Free deep inferior epigastric artery perforator flap for reconstruction of soft-tissue defects in extremities of children

Hydrogels containing KYNA promote angiogenesis and inhibit inflammation to improve the survival rate of multi-territory perforator flaps

BACKGROUND

A new spray adhesive (KYNA-PF127) was established through the combination of thermosensitive hydrogel (Pluronic F127) and KYNA, aimed to investigate the effect of KYNA-PF127 on multi-territory perforator flaps and its possible molecular mechanism.

MATERIALS AND METHODS

36 SD male rats with 250-300 g were randomly divided into 3 groups (n = 12): control group, blank glue group and KYNA-PF127 group. KYNA-PF127 hydrogel was prepared and characterized for its morphology and properties using scanning electron microscopy. CCK-8 assay, scratch wound assay, transwell assay, tube formation assay and Ki67 staining were used to study the effect of KYNA-PF127 on the proliferation, migration, and tube formation of HUVECs. VEGF and FGF2 were measured by qPCR to evaluate the angiogenesis capacity of HUVECs in vitro. In vivo, the effect of each group on the survival area of the cross-zone perforator flap was evaluated, and angiogenesis was evaluated by HE and immunofluorescence (CD31 and MMP-9). The effect of inflammation on skin collagen fibers was assessed by Masson. Immunohistochemistry (SOD1, IL-1β, TNF-α) was used to evaluate the effects of oxidative stress and inflammatory factors on multi-territory flaps.

RESULTS

KYNA-PF127 has good sustained release and biocompatibility at 25% concentration. KYNA-PF127 promoted the proliferation, migration, and angiogenesis of HUVECs in vitro. In vivo, the survival area of multi-territory perforator flaps and angiogenic capability have increased after KYNA-PF127 intervention. KYNA-PF127 could effectively reduce the oxidative stress and inflammation of multi-territory perforator flaps.

CONCLUSION

KYNA-PF127 promotes angiogenesis through its antioxidant stress and anti-inflammatory effects, and shows potential clinical value in promoting the survival viability and drug delivery of multi-territory perforator flaps.

Pre-expanded thin DIEP free flap in pediatric upper extremity reconstruction for burn sequelae: A case report

Deep burns sequelae involving the upper limb are challenging even for experienced surgeons, mainly because local reconstructive options and donor sites are often compromised. The use of free flaps for this type of reconstruction remains difficult due to the small recipient vessel diameter and tendency to vasospasm. Moreover, pediatric cases bring the challenge to another level. We present the case of a 13-year-old girl presenting major retractile sequelae of the upper left limb, including complete wrist immobilization combining wrist hyper-extension, ulnar deviation deformity, and a ulno-carpal dislocation. She was referred to our department where a two-stage reconstruction was performed using a pre-expanded free deep inferior epigastric artery perforator (DIEP) flap. The first surgery consisted of placing two kidney-shaped expanders in a subfascial plane in the hypogastric region. Four months later, after a bi-weekly expansion, an excision of the scar tissue, and the DIEP flap transfer were completed. At the 12-month follow-up evaluation, both aesthetic and functional results were satisfactory, with a good contour and regained mobility of the wrist.

Surgical Considerations of One-Stage Reconstruction of Large Extremity Defects Using a Thin Deep Inferior Epigastric Perforator Flap

Background  One-stage reconstruction with "thin perforator flaps" has been attempted to salvage limbs and restore function. The deep inferior epigastric perforator (DIEP) flap is a commonly utilized flap in breast reconstruction (BR). The purpose of this study is to present the versatility of DIEP flaps for the reconstruction of large defects of the extremities. Methods  Patients with large tissue defects on extremities who were treated with thin DIEP flaps from January 2016 to January 2018 were included. They were minimally followed up for 36 months. We analyzed the etiology and location of the soft tissue defect, flap design, anastomosis type, outcome, and complications. We also considered the technical differences in the DIEP flap between breast and extremity reconstruction. Results  Overall, six free DIEP flaps were included in the study. The flap size ranged from 15 × 12 to 30 × 16 cm 2 . All flaps were transversely designed similar to a traditional BR design. Three flaps were elevated with two perforators. Primary closure of the donor site was possible in all cases. Five flaps survived with no complications. However, partial necrosis occurred in one flap. Conclusion  A DIEP flap is not the first choice for soft tissue defects, but it should be considered for one-stage reconstruction of large defects when the circulation zone of the DIEP flap is considered. In addition, this flap has many advantages over other flaps such as provision of the largest skin paddle, low donor site morbidity with a concealed scar, versatile supercharging technique, and a long pedicle.

