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To explore the clinical and radiological effects of the free vascularized iliac bone flap (FVIBF) based on deep iliac circumflex vessels for Association Research Circulation Osseous (ARCO) stage 3 traumatic osteonecrosis of the femoral head (TONFH) in young adults.From February 2017 to August 2020, a total of 29 (29 hips) TONFH patients with ARCO stage 3 were enrolled in this study. Following the FVIBF standard procedure, the necrotic area of the femoral head was removed and a free vascularized iliac bone flap was harvested and grafted. X-rays were performed at 1, 3, 6, 9, and 12 months and every 6 months thereafter postoperatively for evaluation of the degree of femoral head collapse. The Beijing University of Chinese Medicine X-ray Evaluation Method (BUCMXE) was used to evaluate the hip preservation effects based on anteroposterior hip radiographs. Hip functions were evaluated using the Harris hip score (HHS) every 6 months and annually after 24 months, and the quality of life was assessed using the SF-36 questionnaire at 18 months postoperatively.The mean follow-up time was 30 months (range 12-54 months). None of the patients was lost to follow-up, and the wounds healed primarily without infection and deep venous thrombosis of lower limbs. The HHS at 12 months postoperatively was significantly improved than that before surgery (83.4 ± 7.4 vs. 64.8 ± 14.1; p 0.05). The BUCMXE radiographic score at 12 months postoperatively did not reveal any significant differences in femoral head morphology and osteonecrotic lesion, when compared to preoperation. The SF-36 questionnaire showed significant improvements in social functioning, role physical, bodily pain, and general health (p 0.05). However, eight patients had varying degrees of femoral head collapse after surgery, and only one of them underwent THA due to pain and collapse aggravation. BUCMXE-Osteoarthritis scores showed that 23 hips were stable and six hips were advanced, among which five hips staged ARCO 3B and one staged ARCO 3A preoperatively, with statistically significant differences (p 0.05).Although some patients showed no improvement of radiological outcomes, most patients with severe TONFH could still benefit from the FVIBF procedure. Further studies should attempt to improve this surgical procedure and explore its long-term efficacy.

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

Background Iliac bone flap with deep circumflex iliac artery is a common option in the treatment of Osteonecrosis of the femoral head (ONFH), and dissection of iliac bone flap is the key step for successful operation. This paper aims to introduce a new operative technique for dissecting iliac bone flap with deep circumflex iliac artery based on analysis of its advantages. Methods A total of 49 patients treated by retrograde anatomy and 52 patients treated by anterograde anatomy from January 2010 to December 2020 were recruited. The two groups were then compared in terms of the preoperative baseline conditions, intraoperative data, and postoperative Harris hip score (HHS). Results Compared with the retrograde anatomy group, the anterograde anatomy group had a significantly longer operating time, a significantly heavier intraoperative blood loss, a significantly higher rate of donor complication morbidity, a significantly higher rate of donor–recipient delayed healing, a significantly higher failure rate of iliac bone flap resection, a significantly higher rate of lateral femoral cutaneous nerve (LFCN) injury, and a significantly higher rate of ectopic ossification. No difference was found in postoperative HHS score between the two groups. Conclusion As a new operative technique that can accurately locate the nutrient vessels of the iliac bone flap and quickly dissect the iliac bone flap with deep circumflex iliac artery while maintaining a comparable clinical effect, retrograde anatomy exhibited distinct advantages over anterograde anatomy in terms of simpler intraoperative operation, safer dissection, shorter operation time, lower blood loss, and fewer donor complications. Level of evidence III, Retrospective.

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

The aim of the present study was to report a novel nomenclature system for extended latissimus dorsi musculocutaneous (LD) flaps. To evaluate the clinical application and surgical efficacy of the different extended LD flaps for large wounds in the extremities.From January 2004 to December 2018, 72 consecutive patients who received extended LD flaps were retrospectively analyzed. Patients' ages ranged from 2 to 68 years with 37 males and 35 females. All wounds were extensive in either the upper or lower limbs, while the skin defect area ranged from 18 cm × 10 cm to 37 cm × 21 cm. Forty-one wounds were located in the calf, 18 in the foot and ankle, six in the shoulder and upper arm, four in the thigh, and three at the knee joint. Twenty-eight patients had fractures, and six of these patients with segmental bone defects (ranging in size from 3 to 7 cm) required secondary orthopaedic procedures. Single- and double-wing extended LD flaps were designed and harvested according to the shape of the wounds.The flaps received consisted of 64 single-wing and eight double-wing extended LD flaps, and the mean flap harvest time was 56.2 min. The donor sites were closed primarily for all patients. Additional subcutaneous veins were anastomosed to the recipient's vessels in 14 patients. The venous crisis was noticed on the first postoperative day in four cases. Two flaps were salvaged after emergency re-exploration, and another two patients' flaps were necrosed. In these two patients, lower limb amputation and extended LD flap on the other side were used, respectively, for the final treatment. The wounds healed well, providing reliable soft tissue coverage and good contour in the reconstructed areas. Six patients had segmental bone defects that required secondary orthopaedic procedures, two patients were repaired with vascularized iliac crest bone grafts, and another four patients were reconstructed by the Ilizarov technique. All the patients' bone defects achieved union and most patients achieved good functional recovery at the recipient site. The mean follow-up was 15.7 months (range, 10-56 months). No significant donor site morbidities limiting patients' daily activities occurred during the follow-up. Eight patients developed a donor site hypertrophic scar, three patients on the back, and five on the anterolateral thigh.Single- and double-wing extended LD flaps are simple and reliable methods for large skin and soft tissue defects in the extremity, with good functional and aesthetic results.

