Role of the Gastrocnemius Musculocutaneous with a Propeller Style Skin Flap in Knee Region Reconstruction: Indications and Pitfalls

Sapino Gianluca,Osinga Rik,Maruccia Michele,Guiotto Martino,Clauss Martin,Borens Olivier,Guillier David,di Summa Pietro Giovanni 대한성형외과학회 2023 Archives of Plastic Surgery Vol.50 No.6

Background Soft tissue reconstruction around the knee area is still an open question, particularly in persistent infections and multiple reoperations scenario. Flap coverage should guarantee joint mobility and protection, even when foreign materials are implanted. The chimeric harvesting of the musculocutaneous gastrocnemius flap, based on the sural artery perforators, can extend its applicability in soft tissue reconstruction of the upper leg, overcoming the drawbacks of the alternative pedicled flaps.Methods A multicenter retrospective study was conducted enrolling patients who underwent to a pedicled, chimeric gastrocnemius musculocutaneous–medial sural artery perforator (GM-MSAP) or lateral sural artery perforator (GM-LSAP) flap for knee coverage in total knee arthroplasty (TKA) recurrent infections and oncological or traumatic defects of the upper leg from 2018 to 2021. Outcomes evaluated were the successful soft tissue reconstruction and flap complications. Surgical timing, reconstruction planning, technique, and rehabilitation protocols were discussed.Results Twenty-one patients were included in the study. Nineteen GM-MSAPs and 2 GM-LSAPs were performed (soft tissue reconstruction in infected TKA [12], in infected hardware [4], and in oncological patients [5]). Donor site was closed primarily in 9 cases, whereas a skin graft was required in 12. Flap wound dehiscence (1), distal flap necrosis (1), distal necrosis of the skin paddle (1), and donor site infection (1) were the encountered complications. Flap reraise associated to implant exchange or extensive debridement was successful without requiring any further flap surgery.Conclusion The propeller–perforator GM-MSAP offers qualitative defect coverage and easiness of multiple flap reraise due to skin availability and its laxity.

내측 족저 동맥을 이용한 도피판술의 임상적 고찰

정덕환,한정수,김용환,남기운,김진원,Chung, Duke-Whan,Han, Chung-Soo,Kim, Yong-Hwan,Nam, Gi-Un,Kim, Jin-Won 대한미세수술학회 1993 Archives of reconstructive microsurgery Vol.2 No.1

Soft-tissue deficits over the plantar forefoot, plantar heel, Achilles tendon, and distal parts of lower leg are often troublesome to cover with a simple graft or local flap due to limited mobility of surrounding skin and poor circulation in these area. Soft-tissue reconstruction in these regions should provide tissue components similar to the original lost tissue, supply durability and minimal protective pressure sensation and result in a donor site that is well tolerated and treated. We analysed 7 cases that were treated with the Instep flap due to soft-tissue defects over these regions from July of 1990 to July of 1993. All flaps were viable and successful at follow-up. 1. The age ranged from 9 years to 60 years, and 6 cases were male and 1 case female. 2. The sites of soft-tissue loss were the plantar forefoot(1 case), plantar heel(3 cases), Achilles tendon(2 cases), and distal parts of lower leg(1 case). 3. The causes of soft-tissue loss were simple soft-tissue crushing injury(1 case), crushing injury of the 1st toe(1 case) and posttraumatic infection and necrosis(5 cases). 4. The associated injury were open distal tibio-fibula, fracture(2 cases), medial malleolar fracture of the ankle(1 case), Achilles tendon rupture(2 case) and 1st metatarso-phalangeal disarticulation(1 case). 5. The size of flap was from $3{\times}4cm$ to $5{\times}10cm$(average $4{\times}5.6cm)$. 6. In 7 cases, we were not to find post-operative necrosis and infection, non-viability, limitation of ankle joint, and gait disturbance caused by the Instep flap surgery. 7. This study demonstrates that the Instep flap should be considered as another valuable technique in reconstruction of these regions.

