Special-form radial collateral artery perforator flaps for the reconstruction of complex hand defects.

BACKGROUND: The reconstruction of complex wounds of the hand still has challenges in achieving aesthetic, functional and sensory recovery. We presented our experience of using the polyfoliate and chimeric radial collateral artery perforator flaps (RCAPF) to repair complex hand defects, aiming to explore the feasibility of special-form RCAPFs in hand coverage and enhance the comprehension of their respective indications. METHODS: From June 2014 to March 2021, 26 cases (19 males and 7 females, mean 44.4 years) underwent defect and sensation reconstruction of their hands with special-form RCAPFs, which manifested as multiple adjacent or irregular single wounds and composite tissue defects complicated with a degree of nerve injury. The clinical effects of the free RCAPFs were evaluated by integrating the postoperative and long-term follow-up outcomes of all cases. RESULTS: Altogether 8 polyfoliate flaps, 17 chimeric flaps and 1 polyfoliate-chimeric flap were harvested. Of them, 23 flaps survived uneventfully in one stage. Venous congestion occurred in 3 cases, two of which survived through vascular exploration and another one was finally repaired by the contralateral RCAPF. The follow-up results showed that the appearance of both the recipient and donor sites mostly recovered satisfactory. All the bone flaps properly healed. The BMRC sensory evaluation results of all skin flaps were S4 in 8 flaps, S3 in 18 flaps, and S2 in 9 flaps. CONCLUSIONS: The free RCAPFs can be designed in various forms with a reliable blood supply, contributing to reconstructing simple and multiple wounds of the hand with or without bone defects and dead space.

Reconstruction of the extensor tendon on the dorsal pedis with a chimeric skin-aponeurosis flap from the groin region.

BACKGROUND: Complex defects involving the extensor tendon on the dorsal pedis have been reconstructed using multiple procedures. Skin coverage and tendon transfers have also been performed. This study aimed to present our experience using a chimeric skin-aponeurosis flap for one-stage reconstruction of composite soft-tissue defects on the dorsal pedis. METHODS: Between May 2017 and September 2020, 12 patients with these defects received total treatment using a chimeric groin flap. Based on the superficial circumflex iliac vessels, the skin paddle resurfaced the cutaneous defect, and the vascularised external oblique aponeurosis was rolled to form a tendon-like structure to simultaneously replace the absent segment of the extensor tendons. A suitable "Y" bifurcation was dissected to enlarge the vessel diameter. Single-stage reconstruction was performed using a set of vascular anastomoses at the recipient site. RESULTS: Flap survival was achieved without significant complications. The hammertoe deformity was completely removed. The average dimension of the skin paddle was 8.0 × 13.0 cm (range, 6.5 × 11.0-10.0 × 14.0 cm), and the mean size of the aponeurosis was 8.0 × 4.0 cm (range, 6.0 × 3.0-10.0 × 5.0 cm). At the last follow-up visit, no morbidity was observed at the donor site. Natural shapes and walking functions were successfully achieved with a protective sensation. CONCLUSION: The chimeric groin flap with sheets of external oblique aponeurosis is a great candidate for one-stage reconstruction of composite soft tissue loss on the dorsal pedis. This approach provides cosmetic coverage, allowing faster wound healing and reduced tendon adhesions.

Predesigned chimeric deep inferior epigastric perforator and inguinal lymph node flap for combined breast and lymphedema reconstruction: A comprehensive algorithmic approach.