Comparison of retrograde anatomy iliac bone flap grafting versus anterograde anatomy iliac bone flap grafting for treatment of osteonecrosis of the femoral head

BACKGROUND

Iliac bone flap with deep circumflex iliac artery is a common option in the treatment of Osteonecrosis of the femoral head (ONFH), and dissection of iliac bone flap is the key step for successful operation. This paper aims to introduce a new operative technique for dissecting iliac bone flap with deep circumflex iliac artery based on analysis of its advantages.

METHODS

A total of 49 patients treated by retrograde anatomy and 52 patients treated by anterograde anatomy from January 2010 to December 2020 were recruited. The two groups were then compared in terms of the preoperative baseline conditions, intraoperative data, and postoperative Harris hip score (HHS).

RESULTS

Compared with the retrograde anatomy group, the anterograde anatomy group had a significantly longer operating time, a significantly heavier intraoperative blood loss, a significantly higher rate of donor complication morbidity, a significantly higher rate of donor-recipient delayed healing, a significantly higher failure rate of iliac bone flap resection, a significantly higher rate of lateral femoral cutaneous nerve (LFCN) injury, and a significantly higher rate of ectopic ossification. No difference was found in postoperative HHS score between the two groups.

CONCLUSION

As a new operative technique that can accurately locate the nutrient vessels of the iliac bone flap and quickly dissect the iliac bone flap with deep circumflex iliac artery while maintaining a comparable clinical effect, retrograde anatomy exhibited distinct advantages over anterograde anatomy in terms of simpler intraoperative operation, safer dissection, shorter operation time, lower blood loss, and fewer donor complications.

LEVEL OF EVIDENCE

III, Retrospective.

Comparison of outcomes between single- and multiple-perforator-based free perforator flaps: A systematic review and meta-analysis

BACKGROUND

Perforator-based free perforator flaps have become an important tool for the reconstruction of tissue defects. The effect of the number of perforators on the outcomes of perforator flaps has been widely debated. This study aimed to compare the outcomes of single- and multiple-perforator-based free perforator flaps in free-flap reconstruction.

METHODS

We searched PubMed, Web of Science, EMBASE, Chinese BioMedical Literature Database (CBM), Cochrane Library, and clinicaltrials.gov between January 2000 and June 2021 to identify studies that reported data on the outcomes of free perforator flaps. Two authors individually extracted data and performed quality assessment. Outcomes, including partial flap loss, total loss, fat necrosis, arterial insufficiency, venous insufficiency, hemorrhage and hematoma, wound dehiscence at recipient sites and donor site complications, were evaluated.

RESULTS

Thirty-two studies with 2498 flaps were included in our analysis. No significant difference was found in the rates of partial loss and arterial insufficiency of flaps, hemorrhage and hematoma, wound dehiscence at recipient sites and donor site complications. However, the multiple-perforator group showed significantly lower rates of total loss (relative risk [RR] = 1.08, 95% confidence interval [CI]: 0.78-1.79, p = .754), fat necrosis (RR = 1.79, 95% [CI]: 1.36-2.36, p = .000) and venous insufficiency (RR = 1.72, 95% CI: 1.07-2.79, p = .026) than the single-perforator group.

CONCLUSION

The rates of total loss, fat necrosis and venous insufficiency in the multiple-perforator group were lower than those in the single-perforator group. Hence, we recommend that multiple perforators be included in the free perforator flap when appropriate, to yield better clinical outcomes in reconstruction.

"Systematic Review and Guidelines for Perioperative Management of Pediatric Patients Undergoing Major Plastic Surgery Procedures, With a Focus on Free Tissue Transfer."

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.

Melatonin Improved the Survival of Multi-Territory Perforator Flaps by Promoting Angiogenesis and Inhibiting Apoptosis via the NRF2/FUNDC1 Axis

Background: Multi-territory perforator flaps are a reconstructive measure for repairing large soft tissue defects caused by tumors or trauma. However, the use of these flaps in clinical practice has been restricted due to the uncertain blood supply. Therefore, promoting the survival of the multi-territory perforator flap is critical for clinical repair and reconstruction. In our study, we explored the effects of melatonin (MLT) on multi-territory perforator flaps and the possible molecular mechanisms.

