OBJECTIVETo explore the feasibility and the effect of free chimeric perforator flap with deep inferior epigastric artery for the soft tissue defect on the lower extremity with deep dead space.

METHODSFrom Mar. 2010 to Aug. 2011, 8 patients with soft tissue defects on the lower extremities combined with dead space, bone or joint exposure were reconstructed with free hinged perforator flaps with deep inferior epigastric artery. The muscle flap was inserted into the deep dead space, with perforator flap for superficial defect. The defects on the donor sites were closed directly.

RESULTSAll the flaps survived with primary healing. Good color and texture was achieved. The patients were followed up for 12-24 months, with an average of 16 months. 2 over-thick flaps were treated by flap-thinning surgery. Only linear scar was left on the donor site on abdomen with no malfunction.

CONCLUSIONSThe free chimeric perforator flap with deep inferior epigastric artery can simultaneously construct the dead space and superficial defect with only anastomosis of one set of vascular pedicle. It is an ideal method with good results on recipientsites and less morbidity on donor sites.

Cicatrix ; Epigastric Arteries ; transplantation ; Feasibility Studies ; Follow-Up Studies ; Humans ; Leg Injuries ; surgery ; Lower Extremity ; Perforator Flap ; transplantation ; Soft Tissue Injuries ; surgery ; Time Factors ; Wound Healing

Objective To explore the safety and clinical effect of the human acellular nerve allograft (hANG) for repairing peripheral nerve defects.Methods During November,2009 to October,2010,6 patients with 3 digital nerve defects and 3 radial nerve defects were repaired with hANG.During postoperation period,safety was evaluated by local wound response and laboratory testing,while the efficacy was evaluated by British Medical Research Council sensory function assessment standards,static 2-point discrimination (2PD) and Semmes-Weinstein monofilament testing.Results Three patients with 6 digital nerve defects received hANG transplant.The length of nerve graft was 20-50 mm(mean 30.8 mm).After followed up for 31-40 months,the excellent rate of 2PD was 66.7％.Two of 3 patients rahabilited as well as the normal.Three patients with radial nerve defects,whose length of nerve graft was 35-60 mm(mean 48.3 mm).The strength of extensor carpiradialis longus muscle had restored Ⅲ in 1 case,and other 2 cases had no restoration.Conclusion hANG is safe and effective for repairing peripheral nerve defects,especially for digital nerve defects.

Objective To explore the clinical effect and experience of separating deep circumflex iliac artery osteocutaneous perforator flap (DCIAP) from the bone flap.Methods According to local applied anatomy of groin,vascularized chimerical flaps of deep iliac circumflex artery was designed and applied.From May,2008 to June,2012,12 patients who combined bone and composite skin and soft-tissue defects were positioned by color dopplar ultrasound before operation and treated with vascularized chimerical flaps of deep iliac circumflex artery.The deep circumflex iliac perforator flaps was 8 to 19 cm in length and 2 to 6 cm in width,and the iliac bone grafts ranged from 5 to 8 cm in length.Results All flaps were fully survival.After 8-10 months postoperative followed-up,all the bone defect gained healing.The function and appearance of cutaneous flaps were satisfactory.There was no serious complication in donor sites of groin.The average time of healing was 9 (8-10) months.Conclusion Vascularized iliac bone graft and a perforator flap are nourished by the same deep circumflex iliac artery.There is more mobile scope and only 1 blood vessel between the bone graft and skin flap,which should be called chimeric perforator flap based on the deep iliac circumflex artery,and is a kind of good method to repair bone and soft-tissue defects of limbs.

Objective To investigate the clinical results,indications and precautions of a variety of special forms of the perforator flap for reconstructing limb soft-tissue defect.Methods From January 2008 to December 2013,480 cases suffering from limb soft-tissue defect were treated with special forms of the perforator flap.Types of special forms of the perforator flap included flow-through perforator flaps,micro-dissected perforator flaps,conjointed perforator flaps,polyfoliate perforator flaps and chimeric perforator flaps.Derivative types combined two or three technologies used in basic types.Results Venous crisis of the flap was shown in 10 cases.Through a second surgical exploration,5 cases were diagnosed with anastomotic thrombosis,2 with vascular torsion and 3 with hematoma.After appropriate treatments,flaps survived in 4 cases,but partial necrosis occurred in 6 cases.Twelve cases were found to have infection,which led to arterial crisis followed by total flap necrosis in one of them at postoperative day 5.Other flaps survived and wounds healed by first intention.Donor sites were repaired by skin flap transfer in 8 cases,skin grafting in 3 cases and direct suture in the rest cases.Conclusion Special forms of the perforator flap are optimal for repair of soft-tissue defect of extremities.

Objective To explore the treatment of multifocal lower extremity arteriosclerosis oblitera-tions. Methods From March 2014 to September 2014, combined procedures were performed on 30 lower limbs in 30 patients with multifocal lower extremity arteriosclerosis obliterations for revascularization. All the patients underwent endovascular , 20 of whom received endarterectomy , 10 received artery emboloctomy , and 8 received profundaplasty. The rates of technical success and clinical success were observed. The patients were followed up for 6-12 months to observe the total patency rate and rate of limb reservation. Results The technical success rate was 100%. The perioperative complication rate was 30% (9/30). 29 limbs gained improvement with differ-ent degree and the clinical success rate was 96.67% (29/30). The ankle-brachial index elevated 0.37 ± 0.19 on average (P < 0.001). Primary patency rate was 90% and 73% at 6 and 12 months, and 12-month limb reserva-tion rate was 97.67%. Conclusions The combined procedures for complex lower extremity arteriosclerosis oblit-erations have a higher short- to mid-term patency rate and limb reservation rate.

Objective To describe a technique to achieve primary donor-site closure, extend applications and minimize donor-site morbidity by applying the double skin paddle principle.Methods All 16 cases of the double skin paddle anterolateral thigh perforator flap reconstruction from May, 2008 to June, 2014 were reviewed.Defects locations included calf, dorsum pedis or planta pedis.A long anterolateral thigh perforator flap was marked out using standard points of reference.At least two separate cutaneous perforator vessles were identified on hand-held Doppler.Separating and dissecting flap at superficial layer of fascia lata was adopted in all cases.Then skin paddle was then divided between the two cutaneous perforators to give two separate paddles with a common vascular supply which was the descending branch of the lateral circumflex femoral artery.The skin paddles could be used to cover complex skin defects, whilst still allowing for primary donor-site closure.Results Fifteen patients were successfully treated with the double skin paddle anterolateral thigh perforator flap with no major complications.One case was suffered with partial skin flap necrosis.The type A dumbbell-like flaps was used to cover defects involving two different units of the foot.The type B pattern were stacked side by side on a flap inset, effectively doubling the width of the flap, to resurface a large defect of a single unit of the calf.The type C pattern was used to repair adjacent skin defects.In all cases, the donor site was closed directly.All patients were satisfied with their outcomes.Conclusion The double skin paddle anterolateral thigh perforator flap is an excellent method of resurfacing large defects of the extremity involving multiple subunits with improved morbidity and cosmesis of the donor site.

Objective To explore the feasibility and clinical effect of modified peroneal artery perforatorbased propeller flap which excludes small saphenous vein and sural nerve for coverage of the soft tissue defects of the ankle and foot.Methods From January,2009 to August,2013,20 patients with soft tissue defects of the foot or ankle underwent the procedures of reconstruction.After the proper perforators being identified with doppler sonography,the propeller flap was designed,which selected the location where terminal perforator vessels perforate deep fascia as the pivot point,the line from this point to the point where the second perforator near the wound around the line from the midpopliteal point to the midpoint of the achilles tendon and lateral malleolus perforated the deep facia as the axis.The flap was raised above the level of the deep fascia.The small extrinsic vessels around the sural nerve and small saphenous vein were contained in the flap,while the small saphenous vein and sural nerve were kept in the original position.The donor site was closed directly.The skin flaps measured from 7 cm × 4 cm to 21 cm × 7 cm.Results All 20 flaps survived completely without complications.During 10-28 months' followed-up (average 13 months),all flaps showed good texture matches and contour.All patients recovered walking and shoe wearing function.No one showed sensory disturbances at the lateral foot.Conclusion The modified peroneal artery perforator-based propeller flap excluding small saphenous vein and sural nerve still has stable blood supply,which is an idea way for covering skin and soft tissue defects in foot and ankle.

