The Role of Measurement of Pedicle Length for DIEP Flap Transferring in Breast Reconstruction: A Single-Center, Open-Label, Randomized Controlled Trial.

BACKGROUND: Intraoperative venous congestion is a main complication in deep inferior epigastric artery perforator (DIEP) flap for breast reconstruction. We present a pedicle measuring technique to precisely predict the length of pedicle needed in DIEP free flap, to improve the outcome, and to reduce the risk of donor site morbidity and complications. MATERIALS AND METHODS: A single-center, open-label, prospective, randomized study was carried out to access efficacy and safety of a pedicle measuring technique in 389 patients. Each patient received a delayed breast reconstruction using free unipedicled DIEP flap, and internal mammary vessels were chosen as recipient vessels. During the surgery, the conventional DIEP flap technique was used in the control group, in which the course of the pedicle was fully dissected. In the measuring group, the flap in setting way was decided preoperatively, the distance (A) between the internal mammary vessels (a) and the point of DIEP perforator into the subcutaneous tissue (b) was measured, and then the length (B) of the perforator (c) and the main trunk (d) is measured and dissected to achieve 1 cm longer than A. RESULTS: There are 180 and 209 patients enrolled in the control and measuring group, respectively. Venous congestion occurred in 15 patients (8.3%) in the control group, and 1 patient (0.5%) in the measuring group ( P < 0.001). All the 16 patients were found venous thrombosis. Then successful free flap salvage surgeries were performed in 10 patients. Six patients (3.3%) had total flap necrosis due to recurrent venous thromboembolisms. Fat necrosis occurred in 16 patients (8.9%) in the control group, and 5 patients (2.4%) in the measuring group ( P = 0.006). Partial flap necrosis was found in 12 patients (6.7%) in the control group, and in 3 patients (1.4%) in the measuring group ( P = 0.008). Total flap necrosis occurred in 6 patients (3.3%) in the control group, but no (0%) patient in the measuring group ( P = 0.009). CONCLUSIONS: Measurement of pedicle length for DIEP flap transferring in breast reconstruction is a reliable technique that could secure the DIEP free flap, reduce operative invasiveness, and lower the risk of complications considerably.

NAP1L1 interacts with hepatoma-derived growth factor to recruit c-Jun inducing breast cancer growth.

BACKGROUND: Breast cancer is a common cancer among women in the world. However, its pathogenesis is still to be determined. The role and molecular mechanism of Nucleosome Assembly Protein 1 Like 1 (NAP1L1) in breast cancer have not been reported. Elucidation of molecular mechanism might provide a novel therapeutic target for breast cancer treatment. METHODS: A bioinformatics analysis was conducted to determine the differential expression of NAP1L1 in breast cancer and find the potential biomarker that interacts with NAP1L1 and hepatoma-derived growth factor (HDGF). The expression of NAP1L1 in tissues was detected by using immunohistochemistry. Breast cancer cells were transfected with the corresponding lentiviral particles and siRNA. The efficiency of transfection was measured by RT-qPCR and western blotting. Then, MTT, Edu, plate clone formation, and subcutaneous tumorigenesis in nude mice were used to detect the cell proliferation in breast cancer. Furthermore, coimmunoprecipitation (Co-IP) assay and confocal microscopy were performed to explore the detailed molecular mechanism of NAP1L1 in breast cancer. RESULTS: In this study, NAP1L1 protein was upregulated based on the Clinical Proteomic Tumor Analysis Consortium (CPTAC) database. Consistent with the prediction, immunohistochemistry staining showed that NAP1L1 protein expression was significantly increased in breast cancer tissues. Its elevated expression was an unfavorable factor for breast cancer clinical progression and poor prognosis. Stably or transiently knocking down NAP1L1 reduced the cell growth in vivo and in vitro via repressing the cell cycle signal in breast cancer. Furthermore, the molecular basis of NAP1L1-induced cell cycle signal was further studied. NAP1L1 interacted with the HDGF, an oncogenic factor for tumors, and the latter subsequently recruited the key oncogenic transcription factor c-Jun, which finally induced the expression of cell cycle promoter Cyclin D1(CCND1) and thus the cell growth of breast cancer. CONCLUSIONS: Our data demonstrated that NAP1L1 functions as a potential oncogene via interacting with HDGF to recruit c-Jun in breast cancer.

Postoperative drain after transoral endoscopic thyroidectomy vestibular approach (TOETVA) with single incision.

OBJECTIVE: To find the optimal size of a drain for the reliable drainage and the best cosmetic result in TOETVA. To explore the normal drainage flow rate after TOETVA. METHODS: A prospective randomized controlled trial was performed in a single center from December 2016 to December 2018. One hundred and fifty-three (153) patients had TOETVA with a single incision and were randomly divided into two groups. Self-made drainage tubes with a small diameter (outer diameter 2.0 mm, inner diameter 1.0 mm) were used in 80 patients (experimental group). No. 8 tubes were used in 73 patients (control group). The clinical characteristics and results between both groups were compared by t test or chi-square test, and the results of normal drainage flow rate were calculated. RESULTS: The experimental group had a longer intraoperative tube-inserting time, compared with the control group (9.5 ± 2.5 min vs. 5.6 ± 1.4 min, p = 0.001), a smaller scar six months after the operation (1.8 ± 2.3 mm vs. 3.1 ± 2.6 mm, p = 0.002), and a lower Vancouver Scar Scale score at both one month (3.20 ± 1.44 vs. 4.19 ± 1.92, p = 0.001) and six months after the operation(1.43 ± 1.84 vs. 2.40 ± 2.37, p = 0.006). The drainage volume, pain score on the first day, postoperative complications (tube blockage, air leakage, subcutaneous hydrops, hematoma, regional infection), and the extubation time were not significantly different. The average drainage of 148 patients without postoperative complications was 78.3 ± 10.9 ml. The cumulative drainage within 8 h, and 32 h after the operation accounted for 53.2% and 91.9% of the total drainage, respectively. The residual drainage at 32 h was estimated to be 6.5 ± 2.9 ml (P95 = 11.0 ml). A linear regression equation between total volume (Vt) and the size of resected tissue (S) was established: Vt = 1.625 S + 56.604 (p = 0.0001). CONCLUSION: In TOETVA, a small drain can provide a good cosmetic appearance and reliable drainage. The main exudation period of the wound is within 8 h after the operation. If a residual volume of less than 11 ml is considered to be self-absorbable, the shortest safe extubation point for 95% of patients should be 32 h after the operation.

Bilateral Anterolateral Thigh Myocutaneous Flaps for Giant Complex Chest Wall Reconstruction.

BACKGROUND: Extensive reconstruction of complex full-thickness chest wall oncological defects is challenging. Bilateral free anterolateral thigh (ALT) myocutaneous flap transfer for the complex reconstruction of a large area of the chest wall is discussed. MATERIALS AND METHODS: We reported a single unit's experience in 1-staged multilayered reconstruction of large full-thickness chest wall defects in 22 patients (16 primary chest wall tumor cases, 5 locally advanced breast cancer cases, and 1 osteoradionecrosis case) treated between 2011 and 2018. Bilateral ALT myocutaneous flaps together with traditional cement implant or unmovable/movable joint conformable titanium struts were used for chest wall reconstruction. The anatomical characteristics of pedicle origin and pattern of the venae comitantes of the ALT myocutaneous flap, recipient vessels, and anastomosis patterns were described. RESULTS: Bilateral ALT myocutaneous flaps were used for soft tissue reconstruction in 22 cases. Different methods of flap harvesting and vascular anastomosis were selected as needed. No vein grafts or arteriovenous loops were required. We observed 3 vascular patterns of the flap pedicle, including 1 oblique branch and descending branch (59.1%, n = 26), 2 single descending branch (9.1%, n = 4), and 3 double branches of the descending branch (31.8%, n = 14). The flap was harvested pedicled with solely the oblique branch in 7 (15.9%) cases, solely the descending branch in 28 (63.6%) cases to minimize the donor site morbidity, and pedicled with the oblique and descending branch in 9 (20.5%) cases to achieve multiple vascular anastomosis choices. Stable skeletal reconstructions were achieved using traditional cement implant (13.6%, n = 3) or conformable titanium struts (86.4%, n = 19), with good fixation strength. Complication risk was low. An algorithmic approach to management is presented and recommended. CONCLUSION: Various forms of bilateral ALT myocutaneous flap transfer with different skeletal reconstruction presents as a reliable treatment for patients with large full-thickness chest wall defects. Anatomical variations in the pedicle and pattern of venae comitantes of the ALT myocutaneous flap are reported. In some challenging cases, finding the vessels in the recipient area is difficult. The clinical significance of each vascular pattern is delineated, and surgical technical considerations are discussed on the basis of the recipient area requirements and types of a flap's vascular anatomy.

The clinical application of mental nerve dissection in transoral endoscopic thyroidectomy via an oral vestibular approach.

BACKGROUND: Transoral endoscopic thyroidectomy vestibular approach is the natural orifice surgery to avoid surgical scars. However, mental nerve injury is a characteristic complication. Herein, we report the development of a novel method to dissect the mental nerve proactively during surgery to minimize the morbidity from mental nerve injury. METHODS: In this study, a total of 105 patients from June 2016 to February 2018 were categorized as the mental nerve dissection group (MND) or not mental nerve dissection group (NMND). We analyzed the demographics, operative data, hospital stay, pathologic results, and postoperative complications between the two groups. RESULTS: There were no significant differences with respect to age, gender, tumor size, extent of surgery, the amount of bleeding, or postoperative hospitalization between groups. The specimen removal time was shorter in the MND group. The average operation time in both groups was similar, but the operation time for a hemithyroidectomy with CND in the MND group was shorter than in the NMND group. The VAS pain scores and complication rates that included transient hypocalcemia, seroma, subcutaneous emphysema, transient, and permanent recurrent laryngeal nerve palsy did not differ significantly between groups. In terms of mental nerve injury, the morbidity rate in the MND group was lower than in the NMND group. CONCLUSIONS: The modified endoscopic thyroidectomy involving dissection of the mental nerve via the oral vestibular approach is safe and feasible. It is beneficial to protect the mental nerve and for specimen removal which is worth clinical promotion.

Synchronous Closure of A Large Medial Perforator-Based Superficial Circumflex Iliac Artery Perforator Free Flap Donor Site Using an Ipsilateral Lateral Perforator-Based Superficial Circumflex Iliac Artery Perforator Propeller Flap.

A superior advantage of the superficial circumflex iliac artery perforator flap is that any donor site residue can easily be hidden by clothing. Usually designed as narrow or moderate-sized flaps based on medial perforators of the superficial branch, this readily allows primary donor site closure. However, for larger flaps, tension-free closure requires that the thigh remain flexed or even a skin graft used. Another alternative would be to use an adequate lateral perforator of the deep branch, if available, as the vascular hub of a propeller flap that extended into the adjacent flank, that could then be rotated into the medial groin to facilitate simultaneous direct closure of both flap donor sites.

Extensive Microsurgical Reconstruction of Chest Wall Defects for Locally Advanced Breast Cancer: A 10-Year Single-Unit Experience.

BACKGROUND: Despite improvements in the early detection of breast cancer, locally advanced breast cancer (LABC) involving the chest wall exists in developing countries. Surgical resection remains a controversial management option. This study aims to demonstrate the value of chest wall reconstructive techniques for large LABC defects and report long-term outcomes. MATERIALS AND METHODS: We report a 10-years single-unit experience in the reconstruction of large defects (>300 cm). From 2007 to 2017, all LABC cases managed with large surgical resection with immediate microsurgical chest wall reconstruction were included in this study. Herein, we present the demographics, comorbidities, clinicopathological LABC characteristics, surgical techniques (free flap choice, recipient vessels), and outcomes (survival, complication, cosmesis, and patient satisfaction). RESULTS: Of the 104 LABC cases, free deep inferior epigastric artery perforator flap was performed in 41 (39.4%) cases, free anterolateral thigh flap in 5 (4.8%), free deep inferior epigastric artery perforator combined with pedicled transverse rectus abdominis myocutaneous (TRAM) flap in 23 (22.1%), free muscle-sparing transverse rectus abdominis muscle flap in 30 (28.9%), and free transverse upper gracilis flap in 5 (4.8%). Complications were low. Over a median follow-up of 49.5 months, the 3-year local recurrence rate and distant metastasis-free survival were 13.9% and 84.9%, respectively. In addition, the 3-year disease-free survival and overall survival were 84.2% and 92.0%, respectively. The rate of excellent and good ratings by the esthetic assessment panel was 83.0%, and the patient satisfaction rate was 90.0%. CONCLUSION: Wide resection and microvascular free tissue transfer is oncologically safe in LABC with huge tumors and provides versatile solutions for the reconstruction of extensive chest wall defects. With favorable long-term survival and cosmetic outcomes, surgical resection of LABC combined with flap reconstruction may offer a practical approach in difficult and complicated cases. IMPLICATIONS FOR PRACTICE: In this retrospective review, it was demonstrated that wide resection followed by distinct chest wall reconstructive free flaps transfer is oncologically safe in LABC with huge tumors and provides useful solutions for the reconstruction of extensive chest wall defects.

A Sequential Thoracoacromial Artery Perforator Flap for Reconstructing the Donor Site of Sternocleidomastoid Myocutaneous Flaps: Extended Indications and Technical Modifications.

BACKGROUND: The current study introduces and demonstrates our experience of using a sequential thoracoacromial artery perforator (TAAP) flap to repair the sternocleidomastoid (SCM) flap donor site in this context. The aims of this technique are to optimize both esthetic and functional outcomes and to reduce postoperative complications for patients. METHODS: Between September 2013 and March 2017, the SCM flap combined with sequential TAAP flap was used for reconstruction postradical parotidectomy in 12 patients. Flap characteristics, patient outcomes, and postoperative complications were monitored and objectively measured, with 10 to 24 months of follow-up. RESULTS: There were no incidences of total flap loss. All TAAP flap donor sites were closed directly, and all healed without any complications. The SCM flap and TAAP flap donor areas were esthetically acceptable, with good esthetic and functional outcomes achieved in all 12 patients. CONCLUSIONS: The sequential TAAP flap has a consistent vascular supply and provides a reliable surgical approach to reconstruct the SCM flap donor site with good esthetic and functional outcomes.

Anatomical Basis of the Intermediate Dorsal Pedal Neurocutaneous Perforator Pedicled Propeller Flap: A Cadaveric Dissection.

Soft tissue defects of the forefoot represent a challenging surgical modality to reconstructive microsurgeons. This study describes the anatomical basis and design of the perforator-based intermediate dorsal pedal neurocutaneous vascular flap. Thirty fresh human lower limb specimens were injected with red latex and used for dissection of the dorsal vascular and neural anatomy of the foot. The direction and distribution of the intermediate dorsal cutaneous nerve and the vascular anatomy of the third dorsal artery of the plantar arch, along with the intermediate dorsal neurocutaneous nutrient vessels, were mapped. A simulated flap elevation procedure was performed on one fresh cadaver specimen. A clinical series of five cases is presented to demonstrate the feasibility of using the perforator-based intermediate dorsal pedal neurocutaneous vascular flap to reconstruct soft-tissue defects of the forefoot. The intermediate dorsal cutaneous nerve usually originates from the lateral branch of the superficial peroneal nerve. Crossing the surface of the cruciate ligament, it descends distally to the proximal part of the fourth intermetatarsal space and divides into the third and fourth dorsal metatarsal branches. The intermediate dorsal cutaneous neural nutrient vessels, which are multi-segmental and polyphyletic, offer innervation to the skin paddle of the flap elevated on the basis of the third dorsal perforator of the plantar arch. This perforator occupies a relatively constant position in the proximal part of the intermetatarsal space. It sends multiple tiny branches toward the intermediate dorsal cutaneous neural or paraneural nutrient vessel chain. In terms of clinical application, all flaps survived completely; one patient had partial loss of the skin graft. The design and anatomical basis of the intermediate dorsal pedal neurocutaneous vascular flap based on the third dorsal perforator of the plantar arch is a reliable reconstructive option for reconstructing small soft tissue defects in the forefoot. Clin. Anat. 31:1077-1084, 2018. © 2018 Wiley Periodicals, Inc.

Anatomical basis and design of the distally based lateral dorsal cutaneous neuro-lateral plantar venofasciocutaneous flap pedicled with the lateral plantar artery perforator of the fifth metatarsal bone: a cadaveric dissection.

BACKGROUND: Detailed investigation of the vasculature of the lateral aspect of the foot has rarely been presented. However, harvesting the flap in this area to cover defects of the foot and hand is highly important. Repair of soft-tissue defects at the forefoot remains a challenge in reconstructive surgery. This study explores the characteristics of the distal-based lateral dorsal cutaneous neuro-lateral plantar venofasciocutaneous flap pedicled with the lateral plantar artery perforator of the fifth metatarsal bone to establish a repair procedure for ulcers or defects in the forefoot region. METHODS: This study is divided into two parts: anatomical study and simulated operation. Thirty cadavers were utilized in the anatomical study after arterial injection. The tuberosity of the fifth metatarsal bone was used as the anatomical landmark. The lateral plantar artery perforator of the fifth metatarsal bone was identified through dissection. The perforators were dissected under a microscope. The details of the lateral plantar artery perforators, the distribution of the lateral dorsal cutaneous nerve and lateral plantar vein, the anastomosis in the lateral plantar artery perforator of the fifth metatarsal bone, the nutrient vessels of the lateral dorsal cutaneous nerve and lateral plantar vein, and other arteries of the lateral foot were recorded. The flap-raising procedure was performed on three fresh cadavers. RESULTS: The lateral dorsal cutaneous nerve originated from sural nerve, traveled obliquely downward along the anterior lateral margin of the foot, and accompanied by the lateral plantar vein after bifurcation, and was eventually distributed on the lateral aspect of the foot. The nutrifying arteries to the lateral dorsal cutaneous nerve and lateral plantar vein were present segmentally and mainly originated from the lateral plantar artery perforator of the fifth metatarsal bone. These nitrifying arteries constantly originated from the lateral plantar artery in the area of tuberosity of the fifth metatarsal, ran along the medial side of the fifth metatarsal, traveled between the fifth metatarsal bone and the lateral muscle group (the flexor digitorum brevis and the abductor digiti minimi muscles), pierced the aponeurosis, vascularized the skin of the anterior lateral plantar region, and resulted in many minute branches, which anastomosed with the lateral tarsal artery and fourth dorsal metatarsal artery. The anatomical study showed that (1) the vasculature pattern can roughly be classified into three types and (2) constant anastomoses occurred between the above-mentioned arteries in the lateral-dorsum region of the foot. CONCLUSION: A reliable large- or medium-sized neuro-venocutaneous flap with lateral dorsal cutaneous nerve, lateral plantar vein, and nutrient vessels can be raised using only the perforator of the lateral plantar artery of the fifth metatarsal bone, which is thin, is in the immediate vicinity of the forefoot, and has a reliable retrograde blood supply. This flap can be considered an alternative means to reconstruct soft-tissue defects of the forefoot.

Reconstruction of totally degloved fingers: a novel application of the bilobed spiraled innervated radial artery superficial palmar branch perforator flap design provides for primary donor-site closure.

INTRODUCTION: To investigate the results of resurfacing completely degloved digits using bilobed innervated radial artery superficial palmar branch (RASPB) perforator flap in a spiral fashion. METHODS: A detailed anatomic study on 30 adult fresh frozen cadavers preinjected with silicone rubber compound to demarcate arterial anatomy documented locations, numbers, and diameters of arteries and skin perforators with surrounding nerves. The flap-raising procedure was performed using four fresh cadaver specimen. We reviewed the reconstruction of 12 digits by using a bilobed spiraled innervated RASPB free perforator flap after non-replantable degloving injury. Two skin paddles were marked out using standard points of reference. At least two separate cutaneous perforator vessels were identified using a hand-held Doppler and were dissected back to the RASPB in retrograde fashion. The skin paddles were then divided between the two cutaneous perforators to provide two separate paddles with a common vascular supply. The skin paddles were stacked in a spiral fashion on the flap inset, effectively increasing the width of the flap to cover the totally degloved finger while still allowing closure of the primary donor-site. RESULTS: The RASPB was present within the flap in all cadavers. The direct perforator and the musculocutaneous perforator were available in 93.33 and 76.67 %, respectively, with neither of them in 6.67 % of the cases. The constantly present two perforators allowed the design of a new bilobed spiraled innervated radial artery superficial palmar branch perforator flap. We used the proposed flap to reconstruct completely degloved digits in 12 patients (mean age 28.6 years; range 17-35 years). With our proposed flap, no flap failure or re-exploration occurred and the donor site was closed primarily in all cases. All the flaps survived uneventfully. Total active motion ranged from 92° to 140° and 111° to 155° in the cases with and without metacarpophalangeal joint involvement, respectively. The static 2 point discrimination test varied from 6 to 11 mm. All the patients were satisfied with the overall results. CONCLUSION: The bilobed flap is large enough to cover totally degloved finger defects and contain direct skin perforators, provides a bespoke cover for complex soft tissue defects of completely degloved digits while also improving morbidity and cosmesis of the donor site. LEVEL OF EVIDENCE: Level IV, retrospective series.

Tripaddle Posterior Interosseous Artery Flap Design for 3-Finger Defects: An Evaluation of 3 Surgical Approaches.

INTRODUCTION: The tripaddle posterior interosseous artery (PIA) flap can be used for multifinger defect resurfacing, but interpatient variations in perforator distribution remain an ongoing challenge when using this approach. This study aims to evaluate the efficacy of 3 different tripaddle PIA perforator flap designs according to the PIA perforator distribution for the repair of 3-finger defects. METHODS: In accordance with the size of the 3-finger defects and the position of the perforators, a tripaddle flap was designed on the multiple perforators of the descending branch of the PIA in the distal two thirds of the forearm. Patients received 1 of 3 distinct tripaddle PIA perforator flap designs based on perforator distributions of the PIA. RESULTS: Three cases of 3-finger defects were repaired with type A trefoil-shaped tripaddle flaps, whereas 4 cases were repaired with type B modified trefoil-shaped tripaddle flaps, and the other 3 cases were repaired with type C chain-shaped tripaddle flaps. All flaps survived except 2 paddles with tip necrosis. After 9.1 months of mean follow-up, 9 of the 10 cases demonstrated satisfactory cosmetic appearance, whereas the last case required a debulking procedure in the second stage. CONCLUSIONS: The free tripaddle PIA perforator flap is an effective option for repairing 3-finger skin defects. Various flap designs based on the PIA perforator distribution allow for more individualized treatment approaches.

Anatomic basis and clinical application of the distally based medialis pedis flaps.

BACKGROUND: Soft-tissue defects of the forefoot are difficult to cover adequately, particularly, although multiple options for reconstruction are available. This study especially focused on the vascularization of the medial side of the foot and the determination of the contribution of the nutrient vessels to medialis pedis flap viability. METHODS: Thirty cadavers were available for this anatomical study. Microdissection was conducted under a microscope, and details of the course and distribution and the communication of the first plantar metatarsal artery with the fascial vascular network of the medial side of the foot were recorded. Clinically, six cases of soft-tissue defects at the forefoot region were reconstructed with distally based medialis pedis flap. RESULTS: The perforator of the first plantar metatarsal artery pierces in the superficial fascia of the medial aspect of the foot 2.2 ± 0.7 cm proximal to the first metatarsophalangeal joint, vascularize the skin of the medial plantar region. The anatomical study showed that the vasculature pattern could roughly be classified into two types. In terms of clinical application, all flaps completely survived, and one patient had partial loss of skin graft. CONCLUSION: The perforators of the medialis pedis flap are presented constant. The forefoot region can be repaired by the distally based medialis pedis flap on the perforator of the medial plantar artery of the hallux or the first plantar metatarsal artery perforator with medial plantar vein, medial plantar cutaneous nerve and nutrient vessels.

Thinned chimeric radial collateral artery perforator flap in complex distal thumb reconstruction.

INTRODUCTION: Tissue loss accompanied by bone defects in the thumb is a challenging reconstruction problem. Traditional repair methods are unsatisfactory. METHODS: Microsurgical thumb reconstruction was performed using 13 thinned chimeric radial collateral artery (RCA) perforator flaps. The flap was created with a thinned skin paddle and humeral bone segments using independent perforators. Primary defatting was completed when the thickness of the perforator entry was approximately similar to that in the periphery. The posterior cutaneous nerve of the arm was carried to make a sensory flap. Defects were 8.5 × 4.5 cm(2) on average (ranging in size from 4.5 × 1.5 to 15.0 × 6.0 cm(2)), and flap size was 9.0 × 5.5 cm(2) on average (ranging in size from 5.0 × 2.0 to 16.0 × 7.0 cm(2)), whereas the humeral fragments were 2.0 × 1.0 cm(2) on average (ranging in size from 1.5 × 0.5 to 4.0 × 1.5 cm(2)). All data were expressed as mean ± SD. The cosmetic appearance of the donor and recipient sites, Kapandji opposition score and static two-point discrimination of the operated thumb were evaluated during a follow-up visit. RESULTS: Follow-up time was 16.6 months (ranging from 14 to 28 months). Flap thickness before defatting, measured immediately after flap elevation was 14.5 mm (ranging from 10.0 to 25.0 mm). Average flap thickness after defatting was 3.5 mm (ranging from 3.0 to 6.0 mm). Venous congestion occurred in two cases. Successful microsurgical revision was achieved in both cases. All flaps survived. Bone components achieved union in all cases at an average period of 4.8 months (ranging from 3 to 6 months). Based on Kapandji opposition score, the mean thumb opposition score was 6. The mean sensation of flap was 7.5 mm (ranging from 6 to 11 mm). No further flap revision or defatting procedures were required in all cases. Cosmetically acceptable results were achieved for all patients. CONCLUSIONS: Findings proved that thinned chimeric RCA perforator flap is a beneficial microsurgical alternative for reconstructing complex bone and soft tissue defects in thumb.

Wraparound chimeric radial collateral artery perforator flap for reconstruction of thumb loss.

OBJECTIVE: We present our clinical experience and demonstrate surgical methods to reconstruct the thumb by using a wraparound chimeric radial collateral artery perforator flap. METHODS: Surgical procedures were performed in 12 patients. Flaps with a skin paddle and humeral bone segment were created on the basis of independent perforators. The sizes of the flaps and humeral fragments ranged from 5.5 cm × 2.0 cm to 7.5 cm × 4.5 cm and from 1.5 cm × 0.5 cm to 4.5 cm × 1.5 cm, respectively. The flap pedicle was divided and ligated above the level at which the radial collateral artery was divided into anterior and posterior branches. The following recipient vessels were used: (1) the proper radial digital artery of the thumb and the palmar subcutaneous vein (n = 8) and (2) the radial artery (n = 4) and the venae comitantes. Nerve suture was conducted between the posterior cutaneous nerve of the arm and the proper ulnar digital nerve of the thumb. The cosmetic appearance of the donor and recipient sites and the static two-point discrimination of the operated finger were evaluated in a follow-up visit. RESULTS: Postoperative venous congestion occurred in one case, but this complication was successfully treated after surgery. All of the flaps survived and all of the donor sites were closed directly, leaving a linear scar. Follow-up time ranged from 12 to 28 months. The union of bone components was observed in all of the cases at an average period of 4.5 months (range 3-6 months). Flap defatting was performed in two cases during the late postoperative period. Cosmetically acceptable results were achieved for the rest of the patients. The average of the static two-point discrimination scores was 9 mm (range 7-10 mm). CONCLUSIONS: The wraparound chimeric radial collateral artery perforator flap could be an effective option for thumb reconstruction because no major donor-site complications were found.

Modified chimeric radial collateral artery perforator flap for repairing hand composite defects.

BACKGROUND: The authors presented their clinical experience and demonstrated surgical methods for reconstructing complex bone and soft tissue defects of the hand by using modified chimeric radial collateral artery perforator flaps. METHODS: Surgical procedures that employed 16 modified chimeric radial collateral artery perforator flaps and 3 dual paddle flaps were performed in 16 patients. Among the patients, eight had defects in the metacarpal bones and eight had defects in the phalanx bones. The flaps were created with a skin paddle and humeral bone segments by using independent perforators. The flaps ranged in size from 5.5 × 2.0 to 7.5 × 4.5 cm, whereas the humeral fragments ranged in size from 1.5 × 0.5 to 4.0 × 1.5 cm. The pedicle of the flaps was divided and ligated below the level at which the radial collateral artery separates into anterior and posterior branches. The recipient vessels were the proper digital artery, the palmar subcutaneous vein (n = 12), the deep branch of the palmar ulnar artery (n = 4), and the venae comitantes. The cosmetic appearance of both donor and recipient sites was evaluated during a follow-up visit. RESULTS: Postoperative venous congestion occurred in two cases. The venous obstruction was reanastomosed after venous thrombectomy. The procedures were successful in both cases upon examination. All the flaps survived and all the donor sites were closed directly, leaving only a linear scar. Follow-up time ranged from 12 to 28 months. Bone components achieved union in all cases at an average of 5.4 months (ranging from 3 to 6 months). In two cases, the flap was defatted during the late postoperative period. Cosmetically acceptable results were achieved for the rest of the patients. CONCLUSION: The modified chimeric radial collateral artery perforator flap is a good alternative for reconstructing complex bone and soft tissue defects of the hands. LEVEL OF EVIDENCE: This is a level IV, retrospective series.

Anatomic basis of the distally based venocutaneous flap on the medial plantar artery of the hallux with medial plantar vein and nutrient vessels: a cadaveric dissection.

PURPOSE: This study aims to identify a repair procedure for ulcers or defect of the forefoot region. The general distribution and variation of the vascular anatomy of the distally based venocutaneous flap on the medial plantar artery of the hallux with medial plantar vein and nutrient vessels were investigated. This study especially focused on the vascularization of the medial side of the foot and the determination of the contribution of the nutrient vessels of medial plantar vein and medial dorsal cutaneous nerve to flap viability. Experiments were conducted to obtain information for operating procedures and to understand the vascular reliability of the flap. METHODS: Thirty cadavers were available for this anatomical study after arterial injection. The tuberosity of the fifth metatarsal bone was adopted as the anatomical landmark. Microdissection was conducted under a microscope, and details of the course and distribution of the medial plantar vein and the communication of the medial plantar artery of the hallux with the fascial vascular network surrounding the medial plantar vein were recorded. The flap-raising procedure was performed in a fresh cadaver specimen. RESULTS: The medial plantar vein was incorporated by the medial end of the dorsal pedal vein arch and medial dorsal vein of the hallux around the first metatarsal-medial cuneiform joint. It traveled along the medial margin of the foot and drained into the great saphenous vein at the level of the medial malleolar. The outer diameter of the nerve at the intermalleolar line was 3.2 ± 0.5 mm. These nutrifying arteries to the medial plantar vein were present segmentally and mainly came from the medial plantar artery of the hallux, which traveled forward in the fascia between the abductor hallucis tendon and the first metatarsal bone, emerged into the superficial layer 2.2 ± 0.7 cm proximal to the first metatarsophalangeal joint, and gave off many minute branches. These branches communicated with the fascial vascular network surrounding the medial plantar vein, supplying the fascia and integument of the medial foot. CONCLUSION: Reliable venocutaneous flap with medial plantar vein and nutrient vessel flaps can be raised based solely on the perforator of the medial plantar artery of the hallux. This flap should be considered as a preferential way to reconstruct soft-tissue defects of the forefoot.

Anatomical basis of the reverse lateral plantar artery perforator flap design.

BACKGROUND: This study aims to explore the characteristics of the formation and topography of lateral plantar artery perforators to identify a repair procedure for defects in the forefoot region. METHODS: Thirty-three cadavers were available for this anatomical study. The tuberosity of the fifth metatarsal bone was adopted as the anatomical landmark. The details of the lateral plantar artery perforators and the anastomosis between the lateral plantar artery perforators and other arteries of lateral foot were recorded. RESULTS: The perforators from the base and head of the fifth metatarsal bone constantly originate from the lateral plantar artery in the area of tuberosity of the fifth metatarsal, run along the medial side of the fifth metatarsal, then travel between the fifth metatarsal bone and lateral muscle group, pierce the aponeurosis, vascularize the skin of the anterior lateral plantar region, and finally anastomose with the lateral tarsal artery and the fourth dorsal metatarsal artery. At the point of origin, the mean sizes of the perforator of the fifth metatarsal base and head were 1.3 ± 0.2 and 0.9 ± 0.3 mm (mean ± SEM), respectively. The pedicle lengths were 2.6 ± 0.3 and 3.8 ± 0.5 cm, indicating the possibility of a free perforator flap. CONCLUSION: The lateral plantar artery perforators are presented constant. The forefoot region can be repaired by the reverse perforator flap harvested pedicled with either the lateral plantar artery perforator from the base or head of the fifth metatarsal bone.

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

The deep inferior epigastric artery perforator (DIEP) flap has been a valuable tool in breast reconstruction, but seldom in extremity reconstruction. The aim of this report is to present our experience on the use of the DIEP flap for reconstruction of soft-tissue defects in the extremities of pediatric patients. From January 2007 to February 2011, 22 consecutive free DIEP flap transfers were performed for reconstruction of complex soft-tissue defects in the extremities of children with a mean age of 5.7 years old (ranging 2-10 years old). The flap design included transverse, oblique, and irregular DIEP flaps, containing one to three perforators in the flap. The flap size ranged from 7 × 4 cm to 18 × 17 cm. Primary donor-site closure was accomplished in all of patients. The postoperative course was uneventfully in most of cases. The venous congestion was observed in two cases. One case of venous congestion was caused by flap inset with tension. The other case with venous thrombosis ended with partial loss of the flap after salvage procedure. There was one total flap loss due to the arterial thrombosis. The flap survival rate was 95.5%. The mean follow-up was 12 months (ranging 6-36 months). All reconstructed extremities had satisfactory aesthetic and functional outcomes except two cases undergoing the secondary debulking procedures. The donor sites healed well in all cases without complications. Our experience showed that the free DIEP flap could be an alternative for reconstruction of soft-tissue defects in the extremities of children.