Materials and Methods: Seventy-two Sprague–Dawley rats (250–300 g) were randomly divided into 3 groups (n = 24): Control, MLT and MLT + ML385 groups. First, we assessed the survival area of the flap, followed by the micro-vessel density and CD31-positive vessel expression. Apoptosis of the skin flap under immunofluorescence and expression of the apoptosis-related proteins Bcl-2, Bax and Caspase3 were measured. Additionally, angiogenesis of the skin flaps was shown by angiography, and NRF2 and FUNDC1 mRNA and protein expression was detected by real-time PCR and western blotting.

Results: The results showed that MLT increased the survival area of the multi-territory perforator flap, which was related to increased angiogenesis and decreased apoptosis. We also found that mRNA and protein of NRF2 and FUNDC1 levels were significantly increased after MLT treatment, and an NRF2 inhibitor reversed the ability of MLT to enhance multi-territory perforator flap survival, promote angiogenesis and inhibit apoptosis and reduced FUNDC1 protein expression.

Conclusion: MLT promoted angiogenesis and inhibited apoptosis to promote the survival of multi-territory perforator flaps, which may be regulated via the NRF2/FUNDC1 axis.

One-stage reconstruction of extensive composite extremity defects with low donor site morbidity: A retrospective case series of combined transfer of a vascularized fibula flap and a perforator flap

BACKGROUND

Extensive composite extremity defects remain a challenge in plastic and reconstructive surgery. To preserve the extremity, we used combined transfer composed of the vascularized fibula flap and a perforator flap from various body parts to reconstruct extensive composite extremity defects.

PATIENTS AND METHODS

From January 2004 to December 2018, 14 male patients aged 9 to 55 years with extensive composite extremity defects (large soft-tissue and long bone defect) underwent reconstructive surgery in our institution. The combined transfer surgery consisted of the vascularized fibula bone flap and a perforator flap, such as anterolateral thigh flap, deep inferior epigastric perforator flap, or thoracodorsal artery perforator flap.

RESULTS

All fourteen patients were treated successfully using the combined transfer method. The dimensions of the different perforator flaps ranged from 13 × 6 cm² to 26 × 11 cm², and the size of the skin paddle of the fibular osteocutaneous flap ranged from 9 × 3 cm² to 21 × 7 cm². The median length of the fibular graft was 15 cm. No serious donor site complications were observed. Only one patient developed venous congestion and was salvaged. Another patient had hematoma at the recipient site and underwent debridement. Though all patients achieved bone union (median time of 8 months), two developed a stress fracture of the transferred free fibula.

CONCLUSION

We were able to minimize donor site morbidity and avoid amputation in these patients using the combined transfer technique Our results show that the combined transfer of perforator flap and vascularized fibula flap with or without a skin paddle is a feasible reconstruction option for the treatment of the extensive composite extremity defects.

Strategies for selecting perforator vessels for transverse and oblique DIEP flap in male pediatric patients: Anatomical study and clinical applications

BACKGROUND

Transverse and oblique deep inferior epigastric artery perforator (DIEP) flaps are widely used in breast, lower extremity, urogenital, head and neck reconstruction. In this report, we present our experience with selecting perforator vessels for transverse and oblique DIEP flaps based on an anatomical study and clinical cases.

MATERIALS AND METHODS

A detailed anatomical study of the DIEP flap was carried out using a standardized injection of lead oxide in 10 fresh cadavers. Additionally, 35 male pediatric patients (age 5-12 years) underwent lower extremity reconstruction with a DIEP flap. A transverse DIEP flap was used when the defect template did not exceed zone IV, while an oblique DIEP flap was used when the defect template exceeded zone IV.

RESULTS

Perforators located below the umbilicus in zones I and II were rich in transverse anastomoses across the midline of the abdominal wall, which is the basis for the transverse DIEP flap. Perforators lateral to the umbilicus in zone I had true anastomoses with the musculophrenic artery, the morphological basis for the oblique DIEP flap. The DIEP flap design was transverse in 20 patients and oblique in 15. Flap sizes ranged from 8 × 4.5 cm² to 24 × 9 cm². One oblique DIEP flap was necrosed totally, and it was repaired by a latissimus dorsi musculocutaneous flap.