BACKGROUND Management of large wounds of the lower extremities remains a challenge for plastic and reconstructive surgeons. Herein, a surgical technique and clinical algorithm using the combined transfer of a latissimus dorsi (LD) musculocutaneous flap and flow-through anterolateral thigh (ALT) perforator flap for the treatment of extensive soft-tissue defects is described. METHODS From January 2012 to September 2018, 12 patients (six men and six women) aged 6-37 years, sustained injuries in road traffic accidents with large soft-tissue defects in the lower extremities. Seven cases were Gustillo Anderson type IIIB open fractures and two cases were Gustillo Anderson type IIIC open fractures. Two wounds were located in the knee joint, four in the calf, and six in the ankle and foot. The skin defect size ranged from 25 × 20 cm2 to 36 × 25 cm2 . All patients in this series underwent reconstruction using combined transfer of the LD musculocutaneous flap and flow-through ALT perforator flap, wherein the LD was attached through its pedicle to the distal continuation of the ALT flap. RESULTS The size of the flow-through ALT perforator flaps ranged from 13.5 × 6.5 cm2 to 31 × 8.5 cm2 . The size of the LD musculocutaneous skin paddle ranged from 25 × 6 cm2 to 34 × 7 cm2 , and that of the muscle paddle ranged from 13 × 3.5 cm2 to 30 × 11 cm2 . One patient experienced postoperative thrombosis of the venous pedicle, and the flap was salvaged after emergency re-exploration and thrombectomy. No other complications were observed postoperatively. The mean follow-up period was 26.8 months. All patients were able to ambulate independently at the end of the follow-up period. CONCLUSIONS The combined transfer of the LD musculocutaneous flap and flow-through ALT perforator flap ensured adequate surface coverage, making it a feasible procedure for large soft-tissue defects.

Objective The aim of the present study was to report a novel design of the chimeric deep inferior epigastric artery perforator flap (DIEP) to achieve dead space filling, Achilles tendon bridging, and skin resurfacing simultaneously with minimal donor‐site morbidity. Methods From September 2012 to May 2016, a retrospective study was carried out on six pediatric patients with composite soft tissue defects of the heel that were repaired with the chimeric DIEP flap. The chimeric flap design included a flap of the anterior sheath of the rectus, a block of rectus muscle, and a large skin paddle. All the parts were supplied by a common artery. After harvesting the flap, all element parts were inserted at the corresponding sites in a tension‐free manner. With one set of vessel anastomoses at the recipient site, accurate repair with tendon reconstruction, dead space elimination, and wound covering were accomplished. The donor site incisions were closed initially. Data on patient age, medical history, injury severity, defect size, flap dimensions, recipient vessels, donor site closure, complications, and follow‐up were collected and reviewed. Results Five of the six chimeric DIEP flaps survived without complications. The remaining one case experienced partial necrosis of the skin paddle caused by venous congestion, which healed after routine dressing changes. Primary donor site closure was accomplished in all cases. The mean follow‐up was 18.6 months (range, 10–36 months). Five patients had satisfactory aesthetic and functional outcomes; one patient needed a secondary debulking procedure. Compared to the unaffected side, the affected side showed no obvious difference for ankle movement, tiptoe function, and patient gait during the follow‐up period. Good ankle function was observed in all patients. There was no donor site breakdown, with only a slightly noticeable linear scar. Conclusion The chimeric DIEP flap reduced the operative time, solved the problem of deficiency of recipient vessels, and attained satisfactory functional and aesthetic outcomes with low donor site morbidity. Therefore, it is a promising option for three‐dimensional reconstruction of composite defects with dead space and Achilles tendon defects as well as skin loss in children., We reported a novel design of the chimeric deep inferior epigastric artery perforator flap (DIEP). The chimeric DIEP flap reduced the operative time, solved the problem of the deficiency of recipient vessels, and attained satisfactory functional outcomes. Therefore, it could be a promising option for three‐dimensional reconstruction of composite defects in children.