The combined use of a deep inferior epigastric perforator (DIEP) flap coupled with vascularized inguinal lymph nodes (VILNs) for simultaneous breast and lymphedema reconstruction has already been well established, and promising results have been reported. However, a standardized approach for the planning and shaping of this combined flap is still lacking. We aimed to propose a comprehensive algorithmic approach for delayed unilateral breast and lymphedema reconstruction using a predesigned abdominal flap associated with inguinal lymph node transfer. We present in detail the preoperative measurements and surgical technique of the chimeric flap, which combines a predesigned DIEP template and a preselected inguinal lymph node flap, based on the preoperative computed tomography angiography and SPEC-CT findings, respectively; four different flap types are described according to the location of the pedicles of the two flap components. Our results of a series of 34 consecutive female patients with unilateral mastectomy and arm lymphedema, who underwent this combined predesigned reconstructive procedure, are retrospectively analyzed and reported. We recorded a high survival rate of the chimeric flaps in our series, with only one case of partial ischemic loss of a DIEP skin island. In the majority of our patients, the pedicles of the combined flaps were located in opposite positions. After a mean 35-month follow-up, we recorded a 47% mean volume difference reduction of the lymphedematous compared to the unaffected arm; no donor-site lymphedema was documented. Self-evaluation questionnaires showed high patient satisfaction rates regarding breast reconstruction. This algorithmic approach provides standardized guidance for accurate design and transfer of the DIEP-VILN chimeric flap while achieving highly satisfactory outcomes for both breast and lymphedema reconstruction.

Using Free Chimeric Anterolateral Thigh Flap For Reconstruction Of Composite Dorsal Hand Defect.

Background: Simultaneous repair of the extensor tendons and soft tissues in hand injuries remains challenging. The free chimeric anterolateral thigh (ALT) flap with fascia lata (FL) flap represents an alternative for hand reconstruction. This report describes the reconstruction of the extensor tendon and skin defects using free chimeric ALT flaps with FL. Methods: Eight patients (one female and seven male) underwent reconstruction of complex hand defects with free chimeric ALT and FL flaps. The defects were caused by crushing injuries, burns, snakebite scars, and animal bite wounds. The average skin defect was 116 cm2. Perforators were selected for the skin paddle and the FL flap. The thinning procedure was performed microsurgically. Results: The skin paddle size ranged from 12 to 23 cm in length and 6 to 11 cm in width, and the FL flaps ranged from 3 × 5 to 12 × 5 cm. The mean pedicle length was 7.88 cm. Nine extensor tendons were repaired with FL flaps. The flap thickness after thinning was only 3-6 mm. The donor site was closed primarily in six patients, and skin grafts were used in two cases. All flaps survived without complications. The follow-up period lasted from 17 to 80 months. Range of motion was achieved with satisfaction. Conclusion: The chimeric-thinned ALT and FL flap is a valuable material, and it should be considered a reconstructive option for hand soft tissue and extensor tendon reconstruction. This technique allows us to achieve a good appearance and extensor function without donor-site morbidity.

Variations in deep iliac circumflex artery perforator chimeric flap design for single-stage customized-reconstruction of composite bone and soft-tissue defect.

BACKGROUND: The deep iliac circumflex artery (DICA) perforator (DICAP) chimeric flap is a valuable treatment strategy for single-stage reconstruction of composite bone and soft-tissue defects in upper and lower extremities. However, its utilization rate remains low owing to anatomical variations that lead to challenges when identifying and dissecting perforators. METHODS: A comprehensive anatomical investigation was conducted on the DICA system by injecting lead oxide into 12 fresh cadavers following a standardized procedure. From January 2008 to December 2020, 30 patients with composite bone and soft-tissue defects received reconstruction surgery with DICAP chimeric flap. One of the four specified surgical techniques was used to create a modified DICAP chimeric flap for the patients based on the size, shape, and location of the defect. RESULTS: Two branching patterns of DICA, transverse and ascending branches, were observed, and the former gave off the osteomusculocutaneous perforators and terminal musculocutaneous perforators. Thirty DICAP chimeric flaps were elevated successfully. The size of the skin paddles measured from 9 × 4.5 cm to 22 × 9 cm, and the bone components ranged from 3 × 2.5 × 1.5 cm to 6 × 3.5 × 2 cm. All flaps survived successfully after the operation, and all patients achieved primary closure of the donor sites. No patient encountered the fracture of transferred iliac segments. The mean bone union time was 5.5 months (ranging from 4 to 8 months). CONCLUSION: The DICA system is a suitable source for harvesting the DICAP chimeric flap to reconstruct composite bone and soft-tissue defects. It provides a flexible design for individualized coverage of such defects with limited donor-site morbidity.

Individualized design of thoracodorsal artery perforator chimeric flap for customized reconstruction of complex three-dimensional defects in the extremities.