CONCLUSION

The transverse DIEP flap design based on the perforator located below the umbilicus in zone I is recommended for small skin and soft tissue defects. We recommend the use of the oblique DIEP flap design based on the perforator lateral to the umbilicus in zone I as an extended flap to reconstruct large tissue defects.

Algorithm for covering circumferential wound on limbs with ALTP or/and DIEP flaps based on chain-linked design and combined transplantation

INTRODUCTION

Coverage of circumferential wounds on limbs is a challenging reconstructive job. Here, we propose a skin flap-based algorithm to reconstruct circumferential wound with the chain-linked design and combined transplantation of ALTP and DIEP flap, which could achieve full-coverage and simultaneously primary donor-site closure.

PATIENT AND METHODS

From December 2007 to December 2018, 14 patients with circumferential would on upper or lower limbs underwent reconstruction with ALTP or DIEP flap, by the technique of combined transplantation or chain-linked design, or both. The wound was classified into five different types according to the width compared to the donor site (overall magnitudes and regularity), which was separately reconstructed by five different wound decomposition and corresponding flap design. Flap survivorship, complication on recipient or donor site and any secondary surgeries have been recorded.

RESULTS

14 patients were successfully treated with 22 flaps, including seven patients reconstructed with one flap (4 bi-pedicled, 2 tri-pedicled), 6 patients reconstructed with two flaps (1 in mono-pedicled, 5 in multi-pedicled), one with 3 flaps and skin grafts. Only one donor site was not directly closed, and one experienced dehiscence but finally healed. All flaps survived uneventfully but three had minor edge necrosis and later treated with skin graft.

CONCLUSION

The algorithm is practical in circumferential wound resurfacing on limbs for allowing flexible design, sufficient coverage, and low donor site morbidity.

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

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.

Utilisation of distally based sural fasciocutaneous flaps in lower extremity reconstruction: a single-centre experience with 88 paediatric patients

BACKGROUND

No large series have analysed distally based sural fasciocutaneous (DBSF) flaps in paediatric patients. The aims of this study were to assess the reliability and analyse the potential risk factors for these flaps and to describe complications in the donor site and the functional follow-up results.

METHODS

Between June 2002 and November 2017, 88 DBSF flaps were used to reconstruct soft tissue defects in paediatric patients. Potential risk factors, reconstruction outcomes, and complications in the donor site of the flaps were analysed.

RESULTS

Among the 88 flaps, partial necrosis developed in 8 flaps (9.1%). The partial necrosis rate was significantly higher in flaps with the top edge located in the 9th zone (26.1%), with a length-width ratio (LWR) ≥ 5:1 (28.6%), and with a dimension of the skin island ≥ 100 cm² (22.7%). Partial necrosis did not occur in flaps with a dimension of the skin island < 80.0 cm² or with a skin-island width < 7.0 cm. The reconstruction outcomes in most paediatric patients were evaluated as "excellent" or "good". The incidence of obvious scarring was higher in the donor site.

CONCLUSIONS

Partial necrosis of DBSF flaps will significantly increase when the top edge of the flap is located in the 9th zone, when the LWR of the flap is ≥ 5:1, or when the dimension of the skin island is ≥ 100.0 cm². Flaps with a skin-island width < 7.0 cm or with a dimension of the skin island < 80 cm² are relatively safe and reliable.

Effect of bone marrow mesenchymal stem cells on perforator skin flap survival area in rats

Trans-territory perforator flaps are commonly used to reconstruct large defects of the soft tissues. The distal portion of the flap often becomes necrotic, however, as a result of the jeopardised vasculature of choke zone II. The trophic and vascular regenerative properties of bone marrow mesenchymal stem cells (BMSC) seemed to be a promising approach to prevent flaps becoming ischaemic. The purpose of our study is to evaluate the effects of BMSC on the survival of the three-territory perforator flap. The flap model was created based on the deep circumflex iliac vessel in rats. Eighteen rats were distributed, at random, into three groups. Immediately after the flaps were placed, groups were respectively given a single panniculus carnosus injection at choke zone II of either 1×10⁵ (BMSCs^low), 1×10⁶ (BMSCs^hig) BMSC, or phosphate-buffered saline (PBS). On postoperative day seven, we assessed the gross view of the flap and survival. We also evaluated microvessels by histological examination and angiogenesis-related gene expression by quantitative real-time polymerase chain reaction. After high dosage of BMSC, the flap survival rate, diameter and density of microvessels, vascular endothelial growth factor (VEGF) and platelet endothelial cell adhesion molecule-1 (PECAM-1/CD31) levels were significantly higher in the BMSC treatment group than the control group. We therefore confirmed the positive effects of BMSC on the survival of multi-territory perforator flaps.

