelli 8, 00168, Rome, Italy
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Lee JT, Chen PR, Hsu H, Wu MS, Cheng LF, Huang CC, Chien SH. The proximal lateral lower leg perforator flap revisited: Anatomical study and clinical applications. Microsurgery 2014; 35:115-22. [DOI: 10.1002/micr.22264] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 03/26/2014] [Accepted: 04/03/2014] [Indexed: 11/07/2022]
Affiliation(s)
- Jiunn-Tat Lee
- Division of Plastic Surgery; Buddhist Tzu Chi General Hospital; Hualien Taiwan
- School of Medicine, Tzu Chi University; Hualien Taiwan
| | - Peir-Rong Chen
- School of Medicine, Tzu Chi University; Hualien Taiwan
- Department of Otolaryngology; Buddhist Tzu Chi General Hospital; Hualien Taiwan
| | - Honda Hsu
- School of Medicine, Tzu Chi University; Hualien Taiwan
- Division of Plastic Surgery; Buddhist Dalin Tzu Chi Hospital, Tzu Chi University; Dalin Taiwan
| | - Meng-Si Wu
- Division of Plastic Surgery; Buddhist Tzu Chi General Hospital; Hualien Taiwan
| | - Li-Fu Cheng
- Division of Plastic Surgery; Buddhist Tzu Chi General Hospital; Hualien Taiwan
- School of Medicine, Tzu Chi University; Hualien Taiwan
| | - Chieh-Chi Huang
- School of Medicine, Tzu Chi University; Hualien Taiwan
- Division of Plastic Surgery; Buddhist Dalin Tzu Chi Hospital, Tzu Chi University; Dalin Taiwan
| | - Sou-Hsin Chien
- School of Medicine, Tzu Chi University; Hualien Taiwan
- Division of Plastic Surgery; Buddhist Taichung Tzu Chi Hospital; Taichung Taiwan
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Kim SW, Kwon YH, Kim JT, Kim YH. Foot reconstruction using a serratus anterior muscle flap from the same donor site after failure of a thoracodorsal artery perforator flap. Microsurgery 2013; 34:153-6. [DOI: 10.1002/micr.22181] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2013] [Revised: 08/05/2013] [Accepted: 08/09/2013] [Indexed: 11/06/2022]
Affiliation(s)
- Sang Wha Kim
- Department of Plastic and Reconstructive Surgery; The Catholic University of Korea; Seoul Korea
| | - Young Hun Kwon
- Department of Plastic and Reconstructive Surgery; Hanyang University, College of Medicine; Seoul Korea
| | - Jeong Tae Kim
- Department of Plastic and Reconstructive Surgery; Hanyang University, College of Medicine; Seoul Korea
| | - Youn Hwan Kim
- Department of Plastic and Reconstructive Surgery; Hanyang University, College of Medicine; Seoul Korea
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