Outcomes and Complications of Sole Reconstruction Using Lateral Thoracic Free Tissue Transfer.

BACKGROUND: The complex structure of the sole of the foot makes the repair of extensive defects challenging. The present study, therefore, aimed to address a gap in current research by evaluating the potential of the lateral thoracic free flap, including perforator options and chimeric configurations, to be used as an advanced solution for comprehensive sole reconstruction. PATIENTS AND METHODS: We retrospectively collected the following data from the charts of patients with sole defects, due to various causes, who underwent lateral thoracic free tissue transfers: patient demographics; etiologies; comorbidities; flap types and dimensions; pedicle length; operative time; follow-up period; complications; and management. RESULTS: The present study included 54 patients who underwent lateral thoracic free tissue transfer, citing infection, trauma, tumor, and posttraumatic sequelae as the major etiologies. We used the following techniques for the reconstruction of sole defects: thoracodorsal artery perforator free flap (83.3%); latissimus dorsi musculocutaneous free flap (1.9%); and various chimeric pattern flaps (14.8%). Free tissue transfer in the lateral thoracic region offers versatility for reconstruction, as well as low donor site morbidity. Complications observed in the present study included wound dehiscence (9.3%), partial necrosis (9.3%), and pressure ulcers (22.2%), although most patients healed favorably without flap loss. CONCLUSIONS: The lateral thoracic free flap is a viable option for the reconstruction of the sole of the foot and allows for the effective reconstruction of complex defects. It contains a sustainable skin paddle, and multiple components can be easily included as a chimeric type. Further studies should seek to identify ways to prevent pressure ulcers, which was the only known long-term complication in the present study.

Analysis of Operation Duration in Thoracodorsal Artery Perforator Free-Flap Surgery of the Lower Extremities.

PURPOSE: This retrospective study aimed to identify the factors that affect the duration of thoracodorsal artery perforator (TDAP) free-flap surgery and to offer strategies for optimizing the surgical procedure. METHODS: We analyzed 80 TDAP flap surgeries performed by a single surgeon between January 2020 and December 2022, specifically focusing on free flaps used for lower-extremity defects with single-artery and single-vein anastomosis. The operation duration was defined as the time between the surgeon's initial incision and completion of reconstruction. Linear regression analyses were conducted to identify the factors affecting operation duration. RESULTS: The average operative duration was 149 minutes (range, 80-245 minutes). All flaps survived, although 8 patients experienced partial flap loss. The operative duration decreased with increasing patient age and when end-to-end arterial anastomosis was performed. However, the risk increased with larger flap sizes and in patients with end-stage renal disease. CONCLUSIONS: Our study identified several factors and methods that could accelerate TDAP free-flap procedures. These findings offer valuable insights for optimizing surgical processes and improving overall surgical outcomes. Although further research is needed to confirm and expand upon these findings, our study provides important guidance for surgeons in developing effective strategies for TDAP flap surgery.

Reconstruction of a Severe Open Tibiofibular Fracture using an Ipsilateral Vascularized Fractured Fibula with a Thoracodorsal Artery Perforator Free Flap.

The Gustilo IIIB tibiofibular fractures often result in long bone loss and extensive soft tissue defects. Reconstruction of these complex wounds is very challenging, especially when it includes long bone grafts, because the donor site is limited. We describe our experience using a set of chimeric ipsilateral vascularized fibula grafts with a thoracodorsal artery perforator free flap to reconstruct the traumatic tibia defects. A 66-year-old male suffered a severe comminuted tibia fracture and segmented fibula fracture with large soft tissue defects as a result of a traffic accident. He also had an open calcaneal fracture with soft tissue defects on the ipsilateral side. All the main vessels of the lower extremity were intact, and the cortical bone defect of the tibia was almost as large as the fractured fibula segment. We used an ipsilateral vascularized fibula graft to reconstruct the tibia and a thoracodorsal artery perforator flap to resurface the soft tissue, using the distal ends of peroneal vessels as named into sequential chimeric flaps. After 3 weeks, the calcaneal defect was reconstructed with second thoracodorsal artery perforator free flap. Reconstruction was successful and allowed rapid rehabilitation because of reduced donor site morbidity.