BACKGROUND: It was always challenging to accurately and effectively reconstruct the complicated defects with three-dimensional tissue deficits in the extremities. Muscle-chimeric perforator flap is an excellent choice for repairing those complicated wound. However, problems like donor-site morbidity and time-consuming intramuscular dissection still exist. This purpose of this study was to present a novel design of the thoracodorsal artery perforator (TDAP) chimeric flap for the customized reconstruction of complex three-dimensional tissue defects in the extremities. METHODS: From January 2012 to June 2020, 17 patients with complex three-dimensional deficits in the extremities were retrospectively analyzed. All patients in this series underwent extremity reconstruction using latissimus dorsi (LD)-chimeric TDAP flap. Three different types of LD-chimeric TDAP flaps were performed. RESULTS: A total of seventeen TDAP chimeric flaps were successfully harvested for the reconstruction of those complex three-dimensional defects in extremities. Among them, Design Type A flaps were used in 6 cases, Design Type B flaps were performed in 7 cases, and Design Type C flaps were used in the remaining 4 cases. The sizes of the skin paddles ranged from 6 cm × 3 cm to 24 cm × 11 cm. Meanwhile, the sizes of the muscle segments ranged from 3 cm × 4 cm to 33 cm × 4 cm. All the flaps survived. Nevertheless, one case required re-exploration owing to venous congestion. Moreover, the primary closure of the donor site was successfully achieved in all patients, and the mean follow-up time was 15.8 months. Most of the cases displayed satisfactory contour. CONCLUSION: The LD-chimeric TDAP flap is available for the reconstruction of complicated defects with three-dimensional tissue deficits in the extremities. It provided a flexible design for customized coverage of complex soft tissue defects with limited donor site morbidity.

The free chimeric medial sural artery perforator flap for individualised and three-dimensional reconstruction of complex soft-tissue defects in extremities.

Trauma or lesion resection often causes complex wounds with deep soft tissue defects in extremities. Simply covering with a skin flap will leave a deep dead space resulting in infection, non-healing wounds, and poor long-term outcomes. Thus, effectively reconstructing complex wounds with dead space leaves a clinical challenge. This manuscript presents our experience using chimeric medial sural artery perforator (cMSAP) flap, to reconstruct complex soft tissue defects of the extremities, thereby exploring broader analysis and indications for future reference. Between March 2016 and May 11, 2022, patients (8 males and 3 females) with a mean age of 41 years (range from 26 to 55 years) underwent reconstructive surgery with the cMSAP flap. The cMSAP flap consists of an MSAP skin paddle and a medial sural muscle paddle. The size of the MSAP skin paddle ranged between 9 × 5 cm and 20 × 6 cm, and the size of the medial sural muscle paddle ranged between 2 × 2 cm and 14 × 4 cm. Primary closure of the donor site was achieved in all cases. Of the 11 patients, the cMSAP flap survived in 10 cases. The vascular compromise occurred in one special case and was treated with surgical procedures. The mean follow-up duration was 16.5 months (range of 5-25 months). Most patients present satisfactory cosmetic and functional results. The free cMSAP flap is a good option for reconstructing complex soft tissue defects with deep dead space in extremities. The skin flap can cover the skin defect, and the muscle flap can fill the dead space against infection. In addition, three types of cMSAP flaps can be used in a broader range of complex wounds. This procedure can achieve an individualised and three-dimensional reconstruction of the defects and minimise the donor site morbidities.

Reconstruction of a Composite Defect of the Distal Index Finger Using a Chimeric Reverse Flow Second Dorsal Metacarpal Artery Flap: A Case Report.

The reconstruction for mild tissue loss at the distal part of a finger is challenging. We report about a 29-year-old man presenting with traumatic tissue loss at the distal interphalangeal (DIP) joint of the index finger, including skin, bone, and nerve. Reconstruction using two types of flaps was performed. The dorsal skin flap, nourished by the second dorsal metacarpal artery (SDMA) perforator, was elevated. The vascularized second metacarpal bone, nourished by the SDMA, was also elevated. Using the vascular connection between the DMA and the palmar digital artery (PDA), both flaps were raised to the distal part of the finger, and the pivot point was set at the dorsal proximal phalanx. After arthrodesis of the DIP joint with the vascularized second metacarpal bone, the digital nerve was repaired using the cutaneous nerve in the skin flap, and the skin defect was covered using the perforator flap. The postoperative course, including flap survival and bone union, was uneventful. A good indication for the reconstruction of the distal part of a finger with this technique is when the defect sizes of the skin and bone differ and the vascular connection between the SDMA and dorsal branch of PDA is not injured.

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.

[Combination mode and optimization strategy of harvest procedure of anterolateral thigh chimeric perforator myocutaneous flap].

Objective: To summarize the combination methods and optimization strategies of the harvest procedure of anterolateral thigh chimeric perforator myocutaneous flap. Methods: A clinical data of 359 cases of oral cancer admitted between June 2015 and December 2021 was retrospectively analyzed. There were 338 males and 21 females with an average age of 35.7 years (range, 28-59 years). There were 161 cases of tongue cancer, 132 cases of gingival cancer, and 66 cases of buccal and oral cancer. According to the Union International Center of Cancer (UICC) TNM staging, there were 137 cases of T 4N 0M 0, 166 cases of T 4N 1M 0, 43 cases of T 3N 1M 0, 13 cases of T 3N 2M 0. The disease duration was 1-12 months (mean, 6.3 months). The soft tissue defects in size of 5.0 cm×4.0 cm to 10.0 cm×7.5 cm remained after radical resection were repaired with the free anterolateral thigh chimeric perforator myocutaneous flaps. The process of harvesting the myocutaneous flap was mainly divided into 4 steps. Step 1: exposing and separating the perforator vessels, which mainly came from the oblique branch and the lateral branch of the descending branch. Step 2: isolating the main trunk of the perforator vessel pedicle and determining the origin of the vascular pedicle of muscle flap, which was came from oblique branch, lateral branch of the descending branch, or medial branch of the descending branch. Step 3: determining the source of muscle flap, including lateral thigh muscle and rectus femoris muscle. Step 4: determining the harvest form of muscle flap, which included muscle branch type, main trunk distal type, and main trunk lateral type. Results: The 359 free anterolateral thigh chimeric perforator myocutaneous flaps were harvested. In all cases, the anterolateral femoral perforator vessels existed. The perforator vascular pedicle of the flap came from the oblique branch in 127 cases and the lateral branch of the descending branch in 232 cases. The vascular pedicle of muscle flap originated from the oblique branch in 94 cases, the lateral branch of the descending branch in 187 cases, and the medial branch of the descending branch in 78 cases. The muscle flaps harvested from the lateral thigh muscle in 308 cases and the rectus femoris muscle in 51 cases. The harvest forms of muscle flaps included 154 cases of muscle branch type, 78 cases of main trunk distal type, and 127 cases of main trunk lateral type. The size of skin flaps ranged from 6.0 cm×4.0 cm to 16.0 cm×8.0 cm, and the size of muscle flaps range from 5.0 cm×4.0 cm to 9.0 cm×6.0 cm. In 316 cases, the perforating artery anastomosed with the superior thyroid artery, and the accompanying vein anastomosed with the superior thyroid vein. In 43 cases, the perforating artery anastomosed with the facial artery, and the accompanying vein anastomosed with the facial vein. After operation, the hematoma occurred in 6 cases and vascular crisis in 4 cases. Among them, 7 cases were successfully saved after emergency exploration, 1 case had partial necrosis of skin flap, which was healed after conservative dressing change, and 2 cases had complete necrosis of skin flap, which was repaired by pectoralis major myocutaneous flap. All patients were followed up 10-56 months (mean, 22.5 months). The appearance of the flap was satisfactory, and the swallowing and language functions were restored satisfactorily. Only linear scar left in the donor site with no significant effect on thigh function. During follow-up, 23 patients had local tumor recurrence and 16 patients had cervical lymph node metastasis. The 3-year survival rate was 38.2% (137/359). Conclusion: The flexible and clear classification of the key points in the harvest process of anterolateral thigh chimeric perforator myocutaneous flap can optimize the protocol to the greatest extent, increase the safety of the operation, and reduce the difficulty of the operation.

