Objective:To investigate the feasibility and clinical efficacy of the bilobed anterolateral femoral perforator flap pidicled with the oblique branch of lateral femoral circumflex artery in repair of the wounds in extremities.Methods:A study was conducted on 36 patients with complex limb wounds from December, 2014 to May, 2020. Thirty patients had single-wound sized from 10.0 cm×10.0 cm to 23.0 cm×17.0 cm, and 6 patients had 2 adjacent and discontinuous wounds sized from 4.0 cm×5.0 cm to 11.0 cm×9.0 cm. A total of 78 perforators were identified in routine preoperative CDU examination, and 67 perforators were confirmed. According to the actual requirement of the perforator confirmed in surgery, 19 flaps were designed with completely split up into bilobed flaps and 17 bilobed fascial flaps were designed with segmented skin and deep fascia. The blood supply of flaps relies on the anastomosis of oblique branch with the recipient vessels, therefore bridged blood Flow-through anastomosis was performed in 8 flaps. All thigh donor sites were sutured directly. Regular follow-up were made after surgery.Results:In this group, 35 cases of bilobed flaps survived successfully. Venous crisis was found in 1 case of flap repairing 2 wounds after the operation and was relieved 7 days later by remove some stitches and bloodletting. The donor sites healed by first intension, and the wound healing time was 11-83 days. All patients were followed-up for 6-39 months. The flaps had good colour and texture with S 2-S 3 sensory. All the donor sites left linear scars except 1 where left with a large scar without contracture and pain. Conclusion:The repair of the wounds in extremities by bilobed anterolateral thigh perforator flaps pedicled with the oblique branch of the lateral femoral circumflex artery could obtain a more concealed donor site. It acts as a beneficial supplement when a bilobed flap cannot be harvested on the descending branch of the lateral femoral circumflex artery.

Degloving injury of distal thumb is common in hand surgery. Generally, the degloving tissue is severely damaged without conditions for replantation. It is often treated by methods of stump revision, local flap coverage, free second toe reconstruction, and so on. It inevitably leads to a shortening of distal phalanx, sacrifice of the whole toe and poor appearance after repair. The hallux nail flap is considered to be the best to treat this kind of injury. However, the traditional wrap-around flap excises the toe in a large range and has many complications in the donor site. In April, 2010, a case of degloving injury of the distal thumb was repaired with a combined wrap-around flap of the hallux nail flap and the tibial flap of the second toe. The patient was followed-up for 10 years in our hospital. Both of the appearance and function of the patient's thumb are well recovered.

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.

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.

Objective:To explore the feasibility and clinical effect of repairing the wound of limbs with severe infection by the bilateral chimeric perforator flaps in the anterolateral femoral area.Methods:From December 2015 to October 2018, 12 cases of limb wounds with severe infection were repaired by the lateral femoral bilateral chimeric perforator flaps in the Department of Hand Surgery, Ruihua Affiliated Hospital of Soochow University, including five cases of traffic accident, four cases of machine strangulation and three cases of other injuries. There were eight males and four females, aged from 25 to 48 years old, with an average age of 40-year-old. All the wounds were complicated with the exposure of bone, tendon, or internal fixation and had different degrees of infection, 10 cases were of soft tissue infection, and two cases were of osteomyelitis. The wounds were outlined by sample cloth. A total of nine cases had single-wounds with the dimension of 12 cm × 11 cm to 26 cm × 11 cm, and these bilobed chimeric flaps were designed by dividing the sample cloth into two parts from the center and changing the width to the length. Three cases had two adjacent and discontinuous wounds in just one limb with an area from 6 cm × 4 cm to 14 cm × 6 cm, and the bilobed flaps were designed according to the size and the shape of these wounds. Six cases were reconstructed with the bilateral chimeric flaps of which the branches originate from one artery, three with flaps of different original arteries, two with fascia skin flaps, and one with a flap of mixed blood supply. The lateral thigh muscle or tensor fascia muscle carried in the flap was used to fill the cavity or sinus, and the donor area was sutured directly. The flap survival, wound healing, and donor area recovery were observed after the operation.Results:All the flaps survived without vascular crisis. The flap size ranged from 24 cm × 6 cm to 32 cm × 7 cm in nine cases of the single wound, and 7 cm × 5 cm to 14 cm× 7 cm in three cases with two wounds. The volume of muscle resection ranged from 4 cm × 3 cm × 2 cm to 11 cm× 6 cm × 4 cm. The average time of wound healing was 27 days (range from 12 to 83 days). All the donor areas of the thigh healed primarily. Follow-up time was 7 to 32 months, showing good color and texture. The sensation of the flaps recovered partially. Linear scars were left in all donor sites, except that one case suffereda large scar with no contracture or pain. One patient had an abnormal sensation in the incision area early but recovered gradually after two months without other serious complications. During the follow-up period, two cases of osteomyelitis showed no sinus, skin nonunion, and wound abscess. One case underwent a bone flap operation due to the bone defect one year later, and the defect healed well.Conclusions:Anterolateral femoral bilateral chimeric perforator flaps could be designed flexibly according to the conditions of the recipient area. By carrying the muscle with an abundant blood supply, the infection can be effectively controlled, and the damage to the donor area can be reduced.

