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Abstract
Résumé
La reconstruction de la face dorsale du pied nécessite l’apport d’un tissu fin qui permet de recouvrir les structures nobles du pied (tendons, nerfs, vaisseaux) tout en résistant à la contrainte appliquée sur ces tissus lors de la marche ou du port de chaussures. Nous rapportons le cas d’un enfant de 13 ans qui présentait une séquelle de brûlure de troisième degré du pied droit avec une rétraction cutanée et une ulcération chronique douloureuse en regard du 5e métatarsien malgré de multiples greffes de peau. Il était trop douloureux pour se chausser et la marche était difficile. Nous avons réalisé un lambeau perforant libre type « Superficial Circumflex Iliac Artery Perforator flap » (SCIP) mesurant 12 × 7 cm et prélevé à la région inguinale droite afin d’être anastomosé au pédicule vasculaire du premier espace inter-métacarpien droit. À trois mois postopératoire, l’enfant peut à nouveau marcher et se chausser sans douleur. La cicatrice induite au site donneur est discrète au niveau du creux inguinal, cachée dans le sous-vêtement. Le SCIP est un lambeau souple et fin avec une faible morbidité induite au site donneur. Il convient aux reconstructions des extrémités distales des membres, tant chez l’adulte que chez l’enfant.
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Reconstruction of dorsalis pedis with soft tissue is challenging because it needs to preserve thin structure to ensure that the patient will be able to wear shoes. Here, we report the use of a thin superficial circumflex iliac artery perforator (SCIP) flap in dorsalis pedis reconstruction. A 67-year-old man presented with a third-degree burn, which exposed his extensor tendons. A thin SCIP flap from the left inguinal region measuring 15 × 4 cm was transferred to the dorsalis pedis region. Postoperatively, no major cosmetic or functional problems were observed. Because the invasiveness of the donor site is nearly same between SCIP flap and skin graft from inguinal region, SCIP flap is better solution in point of textural qualities for dorsalis pedis reconstruction.
The basic principle of donor site selection is to take skin from areas that will heal with minimal scarring while balancing the needs of the recipient site. For skin loss from the lower legs and feet, the most common harvest site for split‐thickness skin grafts is the anterior or posterior thigh; grafts from the plantar areas have been mostly used to cover the volar aspect of digits and palms. Between September 2015 and September 2017, 42 patients with areas of skin loss on the legs or feet were treated with plantar skin grafts because of their cosmetic benefits and the convenience of the surgical procedure and postoperative wound care. Our technique of harvesting a single layer of split‐thickness skin graft (0.014 in. thick) from a non‐weight‐bearing area of the foot of the injured leg is simple and provided good functional and cosmetic outcomes at both the donor and recipient sites. All patients were very satisfied with the recovery progress and final results. Therefore, in the management of skin defects in the lower legs or feet that comprise less than 1.5% of the total body surface area, our surgical method is a reliable alternative to anterior or posterior thigh skin grafting.
Background The anterolateral thigh (ALT) flap remains a workhorse for soft tissue reconstruction. However, the traditional ALT flap is often too bulky for resurfacing shallow, distal extremity defects, prohibiting adequate function, or well-fitted orthotics. This study evaluates extremity reconstruction using ALT flaps elevated in the suprafascial or super-thin plane.
Methods Retrospective review of ALT free flap reconstruction from October 2014 to July 2016 was performed. Suprafascial and super-thin flaps were those elevated just above the crural fascia and within the superficial scarpal plane, respectively. Adjunct operative procedures, demographics, and complications were recorded.
Results A total of 25 patients underwent suprafascial (n = 14) or super-thin (n = 11) ALT flap reconstruction for primarily lower extremity wounds (n = 19), with an average age and body mass index of 53.8 years and 26.3 kg/m², respectively. Follow-up was 6.3 months. Comorbidities included smoking (n = 7), diabetes (n = 8), peripheral vascular disease (n = 6), and hypertension (n = 8). The presence of hardware (n = 9), trauma (n = 10), and chronic infection (n = 12) were common risk factors. Average flap size was 8.2 × 21.5 cm, with 64% (n = 16) taken on one perforator. Forty-eight percent (n = 12) were end-to-side anastomoses and 62% (n = 13) utilized one venous anastomosis. Mean hospital stay was 7.8 days with a 24% (n = 6) complication rate. There were no partial or complete flap losses.