Objective To investigate the change of dynamic expression of t-PA and PAI-1 during early venous crisis after free perforator flap transplantation.Methods Thirty healthy New Zealand white rabbits weighed 2.5-3.0 kg were chosen and randomly divided into experimental group (n =15) and control group (n =15).Free transplantation of superficial epigastric artery perforator flap (SEAPF) was implemented in all rabbits firstly.Then the model of venous crisis was established by ligating the anastomosis vein in order to interrupt venous blood outflow in experimental group.The blood supply of all flaps was monitored by observing their color,swelling degree and the filling reaction of the capillaries after operation.Peripheral blood was drawn from femoral artery at different time point for measuring the concentration of t-PA and PAI-1 by Elisa.Partial flap tissue was harvested for pathological examination at corresponding time point.Data analysis was performed by using SPSS 17.0 statistical software.P ＜ 0.05 was considered statistically significant.Results One rabbit died of anesthesia,and the venous congestion was observed in 1 rabbit in control group.The models of free transplantation of SEAPF and venous crisis were established successfully in the remaining rabbits.No significant appearance change was observed within 1 h after the outflow vein being ligated,while typical appearance of venous crisis could be observed 2 hours after the outflow vein being ligated.Compared with the control group,the concentration of t-PA was lower,but the concentration of PAI-1 was higher in experimental group at 2 hours,4 hours,6 hours,8 hours after the outflow vein being ligated(P ＜ 0.05).However,there was no obvious differences between two groups at other time points (P ＞ 0.05).The pathological examination showed the red cells gradually got together and adhered to the venous wall,eventually the microcirculation had been blocked completely and theflap became necrosis after venous crisis being occurred.Conclusion t-PA and PAI-1 can't be used to diagnose early venous crisis of perforator flap transplantation.

Objective To explore a reliable parameter for primary closure of the donor site of the descending branch of the circumflex femoral lateral artery perforator flap and analysis its effective factors.Methods Between August,2014 and December,2015,149 patients undergoing reconstructive procedures using the descending branch of the circumflex femoral lateral artery perforator flaps were included in the study.All patients were divided into two groups:primary closure of the donor site (135 cases) and none primary closure of the donor site (14 cases).The receiver operating characteristic curve for biostatistical analysis was performed to identify the reliable width of the descending branch of the circumflex femoral lateral artery perforator flap.The parameter,including the age,patients' body mass index,subcutaneous fat thickness,thigh circumference and the maximum flap width,were recorded in 79 patients who were randomly choose from all patients.The method through stretching donor site skin was used to assess the maximum flap width.The maximum flap width-to-thigh circumference ratio was calculated.The Pearson test was used to analysis the correction between those parameters.Results Primary closure of the donor site was possible in 135 patients and impossible in 14 patients.The receiver operating characteristic curve for biostatistical analysis identifying the reliable width of the descending branch of the circumflex femoral lateral artery perforator flap was 8.75cm.The method assessed the reliable width of the flap was (8.37±1.67) cm through stretching donor site skin.the reliable width of the flap was (8.55±1.65) cm in the male patients and (7.42±1.5) cm in the female patients.There was significant different between the two group (P ＜ 0.05).Primary closure can be achieved if the flap width-to-thigh circumference ratio was less than (17.23±3.84) percent.There was a significant negative correlation between subcutaneous fat thickness and the ratio (R=-0.299,P ＜ 0.05) and between body mass index and the ratio (R=-0.21,P ＜ 0.05).Conclusion The width of flap less than 8.75 cm is a reliable parameter for primary closure of the descending branch of the circumflex femoral lateral artery perforator flap donor site.The patient's body mass index and subcutaneous fat thickness of the thigh should be taken into consideration.

Objective To explore the feasibility of building a new model of free superficial epigastric artery perforator flap with New Zealand white rabbits.Methods Twenty-five healthy New Zealand white rabbits were used.Five rabbits were dissected to assess the vascular territory,the source and dimension of the superficial epigastric.According to the anatomic results,the superficial epigastric artery perforator flap were designed and harvested with 6 cm× 3 cm in the abdominal,anastomosis had been done between femoral artery/vein and carotid artery,jugular venous to build an animal model of transplantation of epigastric artery perforator flap.The donor sites were directly closured.Results Superficial epigastric artery originated from the proximal femoral artery,and the diameter of superficial epigastric artery was (0.15 ±0.02) mm,2-3 perforators support the areas of the skin of the lower abdominal wall.A rabbit died in the surgery because of anesthesia,the other animals were alive.The results showed that all flaps were survived in the experiment except a flap lost due to venous crisis.Conclusion The experimental model of free superficial epigastric artery perforator flap can be built in New Zealand white rabbits.It is a simple,practical and reliable model for future physiologic and pharmacologic studies.