다양한 연부조직 재건에서의 대망피판의 유용성

이화섭,박세정,류형호,서만수,이동걸,정호윤,박재우,조병채 대한성형외과학회 2005 Archives of Plastic Surgery Vol.32 No.4

Extensive and complicated defects on the body call for an omnipotent tool for a perfect reconstruction. Flaps derived from the omentum has many advantages over the conventional flaps. From 1999 to 2004, Omental flaps were applied for various soft tissue reconstructions. Among total 20 total 7 cases were for immediate reconstruction, 2 cases for chronic infection, 3 cases for simultaneous reconstruction of two defects, 4 cases for functional joint reconstruction and 4 cases were for flow- through revascularization. Among these cases, 3 cases were operated with minimal incision harvest technique. There were no complete flap failures, partial necrosis of the distal parts were noted on three cases. The omental flap is indicated on a large contaminated defect reconstruction due to its large size, well-vascularized, and malleable properties. The omental flap provides several additional advantages over other flaps, which are; the availability of the one staged simultaneous reconstruction of two defects with one flap, providing gliding function for the joint motion, and a flow-through characteristics with long vascular pedicle. But there are some serious shortcomings, including a long abdominal scar and intraabdominal problems. However, these are rare and can be minimized with our minimal incision technique. Due to its unique characteristics. the omentum is one of the ideal tissues for the reconstruction of the complicated soft tissue defects due to its unique characteristics.

연부조직결손의 재건을 위한 전외측 대퇴부 피판술의 유용성

이충훈,조재윤,정덕환,이재훈,Lee, Chung-Hoon,Jo, Jae-Yun,Chung, Duke-Whan,Lee, Jae-Hoon 대한미세수술학회 2005 Archives of reconstructive microsurgery Vol.14 No.2

Purpose: To present our experience and design modification of an anterolateral thigh flap in soft tissue reconstruction. Materials and Methods: Between April of 2004 and May of 2005, 26 anterolateral thigh flaps were used in 26 patients. There were 22 males and 4 females between 23 and 60 years (mean, 40years). The mean follow-up period was 11($4{\sim}18$) months. All cases were a cutaneous flap. Twenty-two were musculocutaneous perforator flaps(85%) and 4 were septocutaneous perforator flaps(15%). Four flaps were used as a sensate flap. While the donor sites were closed directly in 14 cases(54%), 12 cases(46%) underwent skin grafting of the donor site. During the flap design, a triangular skin design was added to a vascular anastomosis site in 14(54%) patients and used as a roof of the tunnel. The healing period of the skin graft between those performed above the fascia and above the muscle were compared. Results: The average size of the flaps was $16{\times}9(11-20{\times}7-12)\;cm$. The overall flap success rate was 96%. Complications encountered were infection in 4 cases, and marginal skin necrosis in 1 case. The healing period was delayed with the infection in 3 of the 6 cases involving a skin graft over the fascia. All 14 cases with the triangular skin design survived, but there was 1 flap failure and 1 marginal necrosis in 12 cases without a triangular skin design. Conclusions: It may be better to undergo a skin graft above the muscle than above the fascia in covering a donor site defect, and to use a triangular skin design in order to prevent vascular insufficiency. An anterolateral thigh flap is a versatile flap for a soft tissue reconstruction because its thickness and volume can be adjusted to the extent of the defect with minimal donor site morbidity.

조직확장술을 이용한 연조직 재건

한기환,김영환,최동원,송중원,강진성 大韓成形外科學會 1994 Archives of Plastic Surgery Vol.21 No.5

Over the 7 years, we have used tissue expansion technique to achieve soft tissue reconstruction in 61 patients with various kinds of congenital or acquire defects of the scalp, face, trunk, and extremities. Of these patients, 25 were male and 36 were female, ranged in age from 5 to 36 years(mean 21). Burn scar(44%) was the most common indication and the rest of them were traumatic scar, microtia, tumor, nevus, vascular malformation, paraffinoma, and cleft lip scar. Twenty five expansions were performed in the face, 12 in the scalp, 9 in the upper extremity, 7 in the ear, 5 in the neck, 4 in the lower extremity, and 1 in the trunk. Rectangular shaped prosthesis with remote internal reservoirs were most commonly used types, and the expander volume ranged from 1.5 to 1,100 mL. Every expander was prefilled to 21 percent of its volume in average and inflation was begun about 2 weeks after implantation. The process was repeated at weekly intervals until adequate tissue expansion was obtained. Expansion period ranged from 2 to 31 weeks(mean 13). Hyperexpansion(mean 130%) was a rule in this series, allowing a skin surplus for reconstruction. Clinical assessment was done with an excellent result of 37%, especially in the scalp. Twenty two percent of the patients had complications requiring specific treatment with consequent alteration of the treatment plan. The most common complication was prosthesis exposure.

