Reconstruction of Soft Tissue Defects in the Hand with a Free Anterolateral Thigh Deep Fascia Flap

Various soft tissue defect reconstructions using anterolateral thigh and vascularized fascia lata composite free flap

The anterolateral thigh flap (ALT) is versatile for soft-tissue reconstruction of various body defects because of its thick and vascularized fascia component. We present our clinical experience with the functional one-stage reconstruction of complicated soft-tissue defects using ALTs with vascularized fascia lata (FL). Between April 2018 and February 2022, we transferred ALTs with FL components for various soft-tissue defects in 15 patients. The FL component was used for reconstruction of hand & forearm tendon, medial and lateral patellar synovial membrane, plantar aponeurosis, abdominal wall, dura and Achilles tendon. Functional outcomes were evaluated in each patient. Partial flap necrosis occurred in 2 patients and were treated successfully with minimal surgical debridement and dressing. The vascularized fascia could replace a tendon and fascial component and all the patients achieved satisfactory results without major postoperative complications. Anterolateral thigh flaps with vascularized FL provide reliable fascial and tendon components for single-stage reconstruction of complex soft tissue defects.

Reconstruction of a lateral thigh defect with a transverse rectus abdominis myocutaneous (TRAM) free flap: A case report

INTRODUCTION

Despite advancements in reconstructive surgery, the repair of large thigh deformities remains challenging. When other options are not feasible, distant flaps become necessary. Successful repairs have been achieved using a transverse rectus abdominis myocutaneous (TRAM) flap for the chest wall, groin, abdominal wall, sternum, and breast.

CASE PRESENTATION

This study presents the case of a 40-year-old man who experienced a large deformity, measuring 20 cm ∗ 10 cm in his left lateral thigh resulting from a road accident that occurred a decade ago. Additionally, he developed osteomyelitis due to exposed bone based on MRI and clinical signs. To address this large defect, a free TRAM flap was utilized, effectively covering the area with a well-vascularized skin graft. This approach eliminated the need for a latissimus flap with a skin graft.

DISCUSSION

In cases of covering large thigh defects, a variety of flaps can also be considered. The latissimus dorsi muscle is mainly used as a free flap, but surgeons should be cautious regarding the use of the latissimus dorsi flap while this flap is an attractive option in many other parts of the body, it's functional loss must be carefully weighed in lower extremity patients who are often crutch- and/or wheelchair-dependent.

CONCLUSION

Based on this experience, the free-TRAM flap has proven to be a highly resilient option for similar defects and ranks among our top choices. It is important to note that in cases of infected and traumatic wounds where fatty tissue is undesirable, the flap may not be the best solution.

Superficial Circumflex Iliac Artery Perforator Flap with Bilobed Design for the Donor Defect after Wrap-Around Flap Transfer Reconstruction

OBJECTIVE

The repair of great toe donor site defect after wrap-around flap transfer is still controversial. The bilobed superficial circumflex iliac artery perforator (SCIP) flap can improve the aesthetics of the great toe while maintaining its function. Thus, this study aimed to report our experience in the reconstruction of big toe donor site defects with the bilobed SCIP flap and describe the clinical outcomes.

METHODS

This study was a retrospective trial. From May 2017 to May 2020, 13 patients with the great toe donor site defect after wrap-around flap transfer were included in this study. The average age of the patients was 44 years (range, 23-60 years). All patients received free bilobed SCIP flaps to reconstruct the donor site defect of the great toe. Relevant clinical features were recorded preoperatively. The thickness and design of the SCIP flap and the harvesting layer of the flap were measured during the operation. The survival rate of flaps and skin grafts and the incidence of infection were recorded after operation. At follow-up, donor site complications and postoperative outcomes were evaluated.

