ObjectiveTo review the nomenclature, functional unit construction, technical essentials, and prevention and treatment of complications of functional perforator flaps, so as to provide references for the structural and functional reconstruction of composite tissue defects. MethodsBy retrieving and analyzing domestic and foreign literature on anatomical research, technical innovation and clinical application of functional design and application of perforator flaps, combined with the clinical practice of our team, the methods for harvesting and integrating functional units of perforator flaps were summarized. ResultsFunctional perforator flap refers to a perforator flap that, on the basis of perforator blood supply, carries one or more tissue functional units (such as muscles, nerves, lymphatic vessels, lymph nodes, bones, mucous membranes, joints or articular cartilages, etc.) with sufficient blood supply located in the supra-fascia and/or sub-fascia, and is used to reconstruct one or more functions of the recipient site. The design and transfer of functional perforator flaps should not only meet the needs of precise coverage of the wound, but also reconstruct the functions of the recipient site such as muscle contraction, flap sensation, lymphatic drainage, blood flow bridging, bone growth, glandular secretion or joint movement, while avoiding iatrogenic dysfunction in the donor site. ConclusionFunctional perforator flaps have broken through the limitation of “wound coverage” and realize the integrated reconstruction of “structure-function-aesthetics”.
Objective To evaluate the effectiveness of functional perforator flaps utilizing the superficial circumflex iliac artery as a vascular pedicle, as well as chimeric iliac bone flaps, in the reconstruction of composite tissue defects in the hand and foot. Methods A retrospective review of the clinical data from 13 patients suffering from severe hand or foot injuries, treated between May 2019 and January 2025, was conducted. The cohort comprised 8 males and 5 females, with ages ranging from 31 to 67 years (mean, 48.5 years). The injuries caused by mechanical crush incidents (n=9) and traffic accidents (n=4). The distribution of injury sites included 8 cases involving the hand and 5 cases involving the foot. Preoperatively, all patients exhibited bone defects ranging from 2.0 to 6.5 cm and soft tissue defects ranging from 10 to 210 cm2. Reconstruction was performed using functional perforator flaps based on the superficial circumflex iliac artery and chimeric iliac bone flaps. The size of iliac bone flaps ranged from 2.5 cm×1.0 cm×1.0 cm to 7.0 cm×2.0 cm×1.5 cm, while the size of the soft tissue flaps ranged from 4 cm×3 cm to 15 cm×8 cm. In 1 case with a significant hand defect, a posterior interosseous artery perforator flap measuring 10.0 cm×4.5 cm was utilized as an adjunct. Likewise, an anterolateral thigh perforator flap measuring 25 cm×7 cm was combined in 1 case involving a foot defect. All donor sites were primarily closed. Postoperative flap survival was monitored, and bone healing was evaluated through imaging examination. Functional outcomes were assessed based on the location of the defects: for hand injuries, grip strength, pinch strength, and flap two-point discrimination were measured; for foot injuries, the American Orthopaedic Foot & Ankle Society (AOFAS) score, visual analogue scale (VAS) score, Maryland Foot Score, plantar pressure distribution and gait symmetry index (GSI) were evaluated. Results All flaps survived completely, with primary healing observed at both donor and recipient sites. All patients were followed up 6-18 months (mean, 12.2 months). No significant flap swelling or deformity was observed. Imaging examination showed a bone callus crossing rate of 92.3% (12/13) at 3 months after operation, and bone density recovered to more than 80% of the healthy side at 6 months. The time required for bone flap integration ranged from 2 to 6 months (mean, 3.2 months). One patient with a foot injury exhibited hypertrophic scarring at the donor site; however, no major complication, such as infection or bone nonunion, was noted. At 6 months after operation, grip strength in 8 patients involving the hand recovered to 75%-90% of the healthy side (mean, 83.2%), while pinch strength recovered to 70%-85% (mean, 80%). Flap two-point discrimination ranged from 8 to 12 mm, approaching the sensory capacity of the healthy side (5-8 mm). Among the 5 patients involving the foot, the AOFAS score at 8 months was 80.5±7.3, VAS score was 5.2±1.6. According to the Maryland Foot Score, 2 cases were rated as excellent and 3 as good. Gait analysis at 6 months after operation showed GSI above 90%, with plantar pressure distribution closely resembling that of the contralateral foot. Conclusion The use of functional perforator flaps based on the superficial circumflex iliac artery, combined with chimeric iliac bone flaps, provides a reliable vascular supply and effective functional restoration for the simultaneous repair of composite bone and soft tissue defects in the hand or foot. This technique represents a viable and effective reconstructive option for composite tissue defects in these anatomical regions.
ObjectiveTo investigate the feasibility and effectiveness of using a modified latissimus dorsi musculocutaneous flap for the treatment of upper limb injuries with complex tissue defects classified as Gustilo-Anderson type ⅢB and ⅢC. Methods Between January 2021 and January 2024, 19 cases of upper limb injuries with complex tissue defects classified as Gustilo-Anderson type ⅢB and ⅢC were repaired with a modified latissimus dorsi musculocutaneous flap. There were 14 males and 5 females, with an average age of 33 years (range, 8-65 years). Among these cases, 12 involved injuries to the upper arm and elbow, while 7 involved injuries to the forearm. The disease duration ranged from 2 hours to 10 days (mean, 2.6 days). The patients underwent emergency internal fixation or external fixation for fractures, along with repair of neurovascular injuries. Subsequently, based on the type and extent of tissue defect, 11 cases were treated with pedicled flap transplantation, while 8 cases underwent free flap transplantation. The size of the muscular flaps ranged from 16.0 cm×10.0 cm to 24.0 cm×14.5 cm, while the size of skin flaps ranged from 12.0 cm×5.0 cm to 27.0 cm×7.5 cm. All incisions at donor sites were sutured. Results All 19 flaps survived completely, with primary wound healing in 17 cases and secondary healing with skin grafting on the muscular flap in 2 cases. The incisions at donor sites healed by first intention. All patients were followed up 10-41 months (mean, 21 months), and limb salvage was successful in all cases. All fractures healed with a healing time of 8-14 weeks. At last follow-up, according to the functional evaluation criteria for upper limb replantation established by the Hand Surgery Branch of Chinese Medical Association, 15 cases demonstrated excellent functional recovery, while 3 cases showed good functional outcomes, 1 case showed poor recovery. Conclusion The modified latissimus dorsi musculocutaneous flap, through partial separation of the latissimus dorsi muscle and musculocutaneous perforators combined with a staggered arrangement of the muscle and skin components, enables flexible reconstruction of defects at different tissue levels. This technique demonstrates advantages including a high flap survival rate, satisfactory limb salvage outcomes, favorable functional recovery, and relatively low donor site morbidity, making it an effective method for reconstruction of Gustilo-Anderson type ⅢB and ⅢC upper limb injuries with composite tissue defects.