Background Compound anterolateral thigh flaps are popular for three-dimensional reconstruction of complex soft tissue defects. We present our 10-year experience using compound vastus lateralis (VL) muscle and anterolateral thigh musculocutaneous perforator (ALTP) flaps, and introduce three versatile customizations of this flap for individualized reconstruction of complex three-dimensional soft tissue defects. Methods From May 2008 to June 2017, compound VL muscle and ALTP flaps were performed in 67 consecutive patients aged 14-75 years (62 men and 5 women). The defects were in either the lower (n = 53) or upper extremity (n = 14), and ranged in size from 8 × 4 cm2 to 25 × 6 cm2. Dead space volume ranged from 4 × 2 × 1 cm3 to 20 × 3 × 2 cm3, and all flaps were harvested from patients' thighs as one of three types. In type A, a single perforator supplied both the skin and muscle components, with the vascular bundle penetrating the muscle component. In type B, a single perforator supplied both skin and muscle components with separate branches to the skin and muscle. In type C, separate vessels supplied the skin and muscle. Results In the 67 patients, 65 flaps survived, and the donor site was closed directly. Vascular compromise occurred in four patients on the first postoperative day. Two flaps were salvaged after emergency re-exploration. Flap loss occurred in two patients, and these defects were repaired using other flaps. The follow-up period ranged from 8 to 60 months (mean, 11.9 months). All flaps had satisfactory appearance and texture, and no patients experienced limited hip and knee joint mobility from the donor site operation. Conclusions Compound VL muscle and ALTP flaps are a reliable option to reconstruct complex defects of the extremities. Identifying three flap types allowed for more precise customization to cover complex defects with limited donor site morbidity.

Purpose The aim of this study was to demonstrate the viability of the transverse circumflex scapular artery perforator flap (TCSAPF) in children with soft tissue defects of the lower limb. Methods In an anatomic study, 25 fresh cadavers were injected with lead oxide-gelatin for spiral computed tomography and 3-dimensional image reconstruction. In a 3-year clinical application study, children with soft tissue defects and exposed tendons and/or bones in the lower limb underwent free-TCSAPF repair of the defect. Results Perforators from the transverse branch of the circumflex scapular artery were identified in both anatomical and clinical studies. The average external diameter was 0.9 ± 0.3 mm. Each perforator supplied an average area of 63.5 ± 16.8 cm in anatomical. Twenty-one children were included in this group (9 boys, 12 girls, mean age, 6.6 ± 2.7 years). The size of the flaps ranged from 6 to 17 cm × 4.5 to 7 cm (average, 65.3 ± 22.6 cm). The average flap harvesting time was 30.1 ± 8.5 minutes, average operation time was 138.6 ± 31.5 minutes, and average blood loss was 89.5 ± 21.9 mL. The average length of the vessel pedicle was 8.2 ± 2.4 cm. Arterial congestion occurred in one child, 18 hours postoperatively; subsequent re-exploration and great saphenous vein transplantation were successful. Of the 3 children who had bulky flaps, 1 patient underwent defatting. Satisfactory outcomes included good appearance and function of the recipient and donor areas. Conclusions The TCSAPF provides high-quality skin and vessel flexibility, providing a reliable blood supply in children. The flap has potential benefits over existing perforator flaps.

Background One-stage reconstruction of complex soft tissue defects of the extremities is a challenging problem. Repair of complex soft tissue defects requires adequate skin tissues to cover the large surface wound and special tissues for obliterating the dead space. The chimeric flap is one of the most popular approaches for reconstruction of complex soft tissue defects. However, the problems of donor-site morbidity and inability to repair very large defects at one-stage remain. The purpose of this study was to present our clinical experience using sequential chimeric perforator flaps for reconstruction of complex extremity defects with primary closure of the donor site. Methods From August 2013 to March 2017, 12 patients with complex soft tissue defects underwent extremity reconstruction using sequential chimeric perforator flaps, which were composed of a chimeric anterolateral thigh perforator (ALTP) flap and an additional free perforator flap. The skin paddles were placed side-by-side to cover the large surface soft tissue defects, and the muscle component was used to obliterate the dead space. Of these patients, one was injured by a crushing accident, while the other 11 patients were injured in traffic accidents. Results The size of the skin paddles ranged from 26 cm × 8 cm-10 cm × 6 cm to 30 cm × 8.5 cm-29 cm × 9 cm. The muscle paddle size ranged from 2 cm × 3 cm × 4 cm to 22 cm × 4 cm × 2 cm. All-components of the sequential chimeric flaps survived in all-patients. Vascular compromise was observed in one case. One case suffered minor wound-edge necrosis and was treated conservatively. Primary closure of donor-site was successfully achieved in all-patients, and all-donor-site wounds healed uneventfully. The mean follow-up time was 15.25 months. Most of the cases showed a satisfactory contour, and only two patients presented with mildly bulky appearance that treated with a debulking procedure. Conclusions The sequential chimeric perforator flap is an alternative procedure for reconstruct complex soft tissue defects of the extremities. This approach allows for flexible design, a larger cutaneous area, and low donor site morbidity.