Oblique Axis Hypothenar Free Flaps: Tips for Harvesting Larger Flaps with Minimal Donor Site Morbidity

Oh Sang Ho,Chung Jae In 대한성형외과학회 2023 Archives of Plastic Surgery Vol.50 No.3

Background Hypothenar free flaps (HTFFs) have been widely used for reconstructing palmar defects. Although previous anatomical and clinical studies of HTFF have been conducted, this technique still has some limitations. In this study, we describe some tips for large flap design that allows for easy harvesting of HTFFs with minimal donor site morbidity.Methods A total of 14 HTFF for hand defect reconstruction were recorded. The oblique flap was designed in the proximal HT area following relaxed skin tension line along the axis between fourth web space and 10 mm ulnar side of pisiform. A flap pedicle includes one or two perforators with ulnar digital artery and HT branch of basilic vein. In addition, innervated HTFF can be harvested with a branch of ulnar digital nerve. Electronic medical records were reviewed to obtain data on patients' information, operative details, and follow-up period. In addition, surgical outcome score was obtained from the patient, up to 10 points, at the last follow-up.Results Mean harvest time was 46 minutes, and two perforators were included in 10 cases. The mean flap area was 10.84 cm2. There were no problems such as donor site depression, scar contracture, keloids, wound dehiscence, numbness or neuroma pain at donor sites, and hypersensitivity or cold intolerance at flap site, either functionally or aesthetically.Conclusion Palmar defect reconstruction is challenging for hand surgeons. However, large HTFF can be harvested without complications using the oblique axis HTFF technique. We believe our surgical tips increase utility of HTFF for palmar defect reconstruction.

수지 재접합 실패시 허혈 상태의 수지골과 피판술을 이용한 구제술

권부경,정덕환,이재훈,Kwon, Boo-Kyung,Chung, Duke-Whan,Lee, Jae-Hoon 대한미세수술학회 2007 Archives of reconstructive microsurgery Vol.16 No.2

Failure of reattachment of finger is inevitable in replantation surgery and that failure rate is about 10 % are reported in many authors. Management of the failed finger replantation is challenge to microsurgeons. We report 7 cases of thumb reconstruction after failure of replantation. The reconstructive surgery composed with early debridement of soft tissue that are under gangrenous processing, extract the phalangeal bone without any soft tissues. Osteosynthesis of the extracted phalangeal bone with host phalangeal bone. The exposed bony portion covered with vascularized flaps such as reverse radial forearm pedicled flap, free radial forearm flap and neurovascular island finger flap. This procedure underwent within a week after vascular insufficiency developed. All of the flaps are survived, bone union achieved within 3 months. The function and external appearance of the reconstructed thumb were encouraging; pinch power was average 1.2 pounds. Early removal of necrotizing soft tissue followed by covering none vascular phalangeal bone which extracted from the dead phalanx with vascularized flap is one of the useful alterative solutions in failed replantation surgery in hand.

Efficacy of Staged Surgery in the Treatment of Open Tibial Fractures with Severe Soft Tissue Injury and Bone Defect