Conclusion The ALT flap, elevated in a suprafascial or super-thin plane, is a safe, effective option for extremity soft tissue reconstruction. The decreased flap volume and bulk provides the improved contour and pliability necessary for appropriate distal extremity function. The potential versatility of super-thin flaps reinforces the importance of continued innovation by reconstructive microsurgeons.
Summary Introduction Superficial circumflex iliac artery perforator (SCIP) flap is based on the perforator of superficial circumflex iliac artery (SCIA) system, and is a highly useful surgical tool with a wide variety of clinical applications. The SCIA system is associated with considerable anatomical variation, however, rendering transfer of a SCIP flap technically difficult. Patients and methods Using preoperative color Doppler ultrasound (US), we examined a total of 11 flaps of 11 patients who had undergone reconstruction with SCIP flap from April to August of 2014. The origin of SCIA from femoral artery and the bifurcation of its superficial branch and deep branch were easily identifiable in all patients. Perforator courses and their penetration points were marked to guide dissection. Results Although one patient required secondary revision and skin grafting because of partial necrosis, there were no serious postoperative complications such as total necrosis or resulting absorption of the transferred adiposal flap. In all cases, findings from the preoperative color Doppler US were useful in delineating the dominant vessel within the groin lesion. Conclusion Using the technique described above, difficulties arising from the anatomical variation within the SCIA system are easily overcome, simplifying SCIP flap harvest. In addition to being relatively easy, the technique is also quick to administer and safe.
Background Perforator flaps have been used extensively in the field of reconstruction, and the thoracodorsal artery perforator (TDAP) flap is very popular. However, the perforator flap can be relatively bulky in some cases, depending on the defect's location. Thus, several methods have been developed to address this bulkiness, including modification of the flap elevation, application of an ultrathin flap using microdissection, and the defatting technique. However, these methods have various disadvantages, so we developed an adjustable thin TDAP flap using modification of the flap elevation and defatting technique. Methods Between January 2012 and February 2015, 13 patients underwent reconstruction of defects of their upper and lower extremities using TDAP flaps. We measured all the flap dimensions, except for thickness, because it was adjusted for the target defect. Results The mean flap size was 94 cm(2) (range: 48-210 cm(2)), and all flaps were ≤10 cm wide to facilitate primary donor-site closure. Two subjects with a history of diabetes exhibited partial flap loss, so we performed secondary skin graft surgery. Conclusions The TDAP flap elevation was modified at the superficial fascia plane, and the defatting technique was used to adjust the flap volume. This technique provided more natural contours and minimized the need for secondary debulking.
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Background When using groin flaps the scars can be easily covered. However, disadvantages including short pedicle lengths, anatomical variations in the vessels, and flap bulkiness, have prevented their widespread use. We examined the use of superficial circumflex iliac artery perforator (SCIP) free flaps to moderate-sized defects in the distal extremities. Methods From July 2011 to August 2014, 52 patients underwent reconstructions using SCIP free flaps for moderate-sized defects in the distal upper and lower extremities. We measured the flap sizes and the thicknesses and pedicle lengths. Results The mean flap size was 75 cm(2). The flaps were up to 7 cm wide as all donor sites underwent primary closure. The mean flap thickness was 5 mm, and mean pedicle length was 4.5 cm. Two cases showed total necrosis, and two cases showed partial losses in the flap margins. Among the two cases with partial necrosis, one case was managed using conservative treatment without surgery, whereas the other case underwent secondary skin-graft surgery. Conclusion We reconstructed moderate-sized defects in the distal upper and lower extremities using SCIP flaps, and observed that SCIP flaps have several advantages. After applying thin flaps to the defects, the contour of the flap site appeared symmetrical and natural when compared with the uninjured contralateral side of the distal limb, and no debulking surgery was required. No complications were observed at donor sites, and the surgical scars were well concealed by underwear.
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.
Superficial circumflex iliac artery perforator (SCIP) flap is based on the perforator of superficial circumflex iliac artery (SCIA) system, and is a highly useful surgical tool with a wide variety of clinical applications. The SCIA system is associated with considerable anatomical variation, however, rendering transfer of a SCIP flap technically difficult.