Profunda Artery Perforator Flaps From the Posteromedial Region of the Thigh for Head and Neck Reconstruction.

OBJECTIVE: Profunda femoris artery perforator flaps (PAPFs) have not been widely used in head and neck reconstructions. The feasibility and outcomes of PAPFs for various head and neck reconstructions need to be investigated. STUDY DESIGN: Retrospective analysis. SETTING: A single-institution review. METHODS: PAPFs were utilized in head and neck reconstructions from 2019 to 2021. Local anatomy, surgical technique, and complications were discussed. Chimeric PAPF applications with muscle components were described for coverage of extensive multiunit defects. Additionally, aesthetic and functional outcomes were compared with anterolateral thigh perforator flaps. RESULTS: A total of 33 cases were included. The average age was 54.2 years (range, 30-74). The most common underlying pathology was oral squamous cell carcinoma (n = 26, 78.8%), while the mean ± SD body mass index was 25.4 ± 2.8 kg/m2 . Middle perforators (n = 14, 42.4%) were the most commonly utilized ones. The perforator-based chimeric/composite applications were used in 9 (27.3%), with the muscular components consisting of gracilis (n = 3, 9.1%), adductor magnus (n = 5, 15.2%), or semimembranosus muscles (n = 1, 3.0%). Venous thromboses of the PAPFs were found in 2 (6.1%), though salvaged. The occurrence of postoperative 90-day morbidity (complication) was related to mandibulectomy/maxillectomy (P = .020). Postoperative validated questionnaires showed a trend of intermediate to high scores, indicating noninferior outcomes in several categories, when compared with the anterolateral thigh perforator flap counterparts. CONCLUSION: PAPFs are a good reconstructive alternative for intermediate to large head and neck reconstructions. Besides, PAPFs can provide sufficient tissue volume and versatility of potentially incorporating adjacent muscle components.

Clinical applications of the chimeric anterolateral thigh (ALT) flap in head and neck reconstruction.

BACKGROUND: Surgical site infection (SSI) is a common complication following head and neck surgery. Dead space at the excision site can increase the risk of infection, abscess formation, and mortality. Herein, we evaluated the performance of the chimeric anterolateral thigh (ALT) flap in addressing these concerns. METHODS: Patients who underwent oncologic head and neck reconstruction between October 2016 and November 2021 were divided in two groups: a normal ALT flap and a chimeric dead space filling (DSF) ALT-vastus lateralis flap group. We evaluated the postoperative outcomes. RESULTS: Twenty-five patients treated with normal ALT flaps (34.7%) and 47 with DSF ALT flap group (65.2%) were included. Only one ALT per case was necessary. Most of the cases involved tongue (31.9%) and lower gingival reconstruction (27.8%). The time to harvest the DSF ALT flap was 134.3 min when compared to the normal ALT flap (116.2 min, p < .001). Vascular occlusion, flap loss, partial necrosis, and fat necrosis were not observed among the different groups. CONCLUSION: The DSF process can be used as a preventive measure for SSI or vessel exposure due to radiation-induced skin damage. This flap allows same-site reconstruction if the primary tumor recurs by using the pedicle of the chimeric flap for reattachment of another free flap.

[Imaging study and clinical application of peroneal perforating chimeric tissue flap].

