Reliable transfer of multiple perforator-based pedicled flaps: Surgical technique and clinical outcomes

Temporal Fascia Free Flap for Thumb Coverage in Electrical Burn Injuries: A Case Series Analysis With DASH Score Outcomes Evaluation

Electrical burns pose unique challenges in reconstructive surgery due to the extensive tissue damage they cause. The thumb is particularly susceptible to electrical burns, leading to severe functional impairment. This case series introduces the use of the temporal fascia free flap for thumb coverage in patients with electrical burn injuries. The study aims to assess the functional outcomes of this approach using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Six male patients underwent thumb reconstruction using temporal fascia free flaps following electrical burn injuries. The extent of the injury was assessed, and necrotic tissue was debrided. Functional outcomes were evaluated using the DASH questionnaire 6 months postoperation. All procedures were conducted in accordance with ethical guidelines, and informed consent was obtained from all patients. All patients achieved successful transplants using temporal fascia free flaps. The average DASH score at the 6-month follow-up indicated satisfactory functional recovery. Patients reported improvements in thumb mobility and functionality, and the cosmetic appearance of the thumb was acceptable. The appearance of the scar in the donor area was well-received. The temporal fascia free flap proved to be an effective method for thumb reconstruction following electrical burn injuries. Its thin and flexible nature allows for optimal contouring and improved range of motion. Although one case of partial flap loss was observed, overall functional and aesthetic outcomes were satisfactory. Further research with larger sample sizes is warranted to optimize surgical techniques and postoperative care for better outcomes.

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.

An animal experiment study on the application of indocyanine green angiography in the harvest of multi-angiosome perforator flap

Background

This study sought to explore the application value of indocyanine green angiography (ICGA) in the harvest of multi-angiosome perforator flap and the effect of low molecular weight heparin (LMWH) on the survival of postoperative flap.

Methods

Twenty-four SD male rats were selected to construct a three-angiosome perforator flap model with the unilateral iliolumbar artery perforator. They were randomly divided into two groups: the control group was injected with indocyanine green (ICG) into the femoral vein during the operation, and the fluorescence signal was collected and quantitatively analyzed using Real-Time Image Guided System to determine the intraoperative fluorescence imaging length. The experimental group was injected subcutaneously with LMWH (400 U/kg) after 0.5 h postoperatively, and the control group was injected with the same amount of normal saline. The injection was repeated at the same time each day from 0 to 7 days postoperatively. After the flap was sutured in situ, ICGA was performed at 0, 1, 3, 5, and 7 days postoperatively to observe the vascular structure of the two groups of flaps. The flap survival length of the control group was counted at 7 days postoperatively, and the correlation between the intraoperative fluorescence imaging length and the survival length at 7 days postoperatively was calculated. The proportion of distal necrosis of the flaps between the two groups was compared at 7 days postoperatively.

Results

The average length of intraoperative fluorescence imaging in the control group was 6.29±0.50 cm, and the survival length of the flap at 7 days postoperatively was 8.24±0.52 cm. The actual survival length was higher than the intraoperative fluorescence imaging length, with a ratio of 1.31±0.08. The difference was statistically significant (P<0.05). At 7 days postoperatively, the flap necrosis ratio of experimental group and control group were 10.92%±1.30% and 19.11%±1.19%, and the flap necrosis ratio of experimental group was lower than that of control group (P<0.001).

Conclusions

ICGA can locate the position of perforator, and can be used to predict and observe the length of distal survival of multi-angiosome perforator flap postoperatively. LMWH can promote the distal survival of flap and reduce flap necrosis.

Efficacy and safety of free medial plantar flap in repair of the high-voltage electrical burns in hands

PURPOSE

The purpose of this work was to validate the efficacy and safety of free medial plantar flap in repair of hand wounds resulted from high-voltage electrical burn.

METHODS

22 patients with high-voltage electrical burn wounds were retrieved between July 2016 and July 2018 in the Affiliated Zhengzhou Central Hospital of Zhengzhou University. All the wounds were the entrance of high-voltage electrical current. After thorough debridement, the blood vessels, nerves, tendons, joints were exposed to defects with different degrees. The soft tissue defects were repaired with the free medial plantar flap repair in 12 patients and medium-thickness skin graft in 10 patients. Postoperative management was similar between the two groups.