A modified induced membrane 2-stage technique using a thoracodorsal artery perforator free flap followed by vascularized or non-vascularized free fibular transfer for the treatment of complex bone infection with concomitant severe soft tissue lesion-A case series of 9 cases.

Treatment of post-traumatic complex bone infection is very challenging. The two principal bone reconstruction approaches are the single-stage vascularized bone graft technique and the two-stage induced membrane technique (IMT). Here we introduce a modified 2-stage induced membrane technique (MIMT) for complex long bone infection with a major bone defect and a concomitant severe soft tissue lesion. The 2-stage procedure consists of bone debridement, placement of a PMMA spacer and soft tissue reconstruction with a thoracodorsal artery perforator free flap ("Tdap") at stage 1. At stage 2, the thoracodorsal artery perforator flap is elevated and a fibular strut graft (either vascularized of non-vascularized) is placed for bone reconstruction. We retrospectively analyzed the extents of lower extremity, long bone, post-traumatic bone infection treated via MIMT from 2008 to 2020. There were nine such cases (eight males) of mean age 59.8 (range 31 to 79) years. The osteomyelitis durations ranged from 3 to 360 months (mean 53 months). The cortical bone defect sizes was ranged from 9 to 14 cm (mean10.7 cm). All skin resurfacing employed Tdap. Vascularized fibular grafts were placed in six patients and non-vascularized grafts were placed in three. The fibular graft size ranged from 12.5 to 19 cm (mean 16.2 cm). Non-vascularized iliac bone grafts served as the fibula docking sites. Unfortunately, all patients suffered complications before bone union was achieved. One case of plate stress fracture and one case of screw fracture required plate and screw change. In three cases of cellulitis, one resolved by use of intravenous antibiotics, others required plate and screw removal. Wound disruption required re-suture and distal skin flap partial necrosis was covered by perforator-based island flap. One case of fibular stress fracture needed cast for 4 weeks. A peroneal nerve palsy patient recovered spontaneously. Bone union was achieved after 6 months in five patients and after 8 months in three (mean 6.9 months). All patients were able to walk unaided. The follow-up period ranged from 2 to 14 years (mean 6.2 years). MIMT saves the limbs in cases with difficult post-traumatic bone infection. It is valid treatment option for complex bone infections with severe soft tissue lesions. However, even with this technique potential complication must be considered.

Fingertip coverage with uni-pedicled volar rotational advancement flap with large Z-plasty: a report on 112 cases.

BACKGROUND: Simple and safe fingertip reconstruction methods involve the use of local neurovascular islands flaps that can preserve functional length and sensitivity, and reconstruction with skin of the same texture. However, techniques involving flaps have numerous drawbacks and do not satisfy all the requirements for fingertip reconstruction. A particular problem is the persistence of contracture deformity due to lack of full flap advancement. We present a new technique using uni-pedicled volar rotational advancement flap with large Z-plasty, and describe the results of long-term follow-up. METHODS: From October 1993 to December 2009, 112 fingers of 98 patients were covered with uni-pedicled volar rotational advancement flap with large Z-plasty after sustaining various types of injuries or finger pulp avulsion. A longitudinal incision was made along the lateral border of the digit and a large neurovascular volar flap was elevated just above the pulleys and flexor tendon sheath. To release tension, a large Z-plasty was applied at the metacarpophalangeal joint or interphalangeal joint crease. The final patient outcomes were reviewed retrospectively. RESULTS: All fingertip injuries were treated without flap necrosis. Partial wound dehiscence was observed in two patients and average static two-point discrimination was 5.2 mm. There were no postoperative contracture deformities, joint stiffness, paresthesia, or hypersensitivity. Most patients were left with acceptable scarring and were free of postoperative pain and cold intolerance during the long-term follow-up. CONCLUSIONS: Our novel technique provides durable, completely sensate, and well-vascularized coverage of the fingertip with minimal discomfort to patients.

Reconstruction of a temporal scalp defect without ipsilateral donor vessel possibilities using a local transposition flap and a latissimus dorsi free flap anastomosed to the contralateral side: a case report.