Objective:To explore the feasibility and clinical effect of repairing the wound of limbs with severe infection by the bilateral chimeric perforator flaps in the anterolateral femoral area.Methods:From December 2015 to October 2018, 12 cases of limb wounds with severe infection were repaired by the lateral femoral bilateral chimeric perforator flaps in the Department of Hand Surgery, Ruihua Affiliated Hospital of Soochow University, including five cases of traffic accident, four cases of machine strangulation and three cases of other injuries. There were eight males and four females, aged from 25 to 48 years old, with an average age of 40-year-old. All the wounds were complicated with the exposure of bone, tendon, or internal fixation and had different degrees of infection, 10 cases were of soft tissue infection, and two cases were of osteomyelitis. The wounds were outlined by sample cloth. A total of nine cases had single-wounds with the dimension of 12 cm × 11 cm to 26 cm × 11 cm, and these bilobed chimeric flaps were designed by dividing the sample cloth into two parts from the center and changing the width to the length. Three cases had two adjacent and discontinuous wounds in just one limb with an area from 6 cm × 4 cm to 14 cm × 6 cm, and the bilobed flaps were designed according to the size and the shape of these wounds. Six cases were reconstructed with the bilateral chimeric flaps of which the branches originate from one artery, three with flaps of different original arteries, two with fascia skin flaps, and one with a flap of mixed blood supply. The lateral thigh muscle or tensor fascia muscle carried in the flap was used to fill the cavity or sinus, and the donor area was sutured directly. The flap survival, wound healing, and donor area recovery were observed after the operation.Results:All the flaps survived without vascular crisis. The flap size ranged from 24 cm × 6 cm to 32 cm × 7 cm in nine cases of the single wound, and 7 cm × 5 cm to 14 cm× 7 cm in three cases with two wounds. The volume of muscle resection ranged from 4 cm × 3 cm × 2 cm to 11 cm× 6 cm × 4 cm. The average time of wound healing was 27 days (range from 12 to 83 days). All the donor areas of the thigh healed primarily. Follow-up time was 7 to 32 months, showing good color and texture. The sensation of the flaps recovered partially. Linear scars were left in all donor sites, except that one case suffereda large scar with no contracture or pain. One patient had an abnormal sensation in the incision area early but recovered gradually after two months without other serious complications. During the follow-up period, two cases of osteomyelitis showed no sinus, skin nonunion, and wound abscess. One case underwent a bone flap operation due to the bone defect one year later, and the defect healed well.Conclusions:Anterolateral femoral bilateral chimeric perforator flaps could be designed flexibly according to the conditions of the recipient area. By carrying the muscle with an abundant blood supply, the infection can be effectively controlled, and the damage to the donor area can be reduced.