[Free sensate intercostal artery perforator flap for hand soft tissue reconstruction]

Objective

To investigate the effectiveness of free sensate intercostal artery perforator flap for the hand soft tissue reconstruction.

Methods

Between March 2010 and September 2015, 19 cases of hand soft tissue defect were repaired with free sensate intercostal artery perforator flap, including 16 males and 3 females, aged from 18 to 53 years, with an average of 35.2 years. The defect was located in the dorsum of the hand in 15 cases and in the palm in 4 cases. The causes of injury were traffic accident injury in 8 cases, hot crush injury in 5 cases, strangulation injury in 4 cases, and avulsion injury in 2 cases. All of them were full-thickness skin and soft tissue defects of hand with exposure of phalanges, tendons, blood vessels, and nerves. The size of defect was 10.0 cm×7.0 cm to 17.0 cm×8.0 cm. There were 12 cases of emergency operation and 7 cases of selective operation. The thickness of flap was 10-25 mm, and the size of the flap ranged from 10.0 cm×7.5 cm to 17.0 cm×8.0 cm. The vascular pedicle of the flap was anastomosed with the snuff nest branch of the radial artery (12 cases), the main radial artery (7 cases), and there accompanying vein, and the intercostal nerve cutaneous branch of the flap was anastomosed with the lateral cutaneous nerve of the forearm. The donor site was closed directly (14 cases) or repaired with medium thickness skin graft (5 cases).

Results

All of the flaps and skin grafts survived; the wounds in the donor and recipient sites healed by first intention. All 19 patients were followed up 10- 18 months, with an average of 12.7 months. After operation, the appearance and function of the hand recovered well, and there was no flap bloated. The two-point discrimination of the flap was 7-11 mm, with an average of 8.8 mm. Only linear scars left in the patients with direct closure of the donor site. The sensory function of the donor site was not significantly affected, and the hand function recovered satisfactorily.

Conclusion

Free sensate intercostal artery perforator flap is a valuable and reliable technique for the hand soft tissue defect.

Anatomic Study and Clinic Application of Transverse Circumflex Scapular Artery Perforator Flap Repair of Lower Limb Soft Tissue Defects in Children

PURPOSE

The aim of this study was to demonstrate the viability of the transverse circumflex scapular artery perforator flap (TCSAPF) in children with soft tissue defects of the lower limb.

METHODS

In an anatomic study, 25 fresh cadavers were injected with lead oxide-gelatin for spiral computed tomography and 3-dimensional image reconstruction. In a 3-year clinical application study, children with soft tissue defects and exposed tendons and/or bones in the lower limb underwent free-TCSAPF repair of the defect.

RESULTS

Perforators from the transverse branch of the circumflex scapular artery were identified in both anatomical and clinical studies. The average external diameter was 0.9 ± 0.3 mm. Each perforator supplied an average area of 63.5 ± 16.8 cm in anatomical. Twenty-one children were included in this group (9 boys, 12 girls, mean age, 6.6 ± 2.7 years). The size of the flaps ranged from 6 to 17 cm × 4.5 to 7 cm (average, 65.3 ± 22.6 cm). The average flap harvesting time was 30.1 ± 8.5 minutes, average operation time was 138.6 ± 31.5 minutes, and average blood loss was 89.5 ± 21.9 mL. The average length of the vessel pedicle was 8.2 ± 2.4 cm. Arterial congestion occurred in one child, 18 hours postoperatively; subsequent re-exploration and great saphenous vein transplantation were successful. Of the 3 children who had bulky flaps, 1 patient underwent defatting. Satisfactory outcomes included good appearance and function of the recipient and donor areas.

CONCLUSIONS

The TCSAPF provides high-quality skin and vessel flexibility, providing a reliable blood supply in children. The flap has potential benefits over existing perforator flaps.