Summary Background Complex soft-tissue defects of upper extremities still have a high rate of amputation, as the reconstruction of complex soft-tissue defects is always difficult even with the largest conventional free flap. The anterolateral thigh perforator (ALTP) flap is one of the most popular procedures used for the coverage of complex soft-tissue defects of extremities. However, problems associated with donor-site morbidity and inability to repair complex soft-tissue defects in a one-stage procedure persist. The purpose of this study was to present a novel design of using chain-linked bilateral ALTP flap and its various designs for customized reconstruction of complex soft-tissue defects in the hands and forearms. Methods From June 2009 to June 2017, we retrospectively analyzed 15 patients with complex soft-tissue defects in the hands and forearms. All patients in this series underwent extremity reconstruction using the chain-linked bilateral ALTP flaps. Three different types of chain-linked bilateral ALTP flaps were created in this study based on wound characteristics and the maximum available skin paddle size at all donor sites. Results The chain-linked bilateral ALTP flaps were successfully harvested for the reconstruction of complex soft-tissue defects in the hands and forearms. Among them, ten cases were repaired with chain-linked bipaddle ALTP flaps, two cases were treated with chain-linked tripaddle ALTP flaps, and the remaining three cases were used with chain-linked multi-lobed ALTP chimeric flaps. The sizes of the skin paddles ranged from 11 cm × 7 cm to 42 cm × 8 cm. The areas of the total flaps ranged from 245 cm2 to 650 cm2 (mean 419.6 cm2). Only one case required re-exploration because of the venous congestion. The donor sites were closed directly. The mean follow-up time was 16.4 months. Most cases showed satisfactory contour. Conclusion The chain-linked bilateral ALTP flap is a reliable option for one-stage reconstruction of complex soft-tissue defects in the hands and forearms with limited donor-site morbidity. It also provides various flap designs, which allow for more individualized treatment approaches.

This study aimed to assess the feasibility and effectiveness of using combined transfer by two or three large skin flaps to cover a single extensive and multiplanar wound on the foot and ankle to achieve full coverage of the wound and primary donor-site closure.Seventeen patients with extensive wounds around their foot and ankle were treated. The flap could either be anterolateral femoral perforator (ALTP) flap, deep inferior epigastric artery perforator (DIEP) flap, or thoracodorsal artery perforator (TDAP) flap. According to the dimensions and shape of the wound and the availability of donor sites, we classified the reconstruction into three different types. Based on the type, the soft-tissue defect was divided into two or three parts to guide the corresponding perforator skin flaps to be harvested within the maximum width and length of the donor sites.All 17 patients were successfully reconstructed, with a total of 35 flaps in 37 paddles. Vascular compromise occurred in one patient and was saved by venous thrombectomy. In total, four flaps experienced a partial loss and were treated either conservatively or by a skin graft. No ulceration due to abrasion occurred on any flap during the entire follow-up. All donor sites were directly closed and healed uneventfully, except for one needing coverage by a skin graft and another experiencing dehiscence and scar widening.Combined transfer by several skin perforator flaps is a flexible reconstructive option for resurfacing extensive and multiplanar wounds on the foot and ankle. The benefit lies in a well-reconstructed contour, an anti-frictional property, a permission of a normal shoe wearing in the reconstructed foot, and meanwhile a primary closure on donor site.

This retrospective study was conducted to compare the outcomes between the free deep inferior epigastric artery perforator (DIEP) flap and the circumflex scapular artery perforator (CSAP) flap in reconstruction of moderate-sized soft tissue defects in the foot and ankle of pediatric patients.From January 2004 to December 2016, 42 patients, ranging from 2 to 13 years old, underwent foot and ankle reconstruction, with a free DIEP flap in 21 cases and a free CSAP flap in the other 21cases.All the flaps survived. No marked differences were observed in the demographics, flap size, recipient vessels, and overall early or late complication rate (p 0.05). The CSAP group had a shorter operation time (134.3 ± 25 min vs. 202.4 ± 24.3 min, p 0.05) and flap harvest time (29.7 ± 8.1 min vs. 52.2 ± 9.8 min, p 0.05) than the DIEP group had. In long-term follow-up, the CSAP group showed a lower fat hyperplasia rate (14% vs. 52%, p 0.05) and better cosmetic outcomes than the DIEP group did (p 0.05). The functional outcomes had no marked differences (p 0.05).The DIEP flap and the CSAP flap are both good options for foot and ankle reconstruction of moderate-sized defects in pediatric patients. The CSAP flap has a shorter operation time and flap harvest time, a lower fat hyperplasia rate, and better long-term cosmetic outcomes than the DIEP flap does.

Summary Background Simultaneous reconstruction of composite bone and large soft-tissue defect areas is challenging for reconstructive surgeons. This study presents a microsurgical sequential chimeric flap composed of a flow-through anterolateral thigh perforator (ALTP) flap and a deep circumflex iliac artery perforator (DCIAP) chimeric flap for one-stage reconstruction of a complex tissue defect in limbs. Methods A retrospective analysis was performed among patients who underwent reconstruction of bone composite and large soft-tissue defect areas in limbs using a sequential chimeric flap. A flow-through ALTP flap and a DCIAP chimeric flap were microsurgically fabricated as sequential chimeric flaps. Results Ten patients were successfully treated with the sequential chimeric flaps. All components of the flaps survived in all patients. Primary closure of the donor site was achieved in all cases. The sizes of the flow-through ALTP flaps ranged from 16 × 6 cm to 27 × 8 cm. The size of the cutaneous portion of the DCIAP chimeric flap ranged from 11 × 4 cm to 20 × 9 cm, and bone flap sizes ranged from 1 × 3 × 2 cm to 2.5 × 8 × 3 cm. A vascular compromise was observed postoperatively in one case. Only one case suffered minor wound-edge necrosis. Mean follow-up time was 13.1 months. Most cases showed a satisfactory contour, and no fracture of transferred iliac segments occurred. Conclusion The sequential chimeric ALTP-DCIAP flap is a valuable alternative for one-stage reconstruction of composite bone and large soft-tissue defects in limbs. This approach is flexible and provides a large cutaneous area with primary closure of the donor site.