RESULTS

In all cases, the SCIP flap covering the donor site of the great toe survived. All patients were followed up for 24-40 months (mean, 30.5 months). The average thickness of the SCIP flap was 0.38cm. All SCIP flaps were harvested from the superficial fascial layer except for three obese patients. The thin SCIP flap had a bilobed design with no further defatting procedures. Postoperatively, the great toe-nail flap donor site regained its original appearance without bloating or flap necrosis. There was a hidden linear scar in the groin donor site, which did not affect hip joint movement. All patients were satisfied with the aesthetics of the surgical site.

CONCLUSION

The SCIP flap with bilobed design for repairing the donor defect of the great toe after wrap-around flap transfer is a kind of surgical method with excellent contour, meeting the requirements of function and aesthetics.

[Repairing large skin defect of hand with modified dorsal metacarpal artery reverse island flap]

OBJECTIVE

To investigate the effectiveness of modified dorsal metacarpal artery reverse island flap based on two adjacent recurrent branches of dorsal metacarpal arteries in repairing large skin defect of the hand.

METHODS

Between September 2017 and March 2021, 15 cases of large skin defect of the hand were treated. There were 11 males and 4 females with an average age of 42 years (range, 24-66 years). The injury causes included machine twist injury in 6 cases, pound injury in 5 cases, and crush injury in 4 cases. The injured parts included 6 cases of finger skin defect and 9 cases of distal skin defect of palm and dorsum of hand, all of which had tendon, joint, and bone exposure. The interval from injury to operation ranged from 2 to 6 hours (mean, 4 hours). The defect sizes after thorough debridement ranged from 3.5 cm×3.0 cm to 8.0 cm×4.5 cm. The modified dorsal metacarpal artery reverse island flap with a range of 3.8 cm×3.3 cm to 9.0 cm×5.0 cm was used to repair the defect, and the flap donor site was repaired with full-thickness skin graft.

RESULTS

All the flaps survived successfully after operation, and the wounds in the recipient site and the skin grafts in the donor site healed by first intention. All patients were followed up 9-24 months, with an average of 14 months. The appearance of the flap was good, and its texture and color were similar to those of the surrounding normal tissue. There was no obvious scar contracture, depression, and pigmentation in the donor site. At last follow-up, the static two-point discrimination of the flap was 8-20 mm, with an average of 13.6 mm. According to the Michigan Hand Outcome Questionnaire, 5 patients were very satisfied with the appearance of the flap, and 10 patients were satisfied.

CONCLUSION

The modified dorsal metacarpal artery reverse island flap based on two adjacent recurrent branches of dorsal metacarpal arteries has reliable blood supply, larger harvested area, simple procedure, and minimal donor site damage, which is suitable for emergency repair of large skin defect of the hand.

Inflammation Self-Limiting Electrospun Fibrous Tape via Regional Immunity for Deep Soft Tissue Repair

Overexpression of inflammatory cytokines and chemokines occurs at deep soft tissue injury sites impeding the inflammation self-limiting and impairing the tissue remodeling process. Inspired by the electrostatically extracellular matrix (ECM) binding property of the inflammatory signals, an inflammation self-limiting fibrous tape is designed by covalently modifying the thermosensitive methacrylated gelatin (GelMA) and negatively charged methacrylated heparin (HepMA) hydrogel mixture with proper ratio onto the electrospun fibrous membrane by mild alkali hydrolysis and carboxyl-amino condensation reaction to restore inflammation self-limiting and promote tissue repair via regional immunity regulation. While the GelMA guarantees cell compatibility, the negatively charged HepMA successfully adsorbs the inflammatory cytokines and chemokines by electrostatic interactions and inhibits immune cell migration in vitro. Furthermore, in vivo inflammation self-limiting and regional immunity regulation efficacy is evaluated in a rat abdominal hernia model. Reduced local inflammatory cytokines and chemokines in the early stage and increased angiogenesis and ECM remodeling in the later phase confirm that the tape is an approach to maintain an optimal regional immune activation level after soft tissue injury. Overall, the reported electrospun fibrous tape will find its way into clinical transformation and solve the challenges of deep soft tissue injury.