Objective:To explore the clinical effects of bilateral overlength anterolateral femoral perforator flaps connected in series or parallel in repairing large area of wounds in limbs.Methods:From January 2017 to July 2019, 9 patients with large area of skin and soft tissue defects in limbs were admitted to the Departments of Hand Surgery and Foot and Ankle Surgery of Ruihua Affiliated Hospital of Soochow University, including 8 males and 1 female, aged 36 to 63 years. The retrospective cohort study was conducted. The wound areas of patients after debridement were 20 cm×15 cm to 30 cm×25 cm, and the wounds were repaired with bilateral overlength anterolateral femoral perforator flaps. One main artery defect in the receiving area of 4 patients was repaired with bilateral flaps connected in series. Two main artery defects in the receiving area of 5 patients were repaired with bilateral flaps connected in parallel. A total of 18 flaps were excised, and the area of a single flap ranged from 20 cm×8 cm to 46 cm×9 cm. The donor sites of 17 flaps were sutured directly, and the donor site of 1 flap was repaired with free full-thickness skin graft from hypogastrium. Harvesting time of flaps, survival condition of flaps after surgery, and wound healing time, and flap observation, two-point discrimination distance of flaps, functional recovery of joint and appearance of recipient site, and recovery of donor site during follow-up were recorded.Results:In this group of 9 patients, the flap harvesting time was 1.0 to 4.5 hours, and all the 18 flaps survived. The wound healing time of recipient site was 18 to 72 days after flap transplantation. They were followed up for 6 to 34 months. The shape of the recipient site was satisfactory, with no deep tissue infection such as osteomyelitis. Four flaps in 2 patients were bloated and were thinned in 6 months after operation; 4 flaps in 2 patients had skin pigmentation on the edge of the flap; the flap of one patient was scalded but healed by dressing change, with patchy scar being observed during follow-up. The rest of the flaps were soft, elastic, and painless with good blood supply. All the flaps restored with protective sensation, with only one point in two-point discrimination. Only linear scars remained in the donor sites of 17 flaps. All the limbs had good blood supply in the distal end of donor sites, and no restriction occurred in range of motion of knee joint and quadriceps muscle strength.Conclusions:The bilateral overlength anterolateral femoral perforator flaps connected in series or parallel have constant anatomy, reliable blood supply, and flexible combination. It is an ideal surgical method for repairing large area of skin and soft tissue defects in limbs at one time.

Objective:To investigate the clinical effect of multiple-perforator extra-large anterolateral thigh flap (ALT) for repairing the circular wound of foot and ankle.Methods:Data of 13 cases with the circular wound of foot and ankle repaired by foot and ankle surgery in Ruihua Affiliated Hospital of Soochow University from October 2011 to June 2018 were retrospectively analyzed. The perforator was located by color Doppler ultrasound before the operation, and the flap was designed according to the size of the wound. Both the perforator vessel and lateral femoral cutaneous nerve entering the flap should be carefully protected. When all perforating branches in the flap come from the same vascular trunk, two or more perforating branches are carried to cover the wound directly; when the branches come from the different trunks, the turbocharging technique was used to ensure that there are two or more perforators to nourish the flap. All the donor areas were closed primarily. The sensory of flaps were elevated by the British Medical Research Council (BMRC) sensory function assessment standard, and the motor function was elevated by the American Orthopedic Foot and Ankle Society (AOFAS) ankle and hindfoot function scoring system.Results:A total of 13 patients were enrolled in this study, including 8 males and 5 females.The age ranged from 21 to 65 years, with an average of 39 years. The wound area was 21.0 cm×6.0 cm to 35.0 cm×18.0 cm with exposure of bone and tendon. 12 cases were repaired with multiple-perforator extra-large anterolateral thigh flap ( ALT) harvested from one thigh, and 1 case was repaired with the combined bilateral ALT flap due to the huge wound. The size of flap was 21.0 cm × 7.0 cm to 35.0 cm×10.0 cm. During the procedure, 14 flaps were successfully harvested, 9 flaps were supplied by two perforators, 4 by three perforators, and 1 by four skin perforators. Each flap had an average of 2.4 perforators. Among them, there were 5 flaps with the common source perforators while the other 9 flaps whose perforators came from different sources. All flaps in this group finally survived. One flap suffered the venous crisis 24 hours after the operation and survived after removing the thrombus and re-anastomosing the vessel again. The stitches were removed 2 to 3 weeks after operation when the wound had healed. All wounds in the donor area healed primarily. 9 flaps underwent flap thinning and plastic surgery 6 to 10 months after the operation. Follow-up for 6 to 18 months showed the color and texture of the flap was close to the recipient area, and the sensation of the flap elevated by BMRC sensory function assessment standard was S2-S3. According to the AOFAS ankle and hindfoot scoring system, the function of the recipient area was 72-98 points, with an average of 92 points. Only linear scars were left in the donor area.Conclusions:Because of the advantages of rich blood supply, strong anti-infection ability, and less damage to the donor area, it is an ideal method to repair the circular wound of the foot and ankle with multiple-perforator extra-large anterolateral thigh flap.