The Effect of Leonurine on Multiterritory Perforator Flap Survival in Rats

BACKGROUND

Leonurine (Leo), a natural active compound of Leonurus cardiaca, has been shown to possess various biological activities. However, it is not known whether Leo promotes perforator flap survival.

METHODS

In this study, a perforator flap was outlined in the rat dorsum. The rats that survived surgery were divided randomly to control and Leo groups (n = 36 per group). Flap viability, flap perfusion, and level of protein linked with oxidative stress, cell apoptosis, and angiogenesis were evaluated.

RESULTS

Relative to control group, the Leo group showed significantly higher the flap survival percentage (70.5% versus 90.2%, P < 0.05) and blood perfusion (197.1 versus 286.3, P < 0.05). Leo also increased 1.8-fold mean vessel density and upregulated 2.1-fold vascular endothelial growth factor protein expression compared with the control group, both of which indicate increased angiogenesis. Moreover, it significantly inhibited apoptosis by lowering caspase-3 activity. Superoxide dismutase expression was remarkably elevated in Leo group compared with the control group (56.0 versus 43.2 U/mg/protein, P < 0.01), but malondialdehyde quantities were significantly lower in the Leo group compared with control group (41.9 versus 57.5 nmol/mg/protein, P < 0.05).

CONCLUSIONS

Leo may serve as an effective drug for improving perforator flap survival in rats via antioxidant and antiapoptotic mechanisms and promotion of angiogenesis.

Reconstructive surgery for foot and ankle defects in pediatric patients: Comparison between anterolateral thigh perforator flaps and deep inferior epigastric perforator flaps

BACKGROUNDS

Due to the delicate tissue, small blood vessels and incomplete development of interarticular ligaments, skin and soft-tissue defects of the foot and ankle in pediatric patients remain a challenge for orthopedic and plastic surgeons. Anterolateral thigh perforator (ALTP) flap and deep inferior epigastric perforator (DIEP) flap are the most commonly used flaps for the repair of lower-extremity soft-tissue defects. The literature contains a shortage of evidence involving the differences between ALTP and DIEP flaps in the reconstruction of young patients with complex foot and ankle defects. This study was designed to determine which type of flap is better for foot and ankle repair in pediatric patients.

METHODS

From January 2004 to January 2018, 79 children younger than 14 years treated with DIEP flap (41 cases) or ALTP flap (38 cases) for composite defects of the feet and ankles were retrospectively investigated. The two groups were homogeneous in terms of age, the location of the defect, etiology, and flap area. Complications, scarring, cosmetic appearance, flap sensory recovery, and functional outcome were analyzed, and statistical analysis was performed.

RESULTS

The ALTP group had shorter operation time (155.0 ± 12.0 min vs 212.2 ± 23.9 min), flap harvested time (39.6 ± 5.1 min vs 57.2 ± 10.4 min), and operative blood loss (143.4 ± 23.7 ml vs 170.7 ± 44.7 ml) than the DIEP group (P <  0.05). In short-term follow-up, ALTP group showed a lower flap necrosis rate (5.3% vs 24.4%) and vascular insufficiency rate (2.6% vs 19.5%) than DIEP group (P <  0.05). In long-term follow-up, ALTP group showed a lower late complication rate and better cosmetic, functional, scar outcomes than DIEP group (P <  0.05).

CONCLUSIONS

The study showed that an ALTP flap may brings better results than a DIEP flap in terms of short- and long-term complications, scarring, and morpho-functional outcomes for pediatric patients undergoing reconstruction of foot and ankle defects.

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

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.

Tetramethylpyrazine improved the survival of multiterritory perforator flaps by inducing angiogenesis and suppressing apoptosis via the Akt/Nrf2 pathway

Background: Multiterritory perforator flaps were commonly designed to cover the large soft-tissue defects in reconstructive surgery. But the high risk of partial necrosis in the distal portion of the flaps hindered their clinical application. The purpose of this study was to evaluate the effects of tetramethylpyrazine (TMP) on the survival of the multiterritory perforator flaps and to explore the underlying mechanism.

Materials and methods: Seventy-two Sprague–Dawley rats underwent multiterritory perforator flap procedure and were divided into three groups with 24 each. Flap survival and water content were measured, and the area of angiogenesis and apoptosis in the ischemia skin flaps were assessed on the postoperative day 7. The expressions of angiogenesis-related protein VEGF and apoptosis-related protein Bax, Bcl-2 in each group were detected by Western blotting, which also had been used to assess the expressions levels of Akt, p-Akt, and Nrf2.