Objective: To explore the feasibility of peroneal perforating chimeric tissue flap in repairing the composite defects of calf and heel based on lower limb angiography, and the clinical effect. Methods: The digital subtraction angiography images of lower limbs of 50 patients met the selection criteria between May 2011 and October 2014 were used as the research object to observe the course of peroneal artery and its perforating vessels. Based on the observation results, between April 2015 and October 2020, the peroneal perforating chimeric tissue flap was designed to repair 7 cases of composite defects of the calf and heel. There were 5 males and 2 females with an average age of 38 years (range, 25-55 years). The causes of injury included traffic accident in 4 cases, falling from height in 2 cases, and machine strangulation in 1 case. There were 5 cases of calf skin defect and tibial defect. The size of skin defect ranged from 5 cm×3 cm to 11 cm×7 cm, and the length of bone defect was 5-8 cm. There were 2 cases of heel skin defect and calcaneal defect. The sizes of skin defects were 5.0 cm×4.0 cm and 7.5 cm×6.5 cm, and the bone defects were 3.0 cm×2.6 cm and 4.0 cm× 3.0 cm. For the calf defect, the size of skin flap ranged from 6 cm×4 cm to 12 cm×8 cm, and the length of the fibula was the same as that of the tibial defect. For the heel defect, the sizes of the skin flaps were 8.5 cm×5.5 cm and 13.0 cm×5.0 cm, and the lengths of the fibulae were 10 cm and 12 cm. Free transplantation was performed in 5 cases and pedicle transplantation in 2 cases. The wound at donor site was repaired with skin grafting or sutured directly. Results: The peroneal artery ran close to the fibula 7.25-8.40 cm below the fibula head and send out 5-7 perforating vessels, with an average of 6.5 vessels. Perforating vessels mainly appeared in four places, which were (9.75±0.91), (13.21±0.74), (18.15±1.22), and (21.40±0.75) cm below the fibular head, with the occurrence rates of 94%, 90%, 96%, and 88%, respectively. Clinical application of 7 cases of peroneal perforating chimeric tissue flap all survived, all wounds healed by first intention. The skin graft at donor site survived and the incision healed by first intention. All patients were followed up 6-36 months, with an average of 12 months. Peroneal perforator chimeric tissue flap had good shape and soft texture. X-ray films showed that the bone graft healed well, and the healing time was 6-11 months (mean, 7 months). No obvious bone resorption was observed during follow-up. Five patients had no pain when walking, and 1 had mild pain with claudication. Postoperative heel ulcers formed in 1 case and healed after wearing custom plantar pressure dispersing shoes. At 6 months after operation, 2 patients were rated as grade Ⅳ and 5 patients as grade Ⅴ according to Holden walking function score. Conclusion: The peroneal perforating vessel distribution is constant and the peroneal perforating chimeric tissue flap is safe and reliable for repairing the composite defects of calf and heel.

[Application of lateral circumflex femoral artery chimeric flap to repair complex wounds of foot and ankle].

OBJECTIVE: To investigate the effectiveness of lateral circumflex femoral artery chimeric flap transplantation in repair of complex wounds of foot and ankle. METHODS: A retrospective study was conducted to analyze the clinical data of 20 patients with complex wounds of foot and ankle treated with lateral circumflex femoral artery chimeric flap between June 2017 and June 2020. There were 14 males and 6 females with an average age of 42.8 years (range, 21-65 years). Among them, 8 cases had dorsalis pedis tendon defect with or without bone exposure, 4 cases had partial or total Achilles tendon defect without bone exposure, and 8 cases had deep cavity and bone exposure. The wound area ranged from 10 cm×6 cm to 21 cm×11 cm. The time from injury to operation ranged from 6 to 22 days, with an average of 9.4 days. The lateral femoral circumflex artery flap was used in 6 cases with fascia lata flap, 6 cases with rectus femoris aponeurosis flap, and 8 cases with lateral femoral muscle flap. The flap area ranged from 12.0 cm×6.5 cm to 35.0 cm×7.5 cm. All flap donor sites were sutured directly. The survival, appearance, texture, sensation of the flap, and complications of the donor site were observed. The foot and ankle function was evaluated by Kofoed score. RESULTS: All patients were followed up 8-24 months (mean, 14.2 months). On the 3rd day after operation, 1 case had partial necrosis of 1 flap with fascia lata flap and healed after dressing change; 1 case of chimeric muscle flap developed venous crisis at 12 hours after operation; the chimeric flaps survived successfully in the other 18 patients and the wounds were primary healing. The color and texture of the flaps were good, the flaps recovered protective sensation. Only linear scar remained in the donor site of thigh. There was no sensory disturbance around the incision or walking disturbance. The Kofoed score of the foot and ankle function at last follow-up was 75-96, with an average of 89.8. Among them, 15 cases were excellent, 4 cases were good, and 1 case was qualified. The excellent and good rate was 95.0%. CONCLUSION: The application of lateral circumflex femoral artery chimeric flap can accurately and stereoscopically repair the complex wounds of foot and ankle and achieve satisfactory effectiveness.

Customized reconstruction of complex soft tissue defects in the upper extremities with variants of double skin paddle anterolateral thigh perforator flap.

BACKGROUND: Complex soft tissue defects in the upper extremities are challenging to reconstruct. The purpose of this study was to share our experience with using four variants of double skin paddle Anterolateral Thigh Perforator (ALT) flap to achieve the customized reconstruction of the complex defects. PATIENTS AND METHODS: From January 2007 to December 2019, 15 patients (14 male and 1 female) aged 15-61 years underwent double skin paddle ALT flap reconstruction of the upper extremities. 10 wounds were located in the wrist or hand, while four wounds were located in the forearm, and one wound in the elbow. All the wounds were large with non-adjacent defects and with or without a dead space. Four variants of double skin paddle anterolateral thigh perforator flaps were harvested according to the patient's needs. RESULTS: The flaps received were consisted of 7 classic double skin paddle ALT flap, 4 vastus lateralis muscle-chimeric double skin paddle ALT flap, 2 microdissected thin double skin paddle ALT flap, and 2 flow-through double skin paddle ALT flap. The size of the skin flap ranged from 6 × 6 cm2 to 26 × 7 cm2, and the size of the muscle segment ranged from 5 × 2 × 1 cm3 to 16× 6 × 2 cm3. Flap necrosis related to the pedicle kinking was observed in one patient, while the rest of the flaps survived without complications. The follow-up period ranged from 7 to 54 months, with a median of 15.6 months. The mean value of the qDASH scores at the last follow-up was 27.12 ± 16.51 (range, 11.4-59.1). None of the patients showed wrist flexion deformity. Postoperatively, three patients developed finger joint stiffness, which correlated with the severity of the injury. CONCLUSIONS: Variants of double skin paddle ALT flaps provide versatile design and allow customized reconstruction of complex soft tissue defects in the upper extremities with limited donor site morbidity. We believe that the algorithm provided will help the surgeons with deciding among variants of double skin paddle ALT flap.

The Use of a Tetraminos Chimeric Free Flap in Lower Limb Trauma.

Major trauma care has improved in the UK since the evolution and acceptance of specialist centers . A mission statement for major trauma care is "reduction in mortality and disability following trauma." The care for extremity trauma has benefited from this specialization. Traumatic loss of skin integument in the extremities, especially over mobile joints, may lead to a compromised functional outcome. Modern reconstructive plastic surgery aims to provide flaps with minimal donor site morbidity. In this case report, we present the use of two chimeric flaps undertaken sequentially (one acutely and the second delayed) around the knee joint to allow a greater range of motion and function after a severe traumatic event. In this clinical case, the original tissue defects had meant that a free flap was used to reconstruct an open fractured bone, and split skin grafting was undertaken on the anterior aspect of the knee. The latter was then replaced after some months of recovery.

The Anterolateral Thigh Perforator Flap: Its Expanding Role in Lower Extremity Reconstruction.

The anterolateral thigh (ALT) flap is a popular flap for lower extremity reconstruction despite its varied pedicle anatomy. Beyond its use for soft tissue coverage, using the chimeric flap concept, the ALT flap is useful for tendon and ligament reconstruction and the creation of a gliding surface with the fascia lata component. The vastus lateralis muscle can be included for dead-space obliteration. The main pedicle is long and is a similar size match for major artery reconstruction. If several perforators are available, a split flap could be fashioned into a multitude of shapes all arising from the same pedicle.

A constant harvest technique for chimeric anterolateral thigh flaps and patient outcomes following their use in reconstructive head and neck surgery.