Objective:To investigate the clinical effect of multiple-perforator extra-large anterolateral thigh flap (ALT) for repairing the circular wound of foot and ankle.Methods:Data of 13 cases with the circular wound of foot and ankle repaired by foot and ankle surgery in Ruihua Affiliated Hospital of Soochow University from October 2011 to June 2018 were retrospectively analyzed. The perforator was located by color Doppler ultrasound before the operation, and the flap was designed according to the size of the wound. Both the perforator vessel and lateral femoral cutaneous nerve entering the flap should be carefully protected. When all perforating branches in the flap come from the same vascular trunk, two or more perforating branches are carried to cover the wound directly; when the branches come from the different trunks, the turbocharging technique was used to ensure that there are two or more perforators to nourish the flap. All the donor areas were closed primarily. The sensory of flaps were elevated by the British Medical Research Council (BMRC) sensory function assessment standard, and the motor function was elevated by the American Orthopedic Foot and Ankle Society (AOFAS) ankle and hindfoot function scoring system.Results:A total of 13 patients were enrolled in this study, including 8 males and 5 females.The age ranged from 21 to 65 years, with an average of 39 years. The wound area was 21.0 cm×6.0 cm to 35.0 cm×18.0 cm with exposure of bone and tendon. 12 cases were repaired with multiple-perforator extra-large anterolateral thigh flap ( ALT) harvested from one thigh, and 1 case was repaired with the combined bilateral ALT flap due to the huge wound. The size of flap was 21.0 cm × 7.0 cm to 35.0 cm×10.0 cm. During the procedure, 14 flaps were successfully harvested, 9 flaps were supplied by two perforators, 4 by three perforators, and 1 by four skin perforators. Each flap had an average of 2.4 perforators. Among them, there were 5 flaps with the common source perforators while the other 9 flaps whose perforators came from different sources. All flaps in this group finally survived. One flap suffered the venous crisis 24 hours after the operation and survived after removing the thrombus and re-anastomosing the vessel again. The stitches were removed 2 to 3 weeks after operation when the wound had healed. All wounds in the donor area healed primarily. 9 flaps underwent flap thinning and plastic surgery 6 to 10 months after the operation. Follow-up for 6 to 18 months showed the color and texture of the flap was close to the recipient area, and the sensation of the flap elevated by BMRC sensory function assessment standard was S2-S3. According to the AOFAS ankle and hindfoot scoring system, the function of the recipient area was 72-98 points, with an average of 92 points. Only linear scars were left in the donor area.Conclusions:Because of the advantages of rich blood supply, strong anti-infection ability, and less damage to the donor area, it is an ideal method to repair the circular wound of the foot and ankle with multiple-perforator extra-large anterolateral thigh flap.

Objective:The morphological characteristics of the oblique branch of lateral circumflex femoral artery (LCFA) were observed by digital subtraction angiography (DSA) in order to provide imaging basis in the application of the ALTF pedicled with the oblique branch of LCFA.Methods:Between February, 2020 and December,2020, for the patients who were requested to repair the wound with ALTF, a DSA radiography was performed before operation. A total of 197 sides of selective DSA were analysed in 113 patients. The occurrence rate, origin and course of the oblique branch of LCFA were observed. Relationships between the oblique branch of LCFA and the upper cutaneous branch, descending branch and transverse branch were analysed. In addition, in order to verify the accuracy of conventional DSA data in describing the morphological characteristics of oblique branches, 10 sites of 10 patients were randomly selected to perform rotational DSA three-dimensional imaging.Results:Femoral artery, deep femoral artery, LCFA and the branches of LCFA were clearly identified on DSA images. The oblique branch appeared in 190 sites, with a occurence rate of 96%. Among them, 1 oblique branch originated from the femoral artery, 2 from the deep femoral artery, and other 187 from LCFA. The oblique branches were found in 10 sites from rotational DSA three-dimensional imaging, which was consistent with conventional DSA imaging.Conclusion:The occurrence rate and morphological characteristics of the oblique branch of LCFA can be directly analysed by DSA. The oblique branch is not a variant branch as reported in the literatures, as it always appears. It may serve the main blood supply artery of the anterolateral thigh flap.