Chih-Kang Chou

The adipofascial turn-over flap for complicated dorsal skin defects of the hand and finger

Six cases of complicated dorsal skin defects of hands and two in fingers were successfully resurfaced with local adipofascial turn-over flaps. Flaps with a base-to-length ratio of 1:1.0 to 1:1.5 survived completely. The width of the attached base was 1.0 to 1.5 cm in hands and 0.5 cm in fingers.

Adipofascial turn-over flap for reconstruction of the dorsum of the foot

Local adipofascial turn-over flaps with skin grafts were successfully used to reconstruct complicated skin defects over the dorsum of the foot in 7 patients. The blood supply of the flap comes from perforators in the base and from the surrounding subcutaneous and fascial plexuses. A new concept of base-to-flap area ratio is proposed to predict the survival of the turn-over flaps in addition to the conventional base-to-length ratio. This appears to be a valuable technique for difficult wounds of the dorsum of the foot.

The distally based posterior tibial arterial adipofascial flap

A distally based posterior tibial artery adipofascial flap with skin graft was used for the reconstruction of soft tissue defects over the Achilles tendon in three cases and over the heel in three cases. Good resurfacing with protective sensation of these wounds was achieved. There was no breakdown of the graft or morbidity of donor sites, which were closed primarily. We believe there were many advantages to this adipofascial flap and that it is an ideal choice for the reconstruction of soft tissue defects in the lower third of the leg and foot, especially over the Achilles tendon.

Limb salvage of infected diabetic foot ulcers with microsurgical free-muscle transfer

This study was comprised of 9 diabetic patients with 10 infected foot ulcers, including osteomyelitis in 4 limbs and gangrene in 3 limbs. Adequate debridement of these complicated wounds inevitably resulted in exposure of bones or tendons. All defects were successfully reconstructed with free gracilis muscle flaps covered with split-thickness skin grafts. No recurrence of ulcer or infection was noted in the muscle-transplanted area during the follow-up period. Laser Doppler perfusion monitor measurement showed that the perfusion unit of the denervated free muscle flap increased to a peak at the second week after transplantation; the neovascularization of the grafted skin, the progressive decrease of the muscle swelling, and the decreased interstitial pressure may be the main contributing factors. The perfusion unit of the muscle flap reached equilibrium with the surrounding tissue at about 8 weeks after microsurgical transfer. Lower extremity amputation is a major health problem in the diabetic population. The microvascular free-muscle transfer was proved to play an effective and important role in limb salvage in diabetic patients with infected foot ulcers. The gracilis muscle flap was recommended due to its lack of bulkiness and minimal donor site deformity.

Reconstruction of soft tissue defects of the lower leg with the distally based medial adipofascial flap

A distally based medial adipofascial flap, based on the lower perforator originating from the posterior tibial vessels, is described. It has been used successfully to cover tibial bone and/or plate exposure on the lower leg in 5 patients.

Early diagnosis of necrotizing fasciitis by utilization of ultrasonography.

Necrotizing fasciitis is a rare and rapid progression soft tissue infection. The only identifiable feature is tissue necrosis along a single fascia plane. Because the skin is initially spared, it is difficult for early recognition prior to extensive tissue destruction. Ultrasonography was used for early diagnosis of this infection in five cases. All 5 patients presented with severe cellulitis. Under the suspicion of necrotizing fasciitis, ultrasonography was performed before surgical debridement. Tissue biopsy was done for histological confirmation of the diagnosis. Three patients were proven to have necrotizing fasciitis and two cellulitis only. The ultrasonographic findings of necrotizing fasciitis included: 1) irregularity of the fascia; 2) abnormal fluid collections along the fascia plane; and 3) diffuse thickening of the fascia when compared with the control site in the normal limb. However, in severe infectious cellulitis, the above mentioned findings were not observed. Our results indicate the usefulness of the ultrasonography for early diagnosis of necrotizing fasciitis.

Innervated reverse digital artery flap through bilateral neurorrhaphy for pulp defects

To provide sensation to the reverse digital artery (RDA) flap, both the dorsal branch from the proper digital nerve and the superficial sensory branch from the corresponding radial or ulnar nerve are sectioned at their proximal ends and included with the RDA flap. These are then anastomosed with the distal ends of both radial and ulnar digital nerves at the recipient wound. Three cases of pulp defects reconstructed by this technique achieved very favourable functional and cosmetic results. The RDA flap, innervated through bilateral neurorrhaphy, seems to be an excellent option for one-stage reconstruction of major pulp defects.

The adipofascial turnover flap for elbow coverage.

Closure of soft tissue defects in the vicinity of the elbow with exposed bone or joint remains a difficult problem. Local adipofascial turnover flaps covered by a skin graft were successfully used to reconstruct two elbow defects. The flaps base was placed 1.5 to 2.0 cm from the wound edge. The flap-to-base area ratio, which is an important index of flap survival, in addition to the traditional length-to-width ratio were 3.25 and 3.3, respectively. The undermined skin of the flap donor site was preserved rather than discarded as in the conventional deepithelialized turnover flap. The primary benefits of this flap are that it is an easy and rapid one-stage procedure, it requires limited immobilization of the involved joint, and it leaves an inconspicuous donor site scar. The motion of the elbow joint was not impeded because the adiposal component of the flap faced the exposed vital structures. The padding is not thick, but is sufficient to cover and protect the elbow. The flap is especially indicated for small- to medium-sized, complicated elbow wounds.

Reconstruction of plantar heel defect using reinnervated, skin-grafted flexor digitorum brevis flap

Two cases with extensive plantar avulsion injuries had their heel defects resurfaced initially with full thickness skin grafts. Two months later, reinnervation presented in areas of grafted skin innervated by medial and lateral plantar nerves. No reinnervation was found in the plantar heel region originally innervated by the medial calcaneal nerve. Heel ulceration in the non-sensate, grafted skin occurred in the first case. Reinnervated, skin-grafted flexor digitorum brevis muscle flaps were then used for reconstructing the non-sensate plantar heels. There was no breakdown of skin during the follow-up period of 8 months and 6 months respectively. This method provides sensate and durable cover for extensive plantar heel defects.

Reconstruction of the upper leg and knee with a reversed flow saphenous island flap based on the medial inferior genicular artery

Soft-tissue defects around the knees and below-the-knee amputation stumps are difficult to reconstruct. We present an option for reconstruction of these defects. Reversed flow saphenous island flaps, based on the medial inferior genicular artery, were successfully transferred in 6 patients. All wounds healed well postoperatively. The donor defect can be closed directly when the width is less than 7 cm. This is a thin and reliable fasciocutaneous flap that is useful in covering defects around the knee joint, popliteal fossa, upper half of the leg, and below-the-knee amputation stump.