Jurding Jigsaw Puzzle Flap Plastic Surgery .pptx

Jurding bedah plastik yang membahas mengenail flap jigsaw

1. Application of the Jigsaw Puzzle Flap Based on Freestyle Perforators to Repair Large and Deep Ulcers on the Buttocks Journal Reading

2. Introduction Pressure ulcers are a significant health issue globally, with a 21.8% prevalence rate in the UK and varying rates in different healthcare settings in the Netherlands. The prevalence of stage III and IV pressure ulcers in China is 13 to 14%, managed in plastic and burn surgery departments. Treatment of deep and large decubitus ulcers often requires soft tissue filling with a good blood supply . Patients with these ulcers often have complicating factors , making them challenging candidates for surgical procedures.

3. Introduction Skin flap transplantation is preferred for deep and large defects, providing full-thickness skin with subcutaneous tissue . The freestyle perforator flap technique allows for the creation of flaps based on detected signals of perforators from Doppler, offering advantages such as shorter operation times and less trauma. The jigsaw puzzle flap technique, combining multiple freestyle perforator flaps, has been successfully used to repair decubitus ulcers with large and deep cavities on the buttocks .

4. Materials and Methods Patients: 50-81 years old (av. 65) Sizes of defects: 6.0 cm × 8.5 cm × 2.5 cm to 10.5 cm × 11.0 cm × 4.0 cm Flap sizes: Min 7.0 x 10.5 cm Max 8.0 x 22.0 cm Different type of flaps 41 perforator propeller flap 19 rotation flap 5 V-Y advancement flap Donor areas for freestyle perforator flaps were selected based on adjacent zones with fast blood flow and good soft tissue mobility All flaps were mobilized to the defect to create a new, large jigsaw puzzle flap without tension Inclusion criteria: cases included decubitus ulcers from traumatic or senile disease exclusion criteria: severe medical conditions, smoking, alcoholism, pregnancy, mental illness, and other unsuitability reasons

5. Operative Technique Mapping the Location of Freestyle Perforators Locate sizable freestyle perforators adjacent to the defect Identify skin-penetrating positions of freestyle perforators and record signal amplitude and blood flow velocity Use the perforator with the most prominent Doppler signal as the flap's pedicle Mark all perforators before surgery to determine the flap's axial phase and safe boundary Detect all free perforating vessels in the defect's periphery using a portable ultrasonic Doppler blood flow detector before the operation

6. Design of the Skin Flap Determine pedicle, axis, and size of free perforator flap based on defect size, freestyle perforator locations, and soft tissue mobility Pre-design and mark flap with Methylene Blue Ink Completely remove necrotic and scar tissue around the decubitus ulcer with meticulous hemostasis Divide the large defect into several parts , each corresponding to a freestyle perforator flap Form a dermal-fat flap from part of the epidermis of the free perforator flap and rotate it 180 degrees to fill the deep cavity of the defect Lap-joint the dermal-fat flap with another freestyle perforator flap using "overlap" approaches to create a new large flap Design the perforator eccentrically to form a perforator propeller flap, V-Y advancement flap, or rotation flap

7. Flap Harvest Harvesting a free perforator flap involves finding and retrograde dissecting the perforator. Dissection is carried out from the skin to the deep fascia or muscle membrane layer along one side of the designed flap. The excision position is located between two selected perforators to ensure they can be detected. Silk suturing is used to stitch the tissue layer on one side of the flap to traction the flap and avoid detachment between layers. Careful lifting of the flap at the deep fascia level is necessary to find the perforator easily. When the perforator is located, it is released and retrograde-dissected with micro-scissors to retain the width of the fascial pedicle . Perivascular tissue that may affect flap blood supply after rotation must be completely released. For flaps filling deep cavities, the epidermis is routinely removed to form a dermal-fat flap supplied by the freestyle perforator.

8. Creating a Jigsaw Puzzle Flap Mobilize all component perforator flaps to the defect and observe for vascular pedicle distortion or bending. If poor blood supply is observed, check the pedicle ; if twisted, release perforators for a larger rotation angle. Cover the flap and pedicle with warm saline gauze while observing the changing blood supply of the distal flap. Once adequate blood supply is confirmed, arrange and overlap all small flaps to form a large "jigsaw puzzle flap." Close all donor sites directly without tension.

9. Follow-up three to six months after the operation includes assessing the function and appearance of the skin flap and recipient area. Check for recurrence of pressure sores and provide nursing guidance, such as using a triangular occipital side rest to avoid long-term hip compression. Post-operation care includes intravenous infusion of dexamethasone, intramuscular injection of papaverine , and light pressure bandaging. Skin flap temperature, color, and capillary reaction should be observed through an observation window. If blood supply is inadequate, vasodilators should be administered, and VSD (vacuum-assisted closure) may be applied. Stitches are typically removed 2 weeks after the operation. Post operative Treatment Post Operative Follow Up

10. Results 30 patients were treated with 65 flaps, all of which survived. One flap healed with a delay due to effusion volume but healed after drainage and appropriate treatment. Flaps were transferred as propeller flaps (41), V-Y advancement flaps (19), and rotation flaps (5) to repair large defects . Flaps were rotated 90-180 degrees without vascular pedicle distortion or bending. All patients achieved satisfactory single-stage reconstruction , and all donor sites were closed directly. After 3-24 months of follow-up, appearance and function of all flaps were satisfactory. One patient had local decubitus ulcer recurrence due to improper care, leading to pressure sore recurrence.

11. Typical Case Two freestyle perforator flaps were designed to repair the defect, with one flap used to fill the bottom of the defect after removing its epidermis. Necrotic and inactivated tissues around the defect were completely removed. Jigsaw puzzle flaps were constructed based on identified freestyle perforators and repaired the defect in a one-stage surgery. Both flaps were transferred as propeller flaps, and the donor sites were directly closed. All flaps survived well after surgery, and there was no ulcer recurrence at a one-year follow-up. A 68-year-old male with a sacrococcygeal ulcer for 3 years due to being bedridden from a stroke, leading to severe craniocerebral limitations. The ulcer became cystic cavity-type, forming a soft tissue defect of 9.5 × 10.0 cm and 3.5 cm deep, with visible necrotic sacrum, coccyx, and adjacent tissue .

12. Discussion Decubitus ulcers are commonly treated in burn and plastic surgery departments, often with reconstruction using flaps or myocutaneous flaps. Cystic cavity-type decubitus ulcers often have potential dead space from infection and require debridement of sac wall and scar tissue with poor blood supply, leading to deeper defects. Local random flaps are limited in repairing decubitus ulcers due to issues like length-to-width ratio and blood supply reliability. Axial flaps with reliable blood supply, such as myocutaneous flaps and free flaps, have been effective. Free flaps like lateral sacral artery perforator flaps can be used for repair, but the complex reconstruction schemes and surgery risks may be challenging for some patients. Designing a reconstruction scheme with a large volume of transplantation tissue, a high safety of blood supply, and less trauma is crucial for repairing cystic cavity-type decubitus ulcers.

13. Freestyle Perforator Flap Freestyle perforator flaps have become important in reconstructive surgery, thanks to wider clinical applications and advanced Doppler ultrasound devices. These flaps use perforator vessels for blood supply , preserving main arteries and muscles, improving postoperative appearance, and reducing functional injury. Surgeons design freestyle perforator flaps based on preoperative detection of perforator blood flow , allowing for different shapes and mobility ranges. While traditionally used for small defects, repairing large defects with a single freestyle perforator flap is challenging due to size limitations and difficulty in closing donor sites. The described approach involves using two to three local freestyle perforator flaps to repair large defects from decubitus ulcers , providing a new, safe, and easy-to-implement procedure.

14. Perforasome The concept of the perforasome , defined as the unique vascular territory of a single perforator , is foundational to this project. Perforasomes are linked by tiny-diameter linking vessels , similar to choke vessels, which act as the physiological boundaries between adjacent angiosomes. Flaps harvested with one perforator as a pedicle across three perforasomes can supply blood to the perforasome and its adjacent ones. The sizes of the flaps in this study were based on the concept of the perforasome , with safety limits extending to the perforasome itself and its adjacent perforasome.

15. Local Condition of the Defect Having abundant soft tissue with good mobility around the defect is crucial for the described procedure. The buttocks are ideal for this procedure due to their many potential donor sites with ample tissue and good mobility, allowing for direct closure of donor sites. This local condition enables the design of multiple flaps and the formation of a puzzle flap to repair large defects. Designing the puzzle flap in a way that avoids tension from the closure of all donor sites is important.

16. Application Experience of the Project Free-style perforator flaps can be used in various forms like propeller flaps, rotation flaps, and V-Y advancement flaps for repairing decubitus ulcers. V-Y advancement flaps are not recommended due to the significant marginal fibers and poor blood supply in decubitus ulcers, which can delay wound healing. Hospitalization time for patients receiving V-Y advancement flaps is longer compared to propeller and rotation flaps, with an average stay of 3.5 weeks versus 2 weeks for the others. Norepinephrine is injected during surgery to reduce bleeding, and a pen-tip electrotome is used for flap harvesting and timely hemostasis. Negative pressure drainage is used post-surgery to manage effusion and promote adequate blood supply between the flap and the repaired defect.

17. Conclusion Further study is needed on reducing scars between small perforator flaps in the jigsaw puzzle flap The jigsaw puzzle flap , based on the freestyle perforator concept, utilizes the large volume of tissue around ulcerative defects on the buttocks. Surgeons focus on safety boundaries and flap quantity rather than traditional perforator vessel shape and classification, simplifying flap design. This flap method can repair large defects of cystic cavity-type decubitus ulcers on the buttocks , allowing for direct closure of the donor flap area. It is easy to implement, ensuring a safe blood supply and minimal trauma compared to conventional myocutaneous flap surgery. 1 2 3 4

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