Clinical application of microdissected thin thoracodorsal artery perforator flaps for repair of diabetic foot ulcers_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

MO Xiaojin ^1,2 , CHANG Shusen ^1,2 ,  WEI Zairong ^1,2 , ZHOU Jian ^1,2 , ZENG Kewei ^1,2 , CHEN Wei ^1,2 , NIE Kaiyu ^1,2 , LI Shujun ^1,2 , DENG Chengliang ^1,2

1. Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi Guizhou, 563003, P. R. China;
2. The Collaborative Innovation Center of Tissue Damage Repair and Regeneration Medicine of Zunyi Medical University, Zunyi Guizhou, 563003, P. R. China;

Corresponding?author：

WEI Zairong, Email: zairongwei@163.com

Keywords：

Diabetic foot ulcers; microdissected thin flap; thoracodorsal artery perforator; wound repair

DOI：

10.7507/1002-1892.202201037

Video：

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Objective To explore the effectiveness of microdissected thin thoracodorsal arterial perforator flap (TDAP) in repairing diabetic foot ulcers (DFUs). Methods The clinical data of 11 patients with DFUs admitted between March 2020 and February 2021 were retrospectively analyzed, including 5 males and 6 females, aged from 22 to 67 years, with an average of 49.3 years. There were 10 cases of type 2 diabetes and 1 case of type 1 diabetes; the duration of diabetes ranged from 3 months to 25 years (median, 8 months). The duration of DFUs ranged from 6 days to 120 months (median, 1 month). There were 6 cases of grade 3 and 5 cases of grade 4 according to Wagner classification. The tissue necrosis and purulent secretions were found in all ulcer wounds, as well as different degrees of tendon and bone exposure; skin defects ranged from 5 cm×3 cm to 17 cm×6 cm. The DFUs were repaired by microdissected thin TDAP, including 6 cases of flaps (including 1 case of lobulated flap), ranging from 10.0 cm×4.5 cm to 26.0 cm×7.0 cm; 5 cases of chimeric perforator flaps, the range of the flap was 10.0 cm×4.5 cm to 16.0 cm×5.5 cm, and the range of the muscle flap was 6 cm×2 cm to 10 cm×3 cm. The donor site was sutured directly. Results The operation time ranged from 3.42 to 11.17 hours, with an average of 5.92 hours. All 11 flaps survived and no vascular crisis occurred; 1 patient had a sinus at the edge of the flap, and the surgical area healed well after dressing change. All 11 patients were followed up 6-12 months, with an average of 9 months. The flap texture was good, the recipient site was in good shape, and there was no swelling; the foot contour was good, the shoes were comfortable to wear, and the movement was good. The incision at the donor site healed by first intention, leaving only linear and concealed scar, without obvious depression deformity, and the shoulder joint function was good. Conclusion On the premise of ensuring sufficient blood supply to the lower extremities and strengthening perioperative management, the microdissected thin TDAP to repair DFUs wounds can achieve better effectiveness and appearance; however, the prolonged operation time increases the probability of anesthesia and surgical risks in patients with DFUs.

Citation： MO Xiaojin, CHANG Shusen, WEI Zairong, ZHOU Jian, ZENG Kewei, CHEN Wei, NIE Kaiyu, LI Shujun, DENG Chengliang. Clinical application of microdissected thin thoracodorsal artery perforator flaps for repair of diabetic foot ulcers. Chinese Journal of Reparative and Reconstructive Surgery, 2022, 36(10): 1266-1272. doi: 10.7507/1002-1892.202201037 Copy

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3.	Zhang P, