Blood supply patterns and clinical application of the bilobate anterolateral thigh perforator flap / 中华骨科杂志

Objective:To investigate the blood supply pattern and characteristics of bilobate anterolateral thigh flaps, and to summarize the clinical experience.Methods:Date of 102 cases of limb wounds repaired by bilateral anterolateral thigh perforator flaps from March 2014 to July 2019 were retrospectively analyzed. There were 80 males and 22 females with an average age of 40.7 years (range, 9-66 years). All of the patients suffered from limb trauma with complex tissue defects, among which 29 cases had two adjacent and discontinuous wound surfaces on the same limb, and the area ranged from 5 cm×5 cm to 30 cm×18 cm, while the other 73 cases remained a single wound with the area ranged from 12 cm×11 cm to 27 cm×15 cm. Ultrasonic Doppler was used to locate the perforating branches. According to different patterns of blood supply, flaps of different types were designed and applied respectively. For those who with perforating branches of common trunk type or fascial type, the wound surface can be covered by the flap directly; for those who with perforating branches of double trunks type or mixed type, the turbocharging technique was performed after dissection of the pedicles of the flap, while the wound was repaired by reconnection. All the donor sites were sutured directly.Results:Total of 105 bilobed flaps were designed in 102 patients, including 43 flaps of common trunk type, 30 flaps of double trunks type, 24 flaps of fascial type and 8 flaps of mixed type. The single harvested flap area ranged from 6 cm×5 cm to 20 cm×9 cm. One patient's one piece of the bilobed flap repairing two wounds suffered an arterial crisis at 17 h after surgery. The surgery confirmed there was an intractable arterial spasm and the crisis was relieved after a vein trans-plantation. Then about 4 cm×3 cm superficial necrosis appeared in the most distal part of the flap and healed in secondary after dressing changes. Two cases with single wounds suffered from a vein crisis at 48 h after operation. After removing the suture and blood letting, the flaps survived a week later. The average healing time was 19 days (range, 8-83 days). All the thigh donor sites healed by first stage. All the cases were followed-up for an average period of 16 month (range, 6-70 months). The latest follow-up showed that the flaps were of good color and texture, and the sensation of the flaps recovered partially. According to the British Medical Research Council sensory rating scale: 21 cases were grade S2 and 81 cases were grade S3. According to the revascularization assessments of digital replantation standard by Hand Surgery Branch of Chinese Medical Association, the results were excellent in 91 cases, good in 11 cases, with excellent and good rate of 100%. Linear scars were left in most donor sites and the VAS scores were all zero. 5 cases had a large scar area which the width was more than 3 cm, but there was no scar contracture or pain. 9 cases had an abnormal sensation in the donor area in the early stage and recovered gradually 3 months later without any movement disorder.Conclusion:The use of the bilobed anterolateral femoral perforator flap with different blood supply patterns to repair the wounds of extremities could overcome the lack or deficiency of blood supply caused by perforators with different sources. To clarify the blood supply types is conducive to the flap cutting and leaf splitting during the operation, which greatly improves the survival rate of the flap.

First dorsal metatarsal-dorsal phalangeal artery flap in repairing large area of soft tissue defect on the palmar side of finger / 中华显微外科杂志

Objective:To investigate the clinical effect of the first dorsal metatarsal-dorsal phalangeal artery flap in repairing large area of soft tissue defect on the palmar side of finger.Methods:From February, 2016 to June, 2018, 11 fingers of 11 patients (7 males and 4 females, aged 19-46 years old with an average of 32.5 years old) with large area of soft tissue defect on the palmar side of the finger were repaired with the first dorsal metatarsal-dorsal phalangeal artery flap. These included 3 with the first dorsal metatarsal-first dorsal phalangeal artery blood supply, and 8 with the first dorsal metatarsal-second dorsal phalangeal artery blood supply. In which 3 with retained finger pulp was for repairing the defects and bridging arteries, including 1 flexor tendon defect repaired by the extensor digitorum brevis tendon of the second toe with the flap. The type of blood vessel was Gilbert I detected by CDU before surgery. The area of the flaps was from 1.5 cm×5.0 cm to 3.0 cm×8.0 cm. The donor area of the flaps was compressed with full thickness skin grafts of the shank. The follow-up data was collected by outpatient clinic visits and telephone interviews.Results:All the 11 flaps survived and were followed-up for an average of 14 months, ranged from 6 months to 24 months. The colour and texture of the flaps were good. Sensing of temperature, pain and touch restored, without swelling. Function of the fingers was well restored. The range of motion of distal and proximal interphalangeal joints was closed to normal. The TPD of the flaps was 5-11 mm, with an average of 8 mm. Ten had primary wound healing in the donor sites of foot. One case had necrosis of the proximal toe of the skin graft and healed after dressing change. Long-term follow-up of the skin grafting area was wear-resistant, and does not hinder walking without rupture.Conclusion:Application of the first dorsal metatarsal-dorsal toe artery flap to repair large area of soft tissue defect on the palmar side of finger has number of advantages such as it, covers the wound and carry the tendons, bridges the arteries at the same time, plus delivers satisfactory outcome.

Clinical application of bilobed anterolateral thigh flaps with turbocharging technique in repairing limb wounds / 中华创伤杂志

Objective:To explore the clinical effect of bilobate anterolateral thigh flaps with turbocharging technique in repairing limb wounds.Methods:A retrospective case series study was conducted to analyze the clinical data of 29 patients with complex wounds of limbs admitted to Ruihua Hospital Affiliated to Soochow University from March 2014 to July 2019. There were 26 males and 3 females, aged 22-60 years [(41.9±11.1)years]. A total of 24 patients had single-wounds with the dimension of 12 cm×10 cm to 38 cm×27 cm, and 5 patients had two adjacent and discontinuous wounds with the area from 7 cm×4 cm to 13 cm×9 cm. The bilobate anterolateral thigh flaps with turbocharging technique were used. All the donor sites were directly sutured by primary closure. Routine treatment was given after operation. The origin artery of perforators, time of flap harvesting and operation time were recorded. The survival of the flap, healing of the donor area, long-term shape of the flap and donor area, sensory recovery and complications were observed.Results:All patients were followed up for 6-64 months [(19.0±12.7)months]. A total of 30 bilobed flaps were designed for the 29 patients. The time of flap harvesting ranged from 25 to 60 minutes [(46.6±20.2)minutes]. The operation time was 4-11 hours [(6.4±1.8)hours]. All flaps survived except one piece of a bilobed flap suffered from a vein crisis, which healed well after conservative treatment. These wounds' healing time ranged from 11 to 53 days [(18.5±9.9)days], and all the donor sites healed by first intention. Four patients underwent skin flap thinning operation 4 to 8 months later due to the bloated appearance of flaps. Acceptable cosmetic outcomes, soft and elastic skin, and sensation recovery were achieved at the final follow-up. All patients 'donor area left linear scars. One patient had large scar area, but there was no scar contracture and pain. Two patients had an abnormal sensation in the incision area in the early stage and recovered gradually 3 months later without any other serious complications.Conclusions:Repair of limb wounds with bilobed anterolateral thigh flaps with turbocharged technique can overcome the limitation that the bilobed flap can not be designed if the perforators do not share the same trunk and expand the application scope of the bilobed flaps. The design of bilobate flaps reduces the width of the donor site, which can effectively avoid the complications of the donor site.

Repairing dorsal complex tissue defect of finger with flaps based on superficial palmar branch of radial artery with palmaris longus tendon / 中华显微外科杂志

Objective:To explore the clinical effects in repairing dorsal complex tissue defect of finger with the flap based on superficial palmar branch of radial artery (SPBRA) with palmaris longus tendon.Methods:From May, 2011 to October, 2017, dorsal complex tissue defects of 15 fingers and thumbs in 15 patients were treated by the flaps which were based on SPBRA with palmaris longus tendon. There were 10 males and 5 females, in an average of 35.8 (19-51) years. All the defects (3 thumbs, 5 index, 2 middle and 5 ring fingers) were dorsal complex tissue defects and all had extensor tendon defects. The areas of soft tissue defect measured 2.0 cm×1.5 cm to 4.0 cm×2.0 cm. The lengths of tendon defect measured 2.0-4.0 cm. All patients received emergency surgery. The time before the surgery was 1.5-3.0 hours. The surgery time was 3.0-4.5 hours, 3.6 hours in an average. Postoperative regular follow-up.Results:All of the wounds healed in stage I and all flaps survived. Texture of the flaps was soft with rosy color. No obvious swelling occurred. All the donor sites healed in stage I. The patients were followed-up for 4-18 months, 8 months in an average. The appearance and function of the repaired fingers and thumbs were satisfactory. The pain, temperature and touch sensations were good. The color of flaps was similar to the normal finger without swelling. The wear resistance of the flaps was good. Thin-line scars were in the wrist donor sites without contracture. The range of motion of active palmar flexion of the wrist was from 0° to 80° and active hyperextension was from 0° to 70°. No obvious limitation was found.Conclusion:It is able to achieve a satisfactory clinical effects by using the flap that is based on SPBRA with palmaris longus tendon in repairing the dorsal complex tissue defect of hand. The advantages of the technique are that the donor site is concealed. The wound is small, and the flap is easy to be harvested and anastomosed.

Using the lateral second toe flap for reconstruction of great toe defect / 中华整形外科杂志

Objective@#To explore the application and effect of using the lateral second toe flap transfer for reconstruction of great toe defect.@*Methods@#The flap on tibial of second toe was designed according to the size of defect. The pedicle of the flap is the tibial proper plantar digital artery of the toe, and the rotation point is located between the toe web.13 cases of the great toe′s defects were repaired by this method, with the donor sites covered by full thickness skin from the leg.@*Results@#13 flaps survived postoperatively. All cases were subject to postoperative follow-up, follow-up time was 6-48 months, an average of 18 months. Skin color and texture was close to that of the surrounding tissues, appearance is not bloated.@*Conclusions@#The second toe lateral skin flap is easy to operate, is flexible for rotating. As local material, it is an ideal skin flap to repair the great toe defect.

Repair of large area skin defect of forearm with overlength thoracic umbilical conjoined perforator flap with double blood supply / 中华显微外科杂志

Objective To explore the surgical method and clinical effect of repairing the large area skin defect of forearm with the perforator flap pedicle with the inferior epigastric artery perforator and the lateral cutaneous branch of the posterior intercostal artery.Methods From January,2006 to January,2016,14 cases of forearm large area of skin defects were treated with the ovedength flap at one stage.The proximal flap to the inferior epigastric artery umbilical perforation and the flap distal to the posterior interphalangeal artery perforation were used for the blood supply of superficial flap.The length of the flap was 25-43 cm (average,36 cm).The width of the flap was 5-14 cm (average,9 cm).All patients were followed-up regularly.The content of the follow-up included three aspects:appearance,hand function and the recovery of the donor site.Results Twelve cases of postoperative flaps successfully survived.Arterial crisis was seen in 1 flap 28 hours after surgery.The re-surgical exploration was adopted after conservation treatment for 1 h without remission and the proximal anastomotic flap embolization was confirmed.The flap survived.Venous crisis was seen in 1 case.The flap survived with the help of removing the suture,smoothing drainage and bleeding for 5 d.The wounds and the donor site of the thoracic and abdominal region healed at the first stage.The follow-up time was 8-72 months,with an average of 31 months.The flaps had no obvious bloated,the skin texture was close to forearm skin and the flaps were restored protected sensation.There was no ulceration,infection and other complications.The healing of skin graft was satisfactory in 2 cases in abdominal donor site.No skin graft contracture occurred.The remaining 12 cases had linear scar in the abdomen of the donor site.The edge of the scar was soft and no obvious contracture occurred.Conclusion Super long thoracic umbilical conjoined perforator flap can repair the lager area skin defect of forearm with double blood supply.The length of flap is significantly longer with enoughblood-supply of distal part of the flap.The clinical efffect is satisfactory.

Repair complex tissue defect of the palm of fingers by the super large vein flap with palmaris longus tendon / 中华显微外科杂志

Objective To investigate the clinical effect of super large venous flap with palmaris longus tendon for repairing the complex tissue defect of the palm of finger.Methods From May,2011 to October,2017,complex tissue defect of the palm of 15 fingers in 15 cases was treated by a super large vein flap with palmaris longus tendon.There were 10 males with 10 fingers and 5 females with 5 fingers.The age was from 19 years to 51 years (average,35.8years).Among these cases,machine injury was in 12 cases and crush injury was in 3 cases.Complex tissue defect of the palm of the finger with tendon defect occurred in all the cases.There were 3 thumbs,5 index fingers,3 middle fingers and 5 ring fingers.The area of skin defect was from 3.5 cm×2.0 cm to 7.5 cm×3.5 cm.The length of tendon defect was 2.0-4.0 cm.Phalangeal fractures occurred in 4 cases (2 cases of proximal phalanx,1 of middle phalanx,and 1 of distal phalanx).All the patients received the operation in one stage.The time between the injury and the operation was 1.5-3.0h(average,2.0 h).The time of the operation was 3.0-4.5 h(average,3.6 h).Regular followed-up was performed after operation.Results All flaps survived.Fourteen cases were followed-up for 6 to 12 months(average,7 months),and 1 case lost.The skin flap has soft texture,good elasticity,and no bloat.The color of skin flap was close to the normal skin.Sensory recovery reached S2 to S3,and the function and appearance of the finger were well restored.Conclusion The super large vein flap with palmaris longus tendon can be used to repair the complex tissue defect of the palm of fingers.The flap can get a satisfactory effect after surviving.It is an ideal method of repairing this kind of damage.

Clinical application of complete transposition of arteriovenous in free flap artery crisis / 中华显微外科杂志

Objective To explore the clinical effect of complete transposition of arteriovenous in free flap artery crisis. Methods From October, 2009 to April, 2017, 13 cases of extremities tissue defect were repaired with free flaps.The intractable arterial crisis appeared after transplantation.Repeated anastomosis vessels were adapted but it was not relieved. Then the complete transposition of arteriovenous was adapted in the flaps. Namely the vein of the flap was anastomosed with the arterial in the recipient site to reconstruct the blood supply, and the arterial of the flap was anastomosed with the vein in the recipient site to reconstruct recirculation.Ten cases of hand defect and 3 cases of crus defect were repaired by 5 low abdominal flaps and 8 anterolateral thigh flaps. The tissue defect area was 16 cm× 7 cm-6 cm×4 cm and the flap area was 18 cm×8 cm-7 cm×4 cm. Results Ten flaps survived completely, the other 3 flaps almost survived that scab healed in 1 case and skin grafted in 2 cases. The flap for skin color was from purple red to dark red, and finally close to normal, and skin flap edge would have different degrees of ecchymosis; the bleed-ing from the incision of the skin flap was from dark red to bright red; the swelling of the flap was obvious in the early stage and the later swelling subsided. All cases were followed-up from 6 months to 32 months with an average of 16 months.The wounds healed well.The flaps had a clear boundary and soft texture. Conclusion Complete transposi-tion of the arteriovenous system can be used as an alternative in the presence of intractable arterial crisis after free flap transplantation, to save the flap and to reduce the trauma to the patient.

Blood bridge venous flap to repair finger wound with proper palmar digital artery defect / 中华显微外科杂志

Objective To explore the application and clinical effect of blood bridge venous flap in finger wound with proper palmar digital artery defect. Methods From February,2007 to September,2016,11 cases of fin-ger wound with artery defect were repaired with forearm vein free flap by the way of bridging blood vessels. The time from injury to surgery was 1.5 to 6 hours(average 2.5 hours).Vascular defect length was 1.4 to 3.4 cm(average 2.3 cm). 8 cases were bridged the unilateral digital artery and 3 cases were bridged the both side. The area of skin flap was 1.5 cm × 2.0 cm to 2.2 cm × 3.5 cm and the donor site was sutured directly. Results One case appeared necrosis in marginal part and healed after dressing change. The other flaps and finger survived and the incisions healed well.All the 11 cases were followed up after operation. The follow-up time ranged from 6 to 20 months, aver-aged 10 months. The color and texture were well,the sensation of temperature, pain and tactile were recovered, and the flap had good contour. According to TAM system evaluation method: 6 cases got excellent results,4 cases were good,1 case was poor. The donor site only had a linear scar and the flexion and extension of wrist were not limited. Conclusion Flow bridging venous flap can reconstruct the finger blood and repair the wound simultaneously. To the finger with nerve or tendon defect,bridged with the cutaneous nerve or palmaris longus tendon can also get satisfactory result.

Repair of fingertip defect with free second toe tibial flap anastomosed by the dorsal nerve of the toe / 中华整形外科杂志

Objective@#To report the operation methods and clinical effects of repairing finger tip defect with the free tibial dorsal nerve flap of the second toe.@*Methods@#13 patients with finger tip defects were repaired by the tibial dorsal nerve flap of the second toe. The area of finger tip defect was 2.5 cm×1.5 cm-1.3 cm×1.0 cm, and the area of cutting flap was 2.7 cm×1.7 cm-1.5 cm×1.1 cm. All donor site defects on the second toe were covered with full-thickness skin graft.@*Results@#There were 13 cases in this group, and all the flaps and skin grafts were survived. Postoperative follow-up ranged from 6 to 18 months, with an average of 13 months. The appearance of the fingers was satisfied and the sensory recovery was good. Two-point discrimination of the flaps returned to 7-13 mm, with an average of 9 mm. According to the total active move(TAM)scale, results were excellent in 11 fingers, good in 1 finger, and fair in 1 finger. The donor site skin graft was well healed, the second toe pulp was full, and the two-point discrimination of the toe pulps were 6-10 mm, with an average of 8 mm.@*Conclusions@#Compared to the traditional method of repairing finger tip defect with the tibial inherent nerve flap of the second toe, our new method can reduce the damage to the donor site, and we can repair finger tip defect as well as the traditional one at the same time. So it was a better operative method to repair finger tip defect with the tibial dorsal nerve flap of the second toe.

Repair of two skin and soft tissue defect in hand by three types of multiple flaps from the foot / 中华显微外科杂志

Objective To explore the clinical outcomes of three types of multiple flaps from the foot for re-construction of two skin and soft tissue defects in hands. Methods From February, 2003 to September, 2015, 23 cases of hands with two skin and soft tissue defects were treated with 3 types of multiple flaps from the foot. Among of them, 10 cases of adjacent fingers were treated with double foliated pulp flaps from the big toe and the second toe based on a single vascular pedicle of the first dorsal metatarsal vessels; 2 cases of composite tissue defect including finger and hand were treated with double foliated pulp flaps from dorsalis pedis flap and the big toe based on a single vascular pedicle of the dorsalis pedis artery;11 cases of two composite tissue defect in hand were treated with dorsalis pedis flaps based on a single vascular pedicle of the dorsalis pedis artery. The donor site was covered with full-thick-ness skin. All patients were followed-up regularly which included three aspects:appearance, hand function and senso-ry recovery. Results Twenty-three cases of double foliated pulp flaps were survived. Postoperative follow-up time ranged from 3 to 36 months, with an average of 15 months. The postoperative follow-up revealed satisfactory shapes of the multiple flaps and recovery of functions. The sensation was recovered to S 2-S4. The grafting skin in donor site sur-vived completely excluding partial necrosis in 3 cases. The wound were treated by wound dressing, local scar hyper-plasia in donor sites. There was no apparent impairment on the foot function. Conclusion Three types of multiple flaps from the foot based on a single vascular pedicle for reconstruction of two skin and soft tissue defects in hand could achieve good clinical outcomes. The type of flaps can be adapted according to the injury.

Study on HPLC Fingerprint of Zhenqi Fuzheng Granules / 中国药房

OBJECTIVE:To establish HPLC fingerprint of Zhenqi fuzheng granules. METHODS:HPLC-ELSD method was ad-opted. The determination was performed on Agilent Zorbax Eclipse XDB-C18 column with mobile phase consisted of acetonitrile-wa-ter(gradient elution)at the flow rate of 1.0 mL/min with column temperature of 40 ℃. The detector evaporation temperature was 50℃,and sample size was 10μL. Using specnuezhenide as reference,HPLC chromatograms of 7 batches of Zhenqi fuzheng gran-ules were determined. The identification and similarity evaluation of common peaks were conducted by using the TCM Chromato-graphic Fingerprint Similarity Evaluation System(2004 A edition). RESULTS:There were 13 common peaks in HPLC chromato-grams of 7 batches of samples. After validated,the similarity of 3 batches of samples in HPLC chromatograms of 7 batches of sam-ples were higher than 0.9,which were in good agreement with control fingerprints. The similarity of 4 batches of samples were <0.9,which were poorly same to control fingerprint. CONCLUSIONS:Established fingerprint can provide reference for quality evalu-ation of Zhenqi fuzheng granules.

Combined tiled flaps from foot with bone graft for reconstruction of thumb defects / 中华显微外科杂志

Objective To explore the operative technique and clinical outcomes of tiled flaps from foot with bone graft for reconstruction of thumb defects.Methods From January, 2008 to December, 2013, 8 cases of thumb defects with varying degrees were treated with tiled flaps from foot and iliac bone graft.Among them, 4 cases caused by emergency trauma, the other 4 cases was old defect after trauma, including 1 case of double thumb defect that caused by electrical burn.The thumb defects was caterorized as type Ⅰ A in 1 case, type Ⅰ B in 2 cases, type Ⅱ A in 1 case, type ⅡB in 2 cases and type ⅢA in 2 cases.Five cases in which were treated with free wrap-around flap from the ipsilateral big toe and tibial lateral-flap from the opposite second toe, 3 cases using free wrap-around flap with series connection of dorsal artery.Results All 8 reconstructed thumbs were survived.The wound healed primarily.In 1 case, the unhealed wound was healing after dressing where skin grafts in the donor sites of the foot were partial necrosis.Postoperative follow-up ranged from 6 to 72 months, the appearance of the thumb was satisfying when was compared with normal thumb.Thumb nail grew well, the blood supply was good, and sensory recovery from S2 to S4.According to the criteria issued by the Hand Surgery Society of Chinese Medical Association for functional assessment of reconstucted thumb and fingers, 5 were excellent and 3 were good.The donor site skin graft had no scar contracture and no ulceration.There was no apparent impairment on the foot function.Conclusion Combined tiled flaps from foot and iliac bone graft for reconstruction of thumb is a good method, which can recover the appearance of thumb without sacrificing toes of the donor foot.

Study of attentional bias in social anxious individuals / 中国行为医学科学

Objective To study the attentional bias to threatening faces images of high and low social anxiety subjects in the threatening and non- threatening conditions.Methods 23 high social anxious subjects (HSAs) and 24 low social anxious subjects (LSAs) were chosen from 500 volunteers according to the score and divided randomly into two groups,one group was under the threatening condition (expecting to give a short speech) and the other under the non- threatening condition,and then a dot-probe task was performed and the attentional bias score (ABS) was recorded.Results Under the threatening condition,the ABS of HSAs and LSAs were (-2.63±1.83)ms and (0.42±1.36)ms,the different was significant (t=-4.641,P=0.000);under the non- threatening condition,the ABS of HSAs and LSAs were (-0.41±1.56)ms and (0.47±0.67)ms,the different was not significant (t=-1.732,P=0.106).The ABS of HSAs under the threatening and non- threatening condition were (-2.63±1.83)ms and (-0.41±1.56)ms,the different was significant (t=-3.122,P=0.005);the ABS of LSAs under the threatening and non- threatening condition were (0.42±1.36)ms and (0.47±0.67)ms,the different was not significant(t=-0.124,P=0.903).The effect of the interaction between social anxiety and the experiment condition on ABS was significant (F=6.881,P=0.012).The separately main effect of social anxiety and the experiment condition on ABS was significant (F=20.429,P=0.000) and (F=6.413,P=0.015) too.Conclusion Social anxious individuals attend to avoid the threatening faces images,especially under the threatening condition.