BACKGROUND: Chimeric anterolateral thigh free flaps (ALT) have been commonly used for head and neck defects, which require two epithelial lined surfaces. However, because of unpredictable vascular anatomy, it is a challenge to consistently elevate large chimeric flaps with multiple perforators based on the Lateral Circumflex Femoral Artery (LCFA). Here, we present our method to reliably harvest a chimeric flap from the ALT territory and investigate its long-term outcomes when used in the reconstruction of extensive head and neck defects. METHODS: A prospective review of practice consisting of 27 patients, between January 2011 and April 2019, with extensive through-and-through head and neck defects, which require dual paddle flaps underwent reconstruction with chimeric ALT harvested with a portion of distal vastus lateralis. The age of the patients ranged from 32 to 68 years (mean 53.2 years). RESULTS: Flap length ranged from 17 to 30 cm (mean, 25.6 cm). The mean flap area was 261.6 cm2 (range, from 225 to 340 cm2). The mean ischemia time was 162.9 min (range, from 59 to 269 min). At a mean follow-up time of 33.4 months (range, from 4 to 91 months), four patients died of cancer recurrence. For the other 23 patients, 4 required revision to achieve better cosmetic lip competence. All flaps survived with two recorded returns to theater for pedicle exploration associated with partial flap loss only. CONCLUSION: Harvesting the chimeric ALT with a portion of vastus lateralis distally negates the need for tenuous intramuscular perforator dissection. It is a reliable option for head and neck surgery, which require composite reconstruction. Using this technique produces a good functional cosmetic outcome. It also allows large defects to be reconstructed in a single sitting with free tissue transfer.

Osteocutaneous proximal fibular flap: an anatomical and computed tomographic angiographic study of skin and bone perforators.

INTRODUCTION: Vascularized proximal fibular epiphyseal transfer is a reconstruction method for joints and growing bones. The authors investigated the vascular supply of the proximal fibula, including skin perforators, for suitability in creating an osteocutaneous flap. METHODS: Twenty fresh cadaveric knees were studied using computed tomographic angiography combined with anatomical dissection. Three-dimensional angiography was used to develop an overview, and multiplanar two-dimension angiography was used for detailed data collection. Anatomical dissection verified by angiography was used to locate skin perforators of the proximal part of the anterior tibial artery. RESULTS: Proximal fibular bone perforators from the anterior tibial artery were found to arise either from the anterior tibial recurrent artery, the posterior tibial recurrent artery or the circumflex fibular artery in every specimen (100%), whereas perforators from the inferolateral genicular artery met those criteria in 12 of 18 specimens (66.7%). In the proximal half of 20 anterior tibial arteries, 129 skin perforators with a diameter larger than 0.5 mm were found. There were 54 potential septocutaneous skin perforators between the extensor digitorum longus and the peroneus longus muscles (EDL/PL), and 18 between the extensor digitorum longus and the tibialis anterior muscles (TA/EDL). Skin perforators from the inferolateral genicular artery emerging from the posterolateral corner of the knee had a diameter of < 0.5 mm. CONCLUSION: Based on this cadaveric study, the reverse flow anterior tibial artery pedicle and the EDL/PL or TA/EDL skin perforators can be considered as options for osteocutaneous proximal fibular transfers.

Functional tongue and floor of mouth reconstruction with a chimeric flap after total glossectomy.

PURPOSE: Presently, the functional reconstruction of the tongue in patients after subtotal or total glossectomy with the removal of the oral floor muscles and spearing of the larynx remains a complicated and unsolved issue. The aim of this case is to describe a method reconstruction of the tongue in patients after total glossectomy with the removal of the oral floor muscles using the chimeric latissimus dorsi and serratus anterior free flap (chimeric LD + SA flap) with motor innervation. METHODS: A 62-year-old woman with advanced cancer of the oral cavity was submitted to total glossectomy and then reconstruction with a chimeric LD + SA flap. With this method reconstruction of the tongue was made the creation a large mound (neotongue) lateral to the mandibular arch which can easily reach the palatal arch and also was made suspension of the larynx is essential given the ablative loss of supra-hyoid attachments. RESULTS: Our preliminary experience shows that this flap is a good reconstructive option for total glossectomy with the removal of the oral floor muscles and with larynx preservation. Functional and objective evaluation of the tongue reconstructed with chimeric LD + SA free flap requires further and standardized evaluation.