Results: Following TMP treatment, the survival area and number of microvessels presented in the skin flaps increased and tissue edema reduced on postoperative day 7. The expressions of angiogenesis-related protein VEGF increased in the TMP treatment group than in the control group. In addition, compared with the control group, TMP inhibited apoptosis, and increased the expression levels of p-Akt, Nrf2 in the areas of ischemia. These effects were reversed by an Akt protein inhibitor LY294002. Similarly, treatment with LY294002 inhibited TMP induced by interfering the Akt/Nrf2 signaling pathway.

Conclusion: These results illustrated that TMP could promote the survival of multiterritory perforator flaps by enhancing angiogenesis and attenuating apoptosis. These were involved in Akt/Nrf2 signaling pathway.

Use of a sequential chimeric perforator flap for one-stage reconstruction of complex soft tissue defects of the extremities

BACKGROUND

One-stage reconstruction of complex soft tissue defects of the extremities is a challenging problem. Repair of complex soft tissue defects requires adequate skin tissues to cover the large surface wound and special tissues for obliterating the dead space. The chimeric flap is one of the most popular approaches for reconstruction of complex soft tissue defects. However, the problems of donor-site morbidity and inability to repair very large defects at one-stage remain. The purpose of this study was to present our clinical experience using sequential chimeric perforator flaps for reconstruction of complex extremity defects with primary closure of the donor site.

METHODS

From August 2013 to March 2017, 12 patients with complex soft tissue defects underwent extremity reconstruction using sequential chimeric perforator flaps, which were composed of a chimeric anterolateral thigh perforator (ALTP) flap and an additional free perforator flap. The skin paddles were placed side-by-side to cover the large surface soft tissue defects, and the muscle component was used to obliterate the dead space. Of these patients, one was injured by a crushing accident, while the other 11 patients were injured in traffic accidents.

RESULTS

The size of the skin paddles ranged from 26 cm × 8 cm-10 cm × 6 cm to 30 cm × 8.5 cm-29 cm × 9 cm. The muscle paddle size ranged from 2 cm × 3 cm × 4 cm to 22 cm × 4 cm × 2 cm. All-components of the sequential chimeric flaps survived in all-patients. Vascular compromise was observed in one case. One case suffered minor wound-edge necrosis and was treated conservatively. Primary closure of donor-site was successfully achieved in all-patients, and all-donor-site wounds healed uneventfully. The mean follow-up time was 15.25 months. Most of the cases showed a satisfactory contour, and only two patients presented with mildly bulky appearance that treated with a debulking procedure.

CONCLUSIONS

The sequential chimeric perforator flap is an alternative procedure for reconstruct complex soft tissue defects of the extremities. This approach allows for flexible design, a larger cutaneous area, and low donor site morbidity.

[Clinical application of Flow-through chimeric anterolateral thigh perforator flap]

Objective

To investigate the feasibility and efficacy of the Flow-through chimeric anterolateral thigh perforator (ALTP) flap for one-stage repair and revascularization in complex defects of the extremities.

Methods

Between May 2014 and June 2017, 6 patients with soft tissue defects on the limbs combined with dead space, bone defects, or tendon and joint exposure, were reconstructed with the Flow-through chimeric ALTP flap. All 6 patients were male. The patients' mean age was 44 years (range, 26-60 years). The mechanisms of injury were traffic accidents in 4 cases, wringer injury in 1 case, and bruise injury caused by heavy object in 1 case. The defects located at the lower extremity in 5 cases and at the upper extremity in 1 case. The area of the wound ranged from 7 cm×4 cm to 26 cm×10 cm. There were 3 cases of bone defect, 3 cases of joint and tendon exposure, 2 cases of chronic osteomyelitis, and 2 cases of main artery injury. The muscle flap was inserted into the deep dead space, with perforator flap for superficial defect. The area of perforator flap ranged from 10 cm×5 cm to 28 cm×11 cm and the area of muscle flap ranged from 5 cm×2 cm to 20 cm×5 cm. The defects on the donor sites were closed directly.

Results

All the flaps were survival without infection and vascular crisis. The wounds of recipient and donor sites healed at first intention. The patients were followed up 3- 24 months (mean, 10 months). Good color and texture of flaps was achieved. The reconstructed main artery patency was achieved and the end of the affected limb was well transported. Only linear scar left on the donor site on thigh with no malfunction.