Using preoperative color Doppler ultrasound (US), we examined a total of 11 flaps of 11 patients who had undergone reconstruction with SCIP flap from April to August of 2014. The origin of SCIA from femoral artery and the bifurcation of its superficial branch and deep branch were easily identifiable in all patients. Perforator courses and their penetration points were marked to guide dissection.
Although one patient required secondary revision and skin grafting because of partial necrosis, there were no serious postoperative complications such as total necrosis or resulting absorption of the transferred adiposal flap. In all cases, findings from the preoperative color Doppler US were useful in delineating the dominant vessel within the groin lesion.
Using the technique described above, difficulties arising from the anatomical variation within the SCIA system are easily overcome, simplifying SCIP flap harvest. In addition to being relatively easy, the technique is also quick to administer and safe.
Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
The superficial circumflex iliac artery perforator (SCIP) flap is an evolved form of groin flap. It overcomes the inherent disadvantages of groin flap by preserving the deep fascia but still requires challenging skills because of short pedicles and small caliber of vessels. The use of SCIP flap was evaluated for lower extremity use.From June of 2009 to August of 2011, a total of 79 cases were performed (age range, 4-80 years) on the lower extremity using supermicrosurgical approach. All flaps were harvested above the deep fat and the pedicles were taken above or just below the deep fascia to reconstruct the defects throughout the lower extremity.Supermicrosurgery technique was used in 71 cases. A total of 75 cases were performed successfully; 1 case underwent revision but failed and 2 cases were lost within 2 days of surgery. Average size of the flap was 75.5 cm, thickness 7 mm, average length of pedicle was 5 cm, and the average caliber of artery was 0.7 mm. Donor sites were all closed primarily but complications were noted with 1 dehiscence and prolong drainage of lymphatics. Flaps provided good functional coverage and appearance. The average follow-up was 12 months.With the modification of elevating the flap on the superficial fascia, we can harvest a thin flap without additional debulking and avoid complications such as lymphorrhea. Furthermore, with the perforator to perforator or perforator to small distal vessel approach, we can apply this flap on all regions of the lower extremity overcoming the difficulties with short pedicle and small vessel caliber. In our hands, the modified SCIP flap is the flap of choice for small to moderate size defects in the lower extremity.
The superficial circumflex iliac artery perforator (SCIP) flap was first reported in 2004, in which the concept of perforator flap was incorporated into the groin flap. Although a SCIP flap has many advantages, reports on its application to head and neck defects are limited. We present cases of SCIP flap transfer for reconstruction of various types of head and neck defects.Twelve patients underwent reconstruction using the free SCIP flap after tumor ablative surgery in the head and neck region. The flap was elevated based on the perforators of the superficial branch and/or deep branch of the superficial circumflex iliac artery. The thickness of the flap was adjusted according to the defect. The Photo Dynamic Eye infrared camera system using indocyanine green was used to detect the location of the perforators preoperatively and to confirm the blood flow after elevation of the flap. The flaps survived completely in all the cases. The mean pedicle length was 7.1 cm (range, 6-9 cm), and the mean flap size was 12.8 × 6.3 cm (range, 4 × 2 to 18 × 8 cm). No vein grafting was necessary in any patient.The advantages of the SCIP flap include 1) low donor-site morbidity; the donor site is in a hairless concealed area, primary donor-site closure is possible, and no muscular dissection is necessary; 2) adjustable thickness of the flap from a superthin flap to a bulky flap; and 3) a long vascular pedicle available.We believe that the SCIP flap will become one of the most versatile options in head and neck reconstruction.
Microtia or pinna deformities with congenital aural atresia are severe conditions that significantly affect the quality of life. Although several surgical treatments have been proposed for aural atresia, revision surgery is often required to address complications associated with the initial procedure, which include external auditory canal stenosis, lateralization of the tympanic membrane and chronic recurrent otorrhea. However, such problems may be addressed by using vascularized skin. We herein report a new method of reconstruction for congenital aural atresia in three cases using the superficial circumflex iliac artery as a pure skin perforator flap.
The branch of the superficial circumflex iliac artery perforator was traced distally to a point where it penetrated the dermis. After identifying the branch of the perforator penetrating the dermis (termed the "pure skin perforator"), the pure skin perforator flap was elevated. A new external auditory canal was then created by drilling through the mastoid air cells and atresia plate. The pure skin perforator flap was folded into a 1.5×3 cm sac, which was placed into the external auditory canal. The superficial circumflex iliac artery and the superficial circumflex iliac vein were anastomosed to the superficial temporal artery and the superficial temporal vein, respectively.
All of the pure skin perforator flaps survived. The flap sizes varied from 10×2.5 to 10×4 cm (average area of 32.5 cm2). These skin perforator flaps were all 2 mm thick.
Pure skin perforator flaps fed only by the dermal subpapillary plexus survived, regardless of the presence of the subdermal plexus. The pure skin perforator flap can be as thin as a skin graft and it has the possibility to reduce the complications that frequently occur when the previously reported procedures are used.
Burns of the feet pose unique and difficult problems in initial management, reconstruction, and the attainment of long-term functional results. The primary reconstructive goals for this region are unimpeded ambulation and weightbearing. These objectives can be achieved by adherence to established principles of wound management, a clear delineation of the reconstructive requirements of the foot, and a team approach toward attaining these goals.
An anatomic study (40 fresh dissected specimens) and clinical experience (14 patients) have shown the reliability of a skin flap designed on the lower third of the lateral aspect of the leg. It is supplied by a cutaneous branch from the perforating branch of the peroneal artery. This perforating branch continues distally deep to the fascia along the anterior ankle and into the foot. This can be used as a reversed pedicle, giving the flap an arc of rotation that allows coverage of the dorsal, lateral, and plantar aspects of the foot, the posterior heel, and the lower medial portion of the leg.
The results of reconstructive procedures for the treatment of burn scar contractures of the feet in 55 children undergoing 90 operations were reviewed. The patients were treated in all but one case by release of the contracture band with placement of a skin graft in the resulting defect. There was an overall recurrence rate of 15 per cent that was not affected by the use of split-thickness versus full-thickness grafts. The time delay from the thermal injury to the reconstructive procedure was also found not to affect the outcome. Postoperative immobilization by the use of either a dynamic or an adynamic splint was found to be important both for preventing graft loss and for decreasing the rate of contracture recurrence.
Scarring and contractures of the foot can be very disabling sequelae of burn injury, leading to recurrent ulcerations and chronic problems in wearing shoes. Proper management during the acute phase and reconstruction can prevent most of these disabilities. At the Galveston Unit of the Shriners Burns Institute, split thickness skin grafts and local flaps have proved satisfactory for reconstructing almost all burn scars of the foot in children. We use skeletal traction immobilization for skin grafting, and firm elastic and orthopedic shoe support after healing. We have reviewed our experience in the acute and reconstructive surgical care of sixty-six patients with third degree burns of the feet including grafting, skeletal traction, Z-plasty, and local and cross-leg flaps. Amputation of a toe or extremity has rarely been needed nor has tendon lengthening been required.
The superficial circumflex iliac artery perforator (SCIP) flap differs from the established groin flap in that it is nourished by only a perforator of the superficial circumflex iliac system and has a short segment (3 to 4 cm in length) of this vascular system. Three cases in which free superficial circumflex iliac artery perforator flaps were successfully transferred for coverage of soft-tissue defects in the limb are described in this article. The advantages of this flap are as follows: no need for deeper and longer dissection for the pedicle vessel, a shorter flap elevation time, possible thinning of the flap with primary defatting, the possibility of an adiposal flap with customized thickness for tissue augmentation, a concealed donor site, minimal donor-site morbidity, and the availability of a large cutaneous vein as a venous drainage system. The disadvantages are the need for dissection for a smaller perforator and an anastomosing technique for small-caliber vessels of less than 1.0 mm.
The free radial forearm flap is a very common material for penile reconstruction. Its major problems are donor-site morbidity with large depressive scar after skin grafting, urethral fistula due to insufficiency of suture line for the urethra, and need for microvascular anastomosis. A new method using combined bilateral island SCIP flaps for the urethra and penis is developed for gender identity disorder (GID) patients. The advantages of this method are minimal donor-site morbidity with a concealed donor scar, and possible one-stage reconstruction for a longer urethra of 22 cm in length without insufficiency, even for GID female-to-male patients. A disadvantage is poor sensory recovery.
Use of split-thickness plantar skin grafts in the management of leg and foot skin defects
- Liu
Specificities in children wound healing
- Sanchez
The thin ALT perforator flap for oropharyngeal robotic-assisted reconstruction
- Qassemyar