From 2000 to 2003, we used 6 different kinds of flaps to repair 99 cases of dorsal skin defects with good results, but we also found the shortcomings of various flaps.
Surgical approach
The type of flap to be used is decided preoperatively according to the extent and nature of the dorsal skin defect. When designing the flap, the flap shape as well as the transfer position and length of the tip were designed according to the size and shape of the trauma as well as the site.
1, the treatment of the recipient area: traumatic wounds are given a thorough debridement, scar tissue is given a full hemostasis after excision, such as the use of free medial foot flap, free dorsal wrist artery and vein to accept the donor area artery and vein.
2, the transplantation of tissue flaps should follow the principle of non-invasive: cut different flaps according to the requirements of the recipient area and move them to the recipient area to cover the wound. The fascial flap of the adjacent fingers should be free implanted on the fascial flap, the original skin of the donor area should be sutured, and the rest of the flap should be free implanted in the donor area for repair.
3.Postoperative treatment: Routine application of anticoagulation, antitussive and antibiotic treatment. The affected hand was fixed with a plaster rest and the blood flow of the tissue flap was observed regularly.
The selection of tissue flap for repairing hand tissue defects should be based on the tissue defect, the characteristics of the tissue flap and the technical conditions of the operator, and in principle, the simpler the better. Most scholars believe that the following principles should be followed for hand wound repair:
1, the trauma can be solved by skin flap grafting without tissue flap grafting.
2, the tissue defect that can be grafted with local flap is not repaired with distant flap.
3, can use non-trunk vascular flap does not sacrifice the trunk vascular flap.
4, anastomosis of the tissue flap transplantation depends on the experience of the surgeon, technical conditions and healing function needs.
5, should pay attention to the donor area tissue flap cut after the impact on the function, aesthetic.
Advantages and disadvantages of each flap.
1, adjacent finger flap: because the donor area and the recipient area have the same tissue properties, it is the best repair tissue, simple to operate, and can be mastered by a low-grade surgeon, but because the two fingers overlap and are fixed after surgery, the patient is uncomfortable, and the tip is easily twisted, thus affecting the flap blood flow, and the repair defect area is limited.
2.Fascial flap: The fascial flap is composed of subcutaneous tissue and deep fascia, the main source of blood supply is the main artery through the muscle septum or muscle gap and from the myocutaneous penetrating branch, the vascular network in the superficial layer of deep fascia is not only close to the fascia, but also travels to the superficial layer, forming a fascial vascular network circulation system, and communicates with the subcutaneous and subdermal vessels, forming a three-dimensional reticular vascular circulation system, so that the fascia has a rich blood supply. The procedure is simple, no need to suture the blood vessels, only need to free the skin on the tissue flap, the disadvantage is that it is impossible to observe the blood flow, and the repair area of the defect is not large.
3, retrograde island flap of the finger: suitable for mid and terminal skin defects, while the finger arteries and soft tissues on both sides of the finger are normal, the surgery is completed in one operation, and one major artery needs to be sacrificed.
4.Dorsal palmar artery island flap: It is based on the fact that each dorsal palmar artery has constant and abundant anastomosing branches with each finger artery at the level of the metacarpal neck, which can retrogradely supply sufficient blood to the flap. Due to the short tip, it is often unable to repair the end skin defect. Because of the retrograde island flap and the subcutaneous tunnel compression, it is also prone to venous reflux obstruction and tension blistering.
5, flap: it is a further improvement of the dorsal palmar artery flap, according to the anatomical characteristics of the dorsal palmar artery and the dorsal carpal artery network have communication, so that the vascular tip of the dorsal palmar artery flap is greatly extended, because of the long tip, it can repair the end dorsal skin defect, but the operation is time-consuming, and because of the long tip, and the subcutaneous tunnel compression, the venous return is poor, and the flap often has tension blisters after surgery.
6, free medial pedal flap: the medial pedal artery deep branch and saphenous vein as the vascular tip, with the saphenous nerve issued by the skin nerve flap, the advantage is that the repair area is large, the operation is completed in one time, the disadvantage is that it requires high microscopic operation techniques, the risk is large, the donor area due to the foot navicular node on the subcutaneous tissue is small, the skin implantation is prone to necrosis, because of the free flap, if the defect area is too small is not adapted.
Factors affecting the efficacy and countermeasures: The transplantation of tissue flap, which requires vascular anastomosis or vascular tip separation, has been widely used, but there are still experiences and lessons to be learned.
1, the recipient area is infected trauma: open hand injury, serious contamination of the trauma or long-term inflammatory reaction, poor conditions for anastomosis, intraoperative antibacterial treatment of the trauma and incomplete debridement of the trauma and vessels, postoperative vascular crisis, resulting in failure due to intravascular infectious thrombosis. Therefore, for infected wounds, the debridement must be thorough, and the vascular debridement must reach the normal place of the vascular wall. If the contamination of the wounds is serious or the tissue damage is extensive and heavy, the operation can be postponed and the surgery can be carried out after repeated debridement, drug exchange and anti-infection treatment.
2.Surgical operation: In addition to the careful design of tissue flap transplantation, the surgical operation should be especially precise and careful, and the technique of small vessel anastomosis should be mastered.
3, the treatment of blood circulation crisis: divided into arterial and venous crisis, arterial crisis is mainly manifested as pale skin flap, skin temperature, capillary response disappeared, as well as the edge of the flap incision does not bleed, the first treatment is to replenish the blood volume, analgesia, insulation and application of antispasmodic treatment, if after the above positive treatment for 2 hours still no improvement, surgery should be investigated as soon as possible. Venous crisis is mainly manifested by swelling of the flap, dark purple color, and purple spots, and serious blisters, which should also be treated promptly, mostly caused by compression, including suture compression or postoperative bleeding after dry constriction compression, which needs to be lifted immediately.