Conclusion

The Flow-through chimeric ALTP flap can construct three-dimensional soft tissue defects without sacrificing the recipient vessels. The Flow-through chimeric ALTP flap is an reliable and ideal method for reconstruction of complex wounds in the limbs with dead space and with or without recipient major vessels injury.

Foot and ankle reconstruction with vertically designed deep inferior epigastric perforator flap

INTRODUCTION

The deep inferior epigastric perforator (DIEP) flap is one of the most commonly utilized flaps of reconstructive surgery. Although the horizontal flap design is the most commonly used, this flap can be vertically designed to avoid drawbacks such as excessive tissue dissection, relatively reduced flap perfusion, and scarification of the contralateral flap opportunity. The aim of this report is to present our case series for foot and ankle reconstruction with vertical designed DIEP flap.

PATIENTS AND METHODS

The free vertically designed DIEP flaps (VDIEP) were used in eight patients (7 male, 1 female) whose age is in a range of 20-66 years for soft tissue reconstructions in the ankle and foot region over a five-year period. The range of defects' size was from 8 × 5 cm to 15 × 7 cm and the causes were electrical burn, trauma and diabetic foot infections.

RESULTS

Flap dimensions varied from 10 × 6 cm to 17 × 9 cm. All the flaps had two or more perforators, and all flaps survived completely. There were no early or late complications. We followed up the patients for 10 months in average. We observed no functional problems, especially in main motions of foot and ankle like eversion, inversion, flexion or extension except one patient. Donor site scars were acceptable in all patients.

CONCLUSIONS

The VDIEP flap may be an option for selected lower extremity soft tissue reconstructions, and it may be an alternative to classically designed abdominal flaps.

Microsurgical Reconstruction Following Oncologic Resection in Pediatric Patients: A 15-Year Experience

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.

Versatility of Free Cutaneous Flaps for Upper Extremity Soft Tissue Reconstruction

The goals of upper extremity soft tissue reconstruction should go well beyond providing coverage and restoring function. As the field of reconstructive microsurgery has evolved, free cutaneous flaps (FCFs) are gaining wider application. The advantages of FCF include minimizing donor-site morbidity by preserving the muscle and fascia, improving versatility of flap design, and superior aesthetic results. This review highlights the application of anterolateral thigh, superficial circumflex iliac artery, deep inferior epigastric perforator, superficial inferior epigastric artery, and flow-through flaps for reconstruction of upper extremity defects. These flaps share several qualities in common: well-concealed donor sites, preservation of major arteries responsible of providing inflow to distal extremity, and potential for a two-team approach (donor and recipient sites). While the choice of flaps should be decided based on individual patient and defect characteristics, FCF should be considered as excellent options to achieve the goals of upper extremity reconstruction.

Microsurgical Reconstruction of Traumatic Lower Extremity Defects in the Pediatric Population

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.

Inflammatory response associated with choke vessel remodeling in the extended perforator flap model

Ischemic necrosis of the surgical flap is a common complication. The behavior of choke vessels has an important role in skin flap survival. However, the mechanism of choke vessel remodeling has remained elusive. The purpose of the present study was to investigate the possible association between inflammatory responses and choke vessel remodeling in the extended perforator flap model in rats. After flap elevation, the animals were randomly divided into three groups (n=6 in each) for tissue analysis at three, five or seven days after flap surgery. Six additional rats served as a control group (no flap elevation). Tissue samples were collected from the choke zone for histological, western blot and PCR analyses. Monocyte chemoattractant protein-1 (MCP-1) and tumor necrosis factor-α (TNF-α) as inflammatory cytokines were examined in the present study. Histopathological analysis showed that dilation of choke vessels and increased vessel wall thickness was obvious after flap elevation. It also showed edema, inflammation cell aggregation after the operation. Compared with the control group, the protein and mRNA expression levels of MCP-1 and TNF-α were significantly increased at days 3, 5 and 7 after flap elevation, while reaching a maximum at day 5. These findings indicated that inflammatory responses may have an important role in choke vessel remodeling. MCP-1 and TNF-α may be considered as potential targets for modulating the behavior of choke vessels.

[Pediatric lower extremity reconstruction]

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.