RESULTS

All the operations were completed within 6 h. In the free medial plantar flap group, the mean follow-up period was (11.3 ± 2.4) months, ranging from 9 to 15 months, and all flaps survived; there were no vessel crises. Flaps of 10 patients healed without any complications, and local necrosis occurred in two cases, with healing after debridement. The two-point discrimination (TPD) was 7.0-11.0 mm, and the mean DASH score was 45.6 ± 7.4. In the medium-thickness skin graft group, the mean follow-up period was (10.9 ± 1.8) months. All flaps survived, and local contracture occurred in 3 cases. The TPD was 8.0-11.0 mm, and the mean DASH score was 60.7 ± 9.3.

CONCLUSIONS

The free medial plantar flap is an ideal option for repairing the hand soft defects resulted from the high-voltage electrical burn.

The Effect of Perforator Skeletonization on Pedicled Fasciocutaneous Flaps of the Lower Extremity: A Systematic Review

Background Lower extremity defects often require free tissue transfer due to a paucity of local donor sites. Locoregional perforator-based flaps offer durable, single-stage reconstruction while avoiding the pitfalls of microsurgery. Multiple harvest techniques are described, yet few studies provide outcome comparisons. Specifically, no study has examined the impact of perforator flap pedicle skeletonization on reconstructive outcomes. This systematic review characterizes technique and impact of pedicle skeletonization on perforator-based fasciocutaneous flaps of the lower extremity.

Methods PubMed, Scopus, and the Cochrane Central Register of Controlled Trials were reviewed for literature examining perforator-based fasciocutaneous flaps from knee to ankle, from January 2000 through November 2018. The Preferred Reporting Items for Systematic Reviews-Individual Participant Data (PRISMA-IPD) structure was used.

Results Thirty-six articles were included for quantitative analysis. Of 586 flaps, 365 were skeletonized (60.1%) with 58 major (9.9%) and 19 minor complications (3.2%). With skeletonization, overall reoperative rate was higher (odds ratio [OR]: 9.71, p = 0.004), specifically in propeller (OR: 12.50, p = 0.004) and rotational flaps (OR: 18.87, p = 0.004). The complication rate of rotational flaps also increased (OR: 2.60, p = 0.04). Notably, skeletonization reduced complications in flaps rotated 90 degrees or more (OR: 0.21, p = 0.02). Reoperative rate of distal third defects (OR: 14.08, p = 0.02), flaps over 48 cm2 (OR: 33.33, p = 0.01), and length to width ratios over 1.75 (OR: 7.52, p = 0.03) was increased with skeletonization. Skeletonization increased complications in traumatic defects (OR: 2.87, p = 0.04) and reduced complications in malignant defects (OR: 0.10, p = 0.01).

Conclusion Pedicled, perforator-based flaps can provide a reliable locoregional alternative to free tissue transfer for lower extremity defects. Though skeletonization increased the overall reoperative rate, the complication rate for flaps with 90 degrees or more of rotation was significantly reduced. This suggests skeletonization should be considered when large rotational movements are anticipated to reduce complications that can arise from pedicle compression and venous congestion.

Soft tissue coverage of a total gluteal defect with a combination of perforator-based flaps: A case report

Soft tissue defects in the buttock area are often related to decubitus ulcers, which are usually small to medium-large size and can be regularly treated with local flaps. However, when the defects have bigger size, such as those involving the whole gluteal region, the coverage can become more challenging, since this specific area needs both a good resistance to pressure and an acceptable functional result. The most common solution for similar cases is the use of multiple local flaps, or, in extreme situations, a free flap. In particular, local flaps based on perforator vessels are, in selected cases, a consolidated alternative to free flap allowing an efficient reconstruction of soft tissue defects using adjacent similar tissues, providing the benefit of "like with like" coverage. Here we present a case of a large mycosis fungoides nidus of the gluteal region measuring 25 cm × 18 cm reconstructed using two large perforator flaps adjacent to the defect combined with a remote one for coverage of the donor site. The cranial flap was designed based on a perforator arising from the superior gluteal artery and transferred into the defect by means of a V-Y advancement, while the two caudal propeller flaps in the posterior thigh were both based on perforators of the profunda femoris artery and rotated 180°, respectively. To obtain a tension-free cover of the donor site defect we applied the concept of "sequential" propeller flaps. Post-operative course was uneventful and the patient was ambulatory with assistive devices after 1 week. At 6 months follow-up, wounds were completely healed without complications and a good functional result was obtained. This report showed the great coverage potential of multiple perforator-based local flaps when properly combined allowing primary closure of the donor site. In particular, we managed to reconstruct a total gluteal defect using just ipsilateral side tissue, reducing morbidity, and obtaining a stable result.