Scalp defects necessitate diverse approaches for successful reconstruction, taking into account factors such as defect size, surrounding tissue, and recipient vessel quality. This case report presents a challenging scenario involving a temporal scalp defect where ipsilateral recipient vessels were unavailable. The defect was effectively reconstructed utilizing a transposition flap and a latissimus dorsi free flap, which was anastomosed to the contralateral recipient vessels. Our report underscores the successful reconstruction of a scalp defect in the absence of ipsilateral recipient vessels, emphasizing the importance of employing appropriate surgical interventions without necessitating vessel grafts.

Multiple digit resurfacing with a lateral thoracic free flap: Two-stage mitten hand and division procedures.

PURPOSE: The conventional abdominal and groin flaps for resurfacing the defect have several disadvantages, including the risk of flap failure due to accidental traction or detachment, immobilization of the arm before division, and aesthetic dissatisfaction because of the flap bulkiness. The aim of this study was to share our experiences with the free lateral thoracic flap and elucidate the optimal timing of division in complex hand reconstruction, which yielded favorable outcomes in terms of both functionality and aesthetics. METHODS: This article is a retrospective review of multiple digit resurfacing using free tissue transfer from 2012 to 2022. Patients who underwent two-stage operation including mitten hand creation using superthin thoracodorsal artery perforator (TDAp) free flap and secondary division were included. A flap was elevated over the superficial fascia layer the midportion between the anterior border of the latissimus dorsi and pectoralis major muscles and once the pedicle was found, an outline that matched the defect was created. A process named "pushing with pressure and cutting" was carried out before pedicle ligation until all the superficial fat tissue had been removed except for around the perforator. Two cases (18%) involved defects of the entire fingers reconstructed by TDAp flap with anterolateral thigh flap. Six cases (55%) had a super-thin TDAp flap only. In two cases (18%), non-vascularized iliac bone grafting was required for finger lengthening. One case (9%) was resurfaced with a TDAp chimeric flap including a skin paddle with the serratus anterior muscle. The primary outcome was defined as the survival or failure of the flap, while the secondary outcomes associated complications such as infection and partial flap necrosis. A statistical analysis was not performed due to the size of the case series. RESULTS: All 13 flaps survived completely without any complications. Flap dimension ranged from 12 cm × 7 cm to 30 cm × 15 cm. Mitten hand duration prior to division was 41.9 days on average which was essential for the optimal result. During the division procedures, there were nine cases of debulking (82%), six cases of split-thickness skin graft (STSG) (55%), and three cases of Z-plasty performed on the first web space (27%). The mean follow-up period was 20.2 months. Mean Disability of the Arm, Shoulder, and Hand (DASH) Questionnaire score was 10.76. CONCLUSIONS: We resurfaced severe soft tissue defects of multiple fingers with thin to super-thin free flaps, mainly TDAp flaps. Surgeons can restore original hand shape using a two-stage reconstructive strategy of mitten hand creation and proper division timing to create a 3-dimensional hand structure, even in severely injured hands with multiple soft tissue defects of the digits.

Long-term results of huge deep-seated liposarcoma in the thigh: Two case reports.

RATIONALE: Liposarcoma is an uncommon malignant tumor that develops in the fatty tissue; thus, the long-term follow-up results of extremely large liposarcomas in the submuscular layer of the thigh have rarely been reported. Here we share the course and outcome of 2 cases of a huge deep-seated liposarcoma in the thigh. PATIENT CONCERNS: Two patients visited our clinic, each with a deep-seated mass in the thigh. First, a 44-year-old man presented to the outpatient clinic with a left thigh mass. Approximately 1 year later, an 80-year-old man presented to the outpatient clinic with a right posterior thigh mass. DIAGNOSIS: Magnetic resonance imaging revealed an approximately 14 × 8 × 21 cm well-differentiated liposarcoma between the sartorius and iliopsoas muscle and an approximately 14 × 12 × 31.5 cm lipomatous mass in the posterior compartment of the right thigh involving the right adductor muscles. After complete marginal resection, an excisional biopsy was performed to confirm the diagnosis. INTERVENTIONS: Both patients underwent complete marginal resection without chemotherapy or radiotherapy. OUTCOMES: A biopsy showed a 20 × 17 × 7 cm well-differentiated, well-encapsulated liposarcoma in the 44-year-old man and a 30 × 17 × 10 cm well-differentiated liposarcoma in the 80-year-old man. These patients have achieved approximately 61 and 44 months of recurrence-free survival to date, respectively. LESSONS: Here we described the long-term outcomes of 2 patients with a huge deep-seated liposarcoma in the lower extremity. Complete marginal excision of well-differentiated liposarcoma can achieve excellent recurrence-free survival.

Strategy for resurfacing complex extremity defect with chimeric, linked flaps: A review with a 10-year experience at major trauma center.

For the reconstruction of the extensive and/or three-dimensional soft-tissue defect in upper and lower extremities, chimeric flaps composed of multiple flaps or tissues with separate vascular supplies can supply economical use of tissue and superior esthetic results. Herein, we investigated the effectiveness of the thoracodorsal axis chimeric flap through the review the largest collection of long-term data. A retrospective review of all patients who received the thoracodorsal axis chimeric flap in complex three-dimensional defects of extremities between January of 2012 and December of 2021. A total of 55 type I/IP classical chimeric flaps, 19 type II/IIP anastomotic chimeric flaps, five type III perforator chimeric flaps, and seven type IV mixed chimeric flaps were analyzed. As the reconstructed area became proximal, flap dimensions increased significantly. And the optimal flap type depended on the location. The TDAp flap can provide large dimensions of skin paddle with latissimus dorsi and serratus anterior muscles with acceptable donor-site morbidities. The TDAp chimeric flaps constructed by microvascular anastomosis of two free flaps can provide large skin dimensions but also tissues with different properties. These characteristics make it possible to resurface the large and extensive defects, reconstruct the complex distal extremity defects, needing tissues with different properties, and cover the three-dimensional defect, obliterating the dead space. The thoracodorsal axis chimeric flap could be a favorable option for extensive, complex, or three-dimensional defects of the upper and lower extremities based on its reliability of the vascular system.

Reconstruction of soft tissue defect around knee with thoracodorsal artery perforator flap and muscle-sparing latissimus dorsi flap.

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.

Diabetic foot resurfacing using microvascular tissue transfer from lateral thoracic region.

AIMS: Diabetic foot ulcer is a major complication of diabetes mellitus and amputation is often needed. Since mortality rate after amputation is comparatively high, saving diabetic foot is required not only for preserving function and life quality, but also for decreasing mortality rate. This study was designed to analyse experience of limb salvage in patients with diabetic foot using free flaps from the lateral thoracic region over a 10-year period. MATERIALS AND METHODS: Between 2009 and 2018, 297 cases of diabetic foot underwent surgical procedures. We analysed the 83 cases who underwent free flap from lateral thoracic region. Patient data were reviewed retrospectively. RESULTS: A total of 83 patients, 56 of them males, were included in this study. Age of patients ranged from 27 to 80 years. Twenty patients underwent percutaneous transluminal angioplasty procedures. The latissimus dorsi muscle sparing technique was used in 7 cases. A thoracodorsal artery perforator flap was used in 68 cases. A thoracodorsal artery perforator chimaeric flap was performed in 8 cases. The flap survival rate was 98.8% and the limb salvage rate was 96.4%. The mean follow-up was 6.5 years. During follow-up 14 patients suffered recurrence of foot ulcers. CONCLUSIONS: Ten-year experience of using flaps from the lateral thoracic region revealed superior outcomes in terms of flap survival and limb saving compared to those in a recent meta-analysis and other reports. Long vascular pedicle technique and the chimaeric technique might be the alternative methods for multiple or vascular insufficient diabetic foot defects.

Resurfacing of lower extremities: Versatility of thigh flap as pedicle extension graft with consecutive thoracodorsal artery perforator-based flap.