윤용철,김영우,송형근,윤영현 연세대학교의과대학 2022 Yonsei medical journal Vol.63 No.10

Purpose: We aimed to report the clinical and radiological outcomes of staged surgery using the acute induced membrane tech nique with an antibiotic-impregnated cement spacer (ACS) and soft-tissue reconstructive surgery and to identify factors affecting clinical outcomes. Materials and Methods: Thirty-two patients with severe open tibia fractures were treated via staged surgery from January 2014 to December 2019 and followed up for ≥1 year. In the first surgery, an ACS was inserted into the bone defect site along with debride ment and irrigation and was temporarily fixed in place with an external fixator. The internal fixator was placed, and flap surgery and cement spacer changes were performed during the next surgery. In the third surgery, an autogenous bone graft was performed. Ra diologic and functional results were investigated according to the Association for the Study and Application of the Method of Ilizarov (ASAMI) criteria, and factors affecting the ASAMI score were analyzed. Results: The average bone defect width was 43.9 mm, and the size of soft-tissue defect was 79.3 cm2. Bone union was achieved in all cases except one and required 9.4 months on average. Complications occurred in 10 cases (31.2%). Good or better clinical ef fects, in terms of ASAMI radiologic and functional scores, were observed in 29 and 24 cases, respectively. Complications and ad ditional surgery were common factors affecting the two scores. Conclusion: Staged surgery using the acute induced membrane technique and soft-tissue reconstructive surgery is an efficacious treatment for open tibial fractures with bone defects.

외상성 연부조직 결손의 재건

박종웅 ( Jong Woong Park ) 대한골절학회 2015 대한골절학회지 Vol.28 No.4

Soft tissue defect combined with an open fracture is a very challenging problem to the orthopaedic surgeon. Many complicated open fractures remain with soft tissue defect, chronic osteomyelitis, and sometimes terminate with major limb amputation. Soft tissue defect should be reconstructed as soon as possible, particularly when the bone, tendon, or neurovascular structures are exposed. Exposure for longer than a week significantly increases the risk of secondary infection and tissue necrosis. For the simple soft tissue defect, negative pressure wound closure technology has been introduced and many superficial wounds have been treated successfully using this method. For the more complicated wounds, many kinds of local flaps, pedicled flaps, muscle and fascisocutaneous flaps can be indicated according to the characteristics of the wounds. The free flaps including free vascularized bone graft can be considered as a final choice for the most difficult wound problems. In this article, various reconstruction strategies for soft tissue defect after traumatic open fracture are reviewed.

경골 개방성 골절의 연부 조직 재건

김영우,박호연,서유준 대한수부외과학회 2020 대한수부외과학회지 Vol.25 No.3

Tibia fractures are the most common long bone fracture and about 24% of them are open fractures. Open fractures accompany disruption of the soft tissue around the fracture site and the fractures are exposed to the external environment. Contamination of the fracture site and devitalization of the injured soft tissue greatly increase the risk of infection, nonunion, and other complications. The first and most important treatment goal of open fractures is prevention of infection. To accomplish this objective, immediate radical debridement and irrigation, second-look operation, and subsequent soft tissue reconstruction should be performed as soon as possible. However, early soft tissue reconstruction is not always possible and when it should be delayed, negative pressure wound therapy is recommended. Among various reconstructive armamentarium including skin graft, local flaps, pedicled flaps, and free flaps, the best method need to be chosen based on patient’s general condition, size of defect, neurovascular status, range of injury zone, and cosmetic and functional perspectives. Preoperative in-depth evaluation of vascular structures is mandatory and free flaps are preferred when the range of injury zone is wide. 장관골 중 가장 흔히 골절되는 뼈는 경골이며 이 중 약 24%는 개방성 골절이다. 개방성 골절은 폐쇄성 골절에 비해 감염이나 불유합 등, 합병증 발생률이 현저히 높기 때문에 세심한 치료가 필요하다. 개방성 골절의 치료에서 가장 중요한 것은 감염 방지이며, 이를 위해서는 일차적으로 철저한 창상 세척과 변연 절제술을 시행하고 가능한 빨리 연부 조직을 재건해야 한다. 다발성 외상 환자처럼 조기에 연부 조직 재건술을 시행하기 불가능할 때는 음압 창상 치료법의 사용이 권장된다. 손상된 연부 조직을 재건할 때는 환자의 전신 상태, 결손의 크기와 깊이, 신경 및 혈관 손상 여부, 손상 구역의 범위, 미용 및 기능적 측면을 모두 고려하여 피부 이식술, 국소 피판술, 유경 피판술, 유리 피판술 중에서 적절한 방법을 선택해야 한다. 특히, 하지의 혈관 손상 여부에 대한 정확한 평가와 손상 구역의 범위에 대한 고려가 중요하며, 손상 구역의 범위가 넓은 경우에는 유리 피판술이 더 유리할 것으로 생각된다.