The anterolateral thigh perforator (ALTP) chimeric flap is one of the most popular procedures for the reconstruction of three-dimensional defects in the extremities. However, the problems of donor-site morbidity and inability to repair very large defects in a one-stage procedure remain. The purpose of this study was to present a novel design of ALTP chimeric flap and its various designs for customized reconstruction of complex three-dimensional defects in the extremities. From January 2009 to June 2017, we retrospectively analyzed 25 patients with complex three-dimensional defects in the extremities. All patients in this series underwent extremity reconstruction using vastus lateralis (VL) muscle-chimeric multi-lobed ALTP flaps, consisting of multi-lobed skin paddles and muscle segment on the same pedicle from the descending branch of the lateral circumflex femoral artery. Three different types of VL muscle-chimeric multi-lobed ALTP flaps were created in this study. The sizes of the multi-lobed skin paddles range from 10 × 6 cm and 9 × 7 cm to 19 × 9 cm and 20 × 9 cm, and the sizes of muscle segments ranged from 9 × 6 cm to 4 × 4 cm. All of the flaps survived. Only one case required re-exploration because of venous congestion. The primary closure of the donor site was successfully achieved in all patients. The mean follow-up time was 14 months. Most of the cases showed satisfactory contour. The VL muscle-chimeric multi-lobed ALTP flap is a reliable option for reconstruction of complex three-dimensional defects of the extremities. It provided flexible design for customized coverage of complex three-dimensional defects with limited donor-site morbidity.

The main drawbacks of the use of the circumflex scapular artery perforator (CSAP) flap for complex soft-tissue defect repair are the limitation of skin paddle size, which can be harvested to allow precise wound coverage and primary closure of the donor site. We developed a variant of the dual skin paddle CSAP flap to extend its applications and minimize donor-site morbidity when reconstructing complex soft-tissue defects in children.A detailed anatomical investigation of circumflex scapular artery (CSA) branches was conducted using a standardized injection of lead oxide in 25 fresh cadavers. Dual skin paddle CSAP flaps were harvested for the reconstruction of complex defects in the extremities in 16 children. Three types of dual skin paddle CSAP flap were used in this study: transverse chain-shaped, oblique chain-shaped, and trefoil-shaped flaps.Three CSA branching patterns with superior branch diameters were observed: 34% of CSAs were of the transverse branch dominant type, 54% were of the descending branch dominant type, and 12% were of the codominant type. Sixteen dual skin paddle CSAP flaps were elevated successfully; they were of the transverse chain-shaped type in 2 cases, the oblique chain-shaped type in 9 cases, and the trefoil-shaped type in 5 cases. All flaps survived postoperatively. Primary closure of the donor site was achieved in all cases.The CSA system is an appropriate source for harvesting dual skin paddle CASP flap. Use of this flap for the reconstruction of complex soft-tissue defects in the extremities in children is an alternative approach that reduces morbidity and improves the cosmetic outcome at the donor site.

Background The closure of massive skin defects remains challenging, particularly in children. In this report, we describe a technique to achieve primary donor site closure using the kiss deep inferior epigastric perforator (DIEP) flap for the reconstruction of large soft tissue defects located in the extremities of children. Methods From May 2011 to May 2016, a retrospective analysis was conducted on 10 pediatric patients with extensive soft tissue defects and reconstruction with double-skin paddle DIEP flap. After harvesting the flap, the skin paddle was divided into 2 separate paddles with a common vascular supply, and then the 2 paddles were sutured side by side through translating 2 paddles or rotating one of the paddles by 90 or 180 degrees, effectively doubling the width of the flap and rejoining it at the recipient site. Data on patient age, medical history, defect size, flap dimensions, recipient vessels, donor site closure, complications, and follow-up were reviewed retrospectively. Results Nine children had major soft tissue defects of the lower limb, and the remaining one had an upper limb defect. Only 1 case was complicated by partial necrosis of 1 paddle. Primary donor site closure was accomplished in all cases. The flaps were well matched on texture and contour, except that the 2 flaps were bulky at postoperative follow-up. There was no donor site breakdown, with only a slightly noticeable linear scar. Conclusion The kiss DIEP flap could be an alternative for reconstruction of large soft tissue defects of the extremities in children, with lower morbidity and improved cosmetic of the donor site.

A 3-year-old boy was transferred to our hospital 2 weeks after sustaining severe burns to his head, face, and hands by a fire. Physical examination revealed a total burn surface area of approximately 15%, an exposed calvarium area of 26 cm × 22 cm, necrosis of the outer table calvarial bone, and granulation wounds (Fig. 40.1).

A 24-year-old man was injured in a car accident, suffering from an open fracture of the right tibia and fibula. Fracture reduction and plate internal fixation were performed in a local hospital. The wound remained non-union after the operation with plate exposed and repeated purulence lasting for 3 years. After removing the steel plate, there was a soft-tissue defect on the medial of the right leg. On the tibial, there was evident osteonecrosis without a blood supply and absence of callus growth at the fracture end.

The patient, a male, 39 years old, was sent to the hospital due to a completely severed left upper arm from machine crushing. Physical examination showed a large area of skin contusion at the distal end of the left upper arm and irregular wound margin at the broken end (Fig. 10.1)

The acromial arterial rete (AAR) is the junction between the skin blood supply of the cervical side and that of the upper arm, and it is the only site crossed by the trans-regional blood supply of the cervico-humeral flap (CHF). The aim of this study was to explore the structures of AAR to optimizing flap design. A body arteriography and spiral CT scan were performed on 33 whole adult corpses. The 3D reconstruction was used to perform continuous digital layered anatomy of the shoulder and upper chest; the acromion and acromioclavicular joint were used as the center to observe the source, route and distribution characteristics of a perforating branch and their anastomosis. The perforating branches were separated from an acromial branch of the transverse cervical artery (97%), posterior humeral circumflex artery (95%), a deltoid branch of the thoracoacromial artery (95%), and the acromial branch of the thoracoacromial artery (93%). The diameter of the acromial branch of the transverse cervical artery at its initial location was 1.18 ± 0.37 mm; the trunk length was 12.53 ± 3.83 cm, and it was anastomosed with other blood vessels in three forms. Deep fascia should be included in the flap design. Three kinds of pedicled transfer flaps can be designed with the acromial branch of transverse carotid artery as the vascular pedicle. Free flaps can be designed with the acromial branch of thoracoacromial artery as the vascular pedicle.

Background: Adverse outcomes after unilateral vs bilateral breast reconstruction involve an unknown level of risk that warrants thorough investigation. Methods: To address this research need, PubMed, Ovid, Medline, EMBASE, and Scopus databases were searched through systematically from January 1, 1990, to January 1, 2019 to retrieve the relevant studies on the risk of postoperative complications after unilateral vs bilateral abdominal flap breast reconstruction. According to the pre-designed inclusion criteria, available data were extracted from the relevant studies, and then analyzed comparatively in order to identify the relative risk (RR) and 95% confidence intervals (CI) applying either a random or a fixed effects model. Results: Eventually, 20 studies involving 8122 female subjects met the inclusion criteria. It was found that unilateral reconstruction involved a significantly higher risk of flap loss (RR: 1.56, 95% CI: 1.21–2.00; P

The success of free vascularized fibular bone graft (FVFBG) has accelerated the osteo reconstruction which results from trauma, resection of a tumor or an infectious bone segment, or correction of congenital deformity. But the complication behind should not be overlooked. The failure could necessitate a second surgery, which prolong the rehabilitation period and produce further health cost. Worst, the patients may suffer a permanent impaired ankle function, or a sustained morpho-functional loss on reconstructive area which are hard to save. To provide an overview of the complication related to reconstruction by FVFBG, a narrative review is conducted to identify the complications including their types and rates, the contributing factors, the approaches to measure and the techniques to avoid. Methodologically, by quick research on Pubmed and abstract reading of reviews, we characterize five reconstructive areas where FVFBG were most frequently applied: extremities, mandible, spine, osteonecrosis of femoral head, and penile. Following, the complications on different reconstructive areas are retrieved, studied and presented in five (or more specifically, six) separate sections. By the way, meaningful difference between FVFBG and other bone flap was presented in a few words if necessary. Donor-site morbidities were studied and summarized as a whole. In these literatures, the evidences documented on limb and mandibular reconstruction have the fullest detail, followed by the spine and lastly the penile. In conclusion, FVFBG, though a mature technique, needs further deep and comprehensive study and maybe device-based assistance to achieve better reconstructive effect and minimize donor-site damage.

This study describes our experience using individually designed double skin paddle anterolateral thigh perforator (ALTP) flaps to reconstruct complex soft tissue defects. An anatomical study of double skin paddle ALTP flaps was conducted in six fresh cadavers (12 thighs). We also performed a retrospective cohort study of 36 patients who underwent reconstruction using double skin paddle ALTP flaps from January 2009 to June 2019. The soft tissue defects were large or non-adjacent defects that could not be repaired by a single flap. Three types of double skin paddle ALTP flaps were designed. In type I, separate perforators supplied each flap: one perforator from the transverse branch of the lateral circumflex femoral artery (LCFA) and one from the descending branch of the LCFA (d-LCFA). In type II, both perforators were from the d-LCFA. In type III, a single perforator from the d-LCFA had two branches that each supplied one flap. In the cadaver study, type I was observed in 11 thighs, type II in 10, and type III in six. All patients were successfully treated using double skin paddle ALTP flaps. Four patients received type I flaps, 23 received type II, and nine received type III. Vascular compromise occurred in one patient, and the flap was saved by emergency revascularization. Most patients had satisfactory contours and functional recovery during follow-up. Individually designed double skin paddle ALTP flaps is a reliable option for reconstructing complex soft tissue defects. Moreover, we created an algorithm for microvascular reconstruction of complex soft tissue defects.

Summary Background A high incidence of osteonecrosis of the femoral head (ONFH), a commonly seen and intractable disease, has been reported. This retrospective study aims to compare the reconstructive outcomes by free vascularized iliac bone flap (FVIBF) with those by vascularized pedicled iliac bone flap (PIBF) to determine which one is better for ONFH patients. Methods From January 2010 to December 2017, 35 patients (40 hips) were treated by PIBF grafting, and 32 patients (36 hips) were treated by FVIBF grafting. The two groups were then compared in terms of the preoperative baseline conditions, intraoperative data, and postoperative Harris hip score (HHS). Results In the PIBF group, the operating time was significantly longer than the FVIBF group (195.5 ± 26.4 vs 147.2 ± 17.7 min, respectively), and the intra-operative blood loss was significantly heavier (330.0 ± 63.9 vs 240.3 ± 37.5 ml, respectively). Meanwhile, the recipient site morbidity rate in the PIBF group outnumbered that in the FVIBF group (27.5% vs 8.3%, respectively), and a higher rate of lateral femoral cutaneous nerve (LFCN) injury was observed in the PIBF group than in the FVIBF group (27.5% vs 8.3%, respectively). No difference was found in postoperative HHS score between the two groups. In both groups, the recovery effect of the patients in stage II was better than that in stage III. Conclusion While maintaining a similar clinical effect, the FVIBF grafting exhibited a distinct advantage over the PIBF grafting, in terms of shorter operative time, less blood loss, and lower risk of LFCN injury.

Background To investigate the feasibility and clinical efficacy of free vascularized iliac bone flap based on deep iliac circumflex vessels graft for the treatment of osteonecrosis of femoral head (ONFH) in young adults. Methods Eighteen patients (19 hips) undergoing ONFH were included from January 2016 to May 2017. After the debridement of the necrotic bones, the contralateral vascularized iliac bone flap was designed and harvested before grafting, in which the deep circumflex iliac vessels and the transverse branch (or ascending branch) of the lateral circumflex femoral artery and their accompanying veins were anastomosed. X-ray was obtained at 1, 3, 6, 9, and 12 months respectively for evaluation of the bone flap healing. Hip function was evaluated with Harris hip score at 18 months postoperatively. Results None of the patients is lost to follow-up. All the hips healed well except for four complications: one patient developed superficial wound infection, one patient had subcutaneous hematoma, and two patients developed anterolateral femoral cutaneous nerve injury. X-ray films at 12 months showed improvement in 13 hips (68.4%), five hips (26.3%) were unchanged, and one femoral head collapse with conversion to total hip arthroplasty (THA) at 14 months postoperatively (5.3%). Postoperative mean Harris hip scores were significantly improved compared to the preoperative results (P Conclusion Free vascularized iliac bone flap based on deep circumflex iliac vessels graft is an acceptable treatment option for young adult ONFH in mid-late stage with low conversion to THA rate at short-term follow-up.

A 37-year-old man complained of a refractory posterior malleolar ulceration on his left ankle. He was diagnosed with Werner syndrome according to the progeroid clinical features and genetic testing. To approach the ulceration, a free flow-through right anterolateral thigh perforator flap with anterolateral thigh cutaneous nerve was harvested. One year later, he was readmitted due to a new ulceration on his right ankle. We harvested the left anterolateral thigh perforator flap with anterolateral thigh cutaneous nerve to reconstruct the defect. After one more year of follow-up, there was no recurrence of ulcers, and the sensation of the flap recovered partially after 6 months. We conclude that free flow-through anterolateral thigh perforator flap is a feasible choice for the repair of foot ulcers in Werner syndrome.

Due to the delicate tissue, small blood vessels and incomplete development of interarticular ligaments, skin and soft-tissue defects of the foot and ankle in pediatric patients remain a challenge for orthopedic and plastic surgeons. Anterolateral thigh perforator (ALTP) flap and deep inferior epigastric perforator (DIEP) flap are the most commonly used flaps for the repair of lower-extremity soft-tissue defects. The literature contains a shortage of evidence involving the differences between ALTP and DIEP flaps in the reconstruction of young patients with complex foot and ankle defects. This study was designed to determine which type of flap is better for foot and ankle repair in pediatric patients.From January 2004 to January 2018, 79 children younger than 14 years treated with DIEP flap (41 cases) or ALTP flap (38 cases) for composite defects of the feet and ankles were retrospectively investigated. The two groups were homogeneous in terms of age, the location of the defect, etiology, and flap area. Complications, scarring, cosmetic appearance, flap sensory recovery, and functional outcome were analyzed, and statistical analysis was performed.The ALTP group had shorter operation time (155.0 ± 12.0 min vs 212.2 ± 23.9 min), flap harvested time (39.6 ± 5.1 min vs 57.2 ± 10.4 min), and operative blood loss (143.4 ± 23.7 ml vs 170.7 ± 44.7 ml) than the DIEP group (P 0.05). In short-term follow-up, ALTP group showed a lower flap necrosis rate (5.3% vs 24.4%) and vascular insufficiency rate (2.6% vs 19.5%) than DIEP group (P 0.05). In long-term follow-up, ALTP group showed a lower late complication rate and better cosmetic, functional, scar outcomes than DIEP group (P 0.05).The study showed that an ALTP flap may brings better results than a DIEP flap in terms of short- and long-term complications, scarring, and morpho-functional outcomes for pediatric patients undergoing reconstruction of foot and ankle defects.

BACKGROUND This study investigates the feasibility and clinical impact of the microdissected thin perforator skin flap strategy on bulky and deformed skin flaps during second-stage revision surgery. METHODS Seventeen patients were selected and underwent the microdissected thin perforator skin flap technique to treat bulky and deformed skin flaps after free flap reconstruction between October 2013 and October 2015. Perforator vessels were isolated and protected under a microscope. Subdermal fat with a thickness of 4 mm to 7 mm was preserved, and excess adipose tissue was resected. RESULTS No skin flap necrosis was observed after the operation in all 17 patients, and all wounds healed without complications. Patients were followed up for 3 to 24 months, with an average follow-up time of 10 months. The skin flaps maintain normal color and texture. Both appearance and function of the recipient sites were improved significantly. CONCLUSIONS The utilization of microdissected thin perforator flap technique to further thin bulky skin flaps at the second stage can be effective in a single operation. The blood supply of all free flaps was preserved, with no evidence of necrosis or healing complications. This technique offers an effective approach for secondary thinning of bulky free flaps.

Background: Reconstruction of complex soft tissue defects remains a challenging problem for microsurgery and plastic surgeons. Perforator flaps have become one of most popular option for extremity defect reconstruction in the past two decades due to minimized donor site morbidity and aesthetically contour. Special form perforator flap is the derivative of the perforators flap, and further expands its indications. In this article, we present our experience on using the optimal design of perforator flap for customized reconstruction of complex soft tissue defects of the extremities. Methods: We retrospectively reviewed data from patient who underwent reconstruction of soft tissue defects of the extremities using individual design of perforator flaps between January 2008 and November 2018. We performed the optimal design of perforator flap through graphic design, hierarchy structure and carrying tissue based on characterization of the soft tissue defect. Results: Various types of perforator flaps including flow-through perforator flap, chimeric perforator flap, conjoined perforator flap, micro-dissected perforator flap and multi-lobed perforator flap were performed for the reconstruction of complex soft tissue defect. Those types of flaps also can be adopted for especially difficult extremity reconstruction by combining with each other. Conclusions: Our ten years experiences show that the optimal design of perforator flaps provides more aesthetically contours and minimizes donor site morbidity. It further expends the range of application and indication of perforator flap.

Background: The purpose of this paper was to introduce our experience on a new operative technique for dissecting perforator vascular in the perforator flap and explore its clinical outcome. Methods: Between June 2013 and December 2016, 119 patients underwent soft tissue defects reconstruction with anterolateral thigh perforator flaps (ALTPs) were included in this study. Ninety-eight patients were male, and twenty-one patients were female. The average age of those patients was 40.58 years. Results: The ALTPs were successfully elevated to reconstruct soft tissue defect for 119 patients. The size of skin paddle was 120.59±59.31 cm 2 . A total of 148 perforators were included in the ALTP (84 percent was musculocutaneous perforator, 16 percent was septocutaneous perforator). The mean flap elevation time was 60.85±20.25 minutes. The success rate of flap elevation was 98%, only three perforators were injured and one perforator occurred vasospasm during the operation. Five cases, including three venous crisis and two artery crisis, presented with vascular crisis after flap transfer. The rate of vascular crisis was 4.2%. All of flaps were completely survived except one flap had partial flap necrosis. The mean follow-up time was 13.32±8.9 months. No muscular weakness was displayed in this group. Conclusions: Orderly retrograde dissection of the perforator vessels in the perforator flap can provide with less donor site morbidity, shorter operative time and safer than the traditional methods. It is a reliable operation for elevating the perforator flap.

Venous crisis represents the most common complication in flap surgery and often results in flap failure. The gold standard for free flap monitoring is frequent clinical examination. The current study examined the systemic inflammatory response during the immediate post-operative period following flap venous crisis. Superficial epigastric artery perforator flap transplantation was performed in a total of 30 rabbits. Fifteen animals received venous obstruction by vein ligation (venous crisis group, n = 15) and others were sham treated (control group, n = 15). Venous thrombosis was examined by immunohistochemistry staining. Plasma levels of inflammatory response markers (IL-6, IL-8, TNF-α, and C-reactive protein) and thrombosis biomarkers (von Willebrand factor and tissue factor) were measured at 0, 2, and 4 h post-operation by enzyme-linked immunosorbent assay. The mRNA levels of relevant biomarkers in the flap were analyzed with quantitative real-time PCR. Flap histopathological examination showed erythrocyte and neutrophil aggregations in venous lumen and erythrocyte diapedesis. At 8 h post-operation, serious edema and fibrinoid necrosis were observed and the venous lumen was almost blocked by thrombus. The venous crisis group had higher plasma levels of IL-8, TNF-α, and thrombosis biomarkers. Vein ligation also increased the mRNA levels of IL-8, TNF-α, C-reactive protein, von Willebrand factor, and tissue factor in the flap. No significant change in IL-6 levels was observed between the control group and the venous crisis group. Flap venous crisis was accompanied by the increase in a number of inflammatory and thrombosis markers, both in the peripheral blood and the flaps.