BACKGROUND: For successful microsurgical reconstruction using free tissue transfer, healthy recipient vessels must be obtained from outside the zone of injury. Securing an appropriate length pedicle length is also essential, and various techniques for lengthening a vascular pedicle have been developed. Herein, we present our experience using the descending branch (DB) of the lateral circumflex femoral vessels (LCFVs) with a thigh flap as an extender graft for consecutive second flap. METHODS: We reconstructed the complex and vessel-depleted defects of nine patients. The mean age was 47.6 years. The defects were located in the lower leg in four patients, in the perineum in two patients and in the forearm in three patients. The two patients who suffered from Fournier's gangrene underwent a pedicled anteromedial thigh (pAMT) flap with the DB of the LCFVs and seven patients, five who suffered high-energy trauma and two who had scar contracture, underwent a free anterolateral thigh (ALT) flap with the distal run-off DB of the LCFVs. In all patients, second consecutive free latissimus dorsi or thoracodorsal artery perforator flaps were prepared and the thoracodorsal vessels of the second flap were anastomosed to the distal DB of the LCFVs. RESULTS: The total length of the thigh flap pedicles measured from both ends of the DB of the LCFVs varied from 15 to 20 cm, which was sufficient for use as a vascular conduit. Of the 18 flaps, 17 survived completely without any complications and 1 pAMT flap showed partial necrosis, which was covered with a perineal perforator-based island flap. The mean follow-up period was 16.7 months. Unfortunately, one patient, who suffered a total amputation below the knee and had replantation surgery, underwent amputation due to venous congestion in the distal leg. However, the previous two flaps survived and were used for coverage of the stump. CONCLUSIONS: Using a thigh flap as a vascular extender graft for second flap may be an alternative option in vessel-depleted reconstructions.

Resurfacing of Face and Neck Using Superthin Thoracodorsal Artery Perforator Free Flaps.

BACKGROUND: Resurfacing of facial and neck defects is challenging due to the unique skin color, texture, and thickness of the region. With the development of microsurgical reconstruction, perforator- free flaps can provide adequate soft tissue. However, despite various modifications, such flaps hardly satisfy cosmetic requirements, due to differences in color and bulkiness. We have used superthin thoracodorsal artery perforator (TDAp) free flaps to overcome these limitations. METHODS: Between January 2012 and January 2020, 15 patients underwent reconstructive procedures for facial and neck soft tissue defects using superthin TDAp free flaps. First a perforator was found above the deep fascia and a flap was elevated over the superficial fascia layer. A process named "pushing with pressure and cutting" was carried out before pedicle ligation until all the superficial fat tissue had been removed except for around the perforator. Patient satisfaction was evaluated using a questionnaire about color, contour, and overall satisfaction a minimum of 12 months after surgery. RESULTS: Flap size ranged from 6 × 4 cm to 25 × 14 cm (mean, 126.3 cm2). Final flap thickness ranged from 4 to 6 mm. (mean, 4.97 mm). All flaps survived without any loss and there were no flap-related complications. After a mean follow-up period of 14.4 months, patients were satisfied with the aesthetic results, and cervical range of motion increased by 11.25 degree on average in burn scar contracture patients. CONCLUSIONS: The superthin TDAp free flap is an excellent alternative to face and neck resurfacing, providing a large and thin flap with excellent color matching and good vascularity.

A Prospective Randomized Controlled Multicenter Clinical Trial Comparing Paste-Type Acellular Dermal Matrix to Standard Care for the Treatment of Chronic Wounds.

The treatment of chronic wounds remains challenging. Acellular dermal matrix (ADM) has been shown to be effective for various types of wound healing. This study was designed to compare the wound size reduction rate after 12 weeks between patients receiving paste-type ADM and standard wound care. Patients over 19 years old with chronic wounds, deeper than full-thickness skin defects, more than 4 cm2 in size that did not heal over the 3 weeks before the study were included. After a screening period of 7 days, patients were randomized to receive either paste-type ADM or standard wound care. The wound status was evaluated at baseline, 1, 2, 4, 8, and 12 weeks. A total of 86 patients were enrolled in this study. The wounds continuously and constantly reduced in size from week 1, and the reduction rate was significantly greater in the study group from week 2 until the end (week 12). In the study group, wound healing was achieved in 29 of 38 wounds (76.3%). Paste-type ADM might be a useful option for wound healing and can be applied safely and efficiently for advanced wound care.

Correction of Temporal Hollowing Deformity Using Serratus Anterior Muscle Flap.

Temporal hollowing deformity (THD) is a contour irregularity in the frontotemporal region, which results in facial asymmetry in the frontal view. Here, we present our clinical experience of correction of THD using serratus anterior (SA) muscle and fascia free flaps. Between March 2016 and December 2018, 13 patients presenting with THD were treated with SA free flap. The mean age of the patients was 47.8 years. The patients received craniectomy due to subarachnoid hemorrhage, epidural hematoma, or brain tumor. On average, correction of THD was performed 17 months after cranioplasty. The SA flap size ranged from 5 × 5 cm to 10 × 8 cm. The mean operation time was 107.3 minutes. All of the flaps survived without complications. The mean follow-up duration was 20.3 months. For correction of THD, the SA muscle and fascia flap is among the best candidates to permanently restore aesthetic form and symmetry.

Reconstruction of recalcitrant pressure ulcers with latissimus dorsi muscle-splitting free flaps.

BACKGROUND: Reconstruction of recalcitrant pressure ulcers is very challenging because all available local tissues have been exhausted. Although occasionally suggested as reconstructive options in some reports, free flaps are still not favored for pressure ulcers because of the less available recipient vessels in buttock area and the need for position change. Here, we describe our experience with latissimus dorsi muscle-splitting free flaps harvested in prone position for recalcitrant pressure ulcers. METHODS: Between January 2012 and January 2020, 10 patients of recalcitrant pressure ulcers underwent reconstruction using latissimus dorsi muscle-splitting free flaps. To harvest flaps in the prone position, the curvilinear incision was made along the line connecting the lateral border of the scapula and the midaxillary line of the armpit and the latissimus dorsi muscle was split just below the skin incision. Only the required amount of muscle was harvested including the 5 × 3 cm sized muscle cuff around bifurcation points of the transverse and descending branches. RESULTS: Flap size ranged from 16 × 9 to 24 × 14 cm and the gluteal vessels were mainly used as recipients. The mean operation time was 170 mins. All the flaps survived but two patients suffered wound disruption and partial flap loss, respectively. During the mean follow-up periods of 2.45 years, there were no recurrences at the reconstruction site, and no patient complained of donor site morbidity. CONCLUSIONS: Based on the results obtained from this consecutive series of patients, latissimus dorsi muscle-splitting free flaps are valuable option for recalcitrant pressure ulcer reconstruction.

Resurfacing the donor sites of reverse sural artery flaps using thoracodorsal artery perforator flaps.

BACKGROUND: The reverse sural artery (RSA) flap is widely used for lower extremity reconstruction. However, patients sometimes suffer from donor site complications such as scar contracture and paresthesia, resulting in dissatisfaction with the aesthetic outcomes. This study investigated the characteristics of donor site morbidity associated with RSA flaps and described our experiences of dealing with complications by performing resurfacing surgery using thoracodorsal artery perforator (TDAP) flaps. METHODS: From April 2008 to August 2018, a total of 11 patients underwent contracture release and resurfacing surgery using TDAP flaps due to donor morbidity associated with RSA flaps. All affected donor sites were covered with a skin graft, the most common of which was a meshed split-thickness skin graft (six cases). RESULTS: Eight of the 11 patients (72.7%) suffered from pain and discomfort due to scar contracture, and seven (63.6%) complained of a depression scar. The donor sites were located 6.3±4.1 cm below the knee joint, and their average size was 140.1 cm². After resurfacing using TDAP flaps, significant improvements were found in the Lower Extremity Functional Scale (LEFS) scores and the active and passive ranges of motion (AROM and PROM) of the knee joint. The LEFS scores increased from 45.1 to 56.7 postoperatively (P=0.003), AROM increased from 108.2° to 118.6° (P=0.003), and PROM from 121.4° to 126.4° (P=0.021). CONCLUSIONS: Planning of RSA flaps should take into account donor site morbidity. If complications occur at the donor site, resurfacing surgery using TDAP flaps achieves aesthetic and functional improvements.

Application of paste-type acellular dermal matrix in hard-to-heal wounds.

OBJECTIVE: The extracellular matrix (ECM) is one of the most important elements in wound healing. Absence or dysfunction of the ECM may impair wound healing. The application of acellular dermal matrix (ADM) as a substitute for ECM has been suggested. This study investigated the clinical application and wound healing effects of a paste-type ADM in patients presenting with hard-to-heal wounds due to various causes. METHOD: Patients with a hard-to-heal wound for >1 month, from September 2017 to February 2019, were included in this study. After debridement, the paste-type ADM was applied, at zero (baseline), two and four weeks. After application of the paste-type ADM, a conventional dressing was applied using polyurethane foam. Wound size, the formation of granulation tissue, re-epithelialisation, complete healing and adverse events were recorded at zero (baseline), one, two, four, eight and 12 weeks after the initial treatment. RESULTS: A total of 18 patients took part (eight male, 10 female, mean age of 56±16.16 years). The mean wound area decreased from 17.42±10.04cm2 to 12.73±7.60cm2 by week one (p<0.05), to 10.16±7.00 by week two (p<0.0005), to 5.56±5.25 by week four (p<0.0001), to 2.77±5.15 by week eight (p<0.0001) and to 2.07±4.78 by week 12 (p<0.0001). The number of patients with >75% re-epithelialisation increased from two (11.1%) at two weeks to five (27.8%) at four weeks, to 11 (61.1%) at eight weeks and to 13 (72.2%) at 12 weeks. The number of patients showing complete wound healing was two (11.1%) at four weeks, nine (50.0%) at eight weeks and 12 (66.7%) at 12 weeks. No adverse events were reported during treatment. CONCLUSION: The paste-type ADM used in this study is a viable option for facilitating wound healing; it can shorten hospitalisation, and promote a faster recovery and return to normal life activities.

Reconstruction of burn scar contracture deformity of the extremities using thin thoracodorsal artery perforator free flaps.

BACKGROUND: Severe burn scar contracture of the extremities, especially the joint areas, causes aesthetic problems and functional limitation. Release of burn scar contractures requires complete removal of the scars and resurfacing of the resulting defects. Here, we describe thoracodorsal artery perforator (TDAP) free flaps for reconstructing burn scar contractures. METHODS: Between August 2013 and July 2018, 25 patients with severe burn scar contractures of the extremities underwent reconstruction using TDAP free flaps. Twelve were men and the mean age of the patients was 38.1 years (range, 12-66 years). Five patients had upper extremity contractures and 20 had lower extremity contractures. RESULTS: Twenty-one patients underwent reconstruction with a TDAP flap alone, while three received two perforator flaps, a TDAP and an anterolateral thigh flap or deep inferior epigastric artery perforator (DIEP) flap. The remaining patient received three perforator flaps, two TDAP and an anterolateral thigh flap. Fourteen patients had an improved range of motion after reconstruction. All the flaps survived except in the case of four patients who suffered partial loss of a TDAP flap. In one patient, there was partial skin graft loss at the donor site. The mean follow-up was 17.2 months (range 6-36 months). CONCLUSION: Ideal reconstruction of burn scar contracture yielding functional and aesthetic results involves complete removal of scar tissue and reconstruction. Depending on the extent of the defect, the TDAP flap, with its thin and pliable tissue and minimal donor site morbidity, may be the best option for reconstruction of burn scar contracture.

Limb Salvage Using Combined Linking Perforator Free Flaps.

Microsurgical free tissue transfer is the most effective method for extensive reconstruction of lower limb defects. The purpose of this report is to describe our experience of using microsurgically fabricated combined linking perforator flaps for one-stage reconstruction of extensive lower limb defects. Between April 2008 and November 2016, 16 cases of extensive lower defects were reconstructed using combined linking flaps. Of the patients, 10 were males, and the mean age was 45.3 years (range = 20-76 years). The flaps used were thoracodorsal artery perforator flaps together with deep inferior epigastric artery perforator flaps or anterolateral thigh flaps. There were no total flap failures; however, 3 anterolateral thigh flaps were partially lost and required skin grafts. One wound disruption healed conservatively. Donor site healing was achieved primarily without any dehiscence. The follow-up period was 15.4 months (range = 8-24 months). The use of combined linking perforator flaps for lower limb defects is uncommon; however, in cases of extensive limb defects these flaps can salvage limbs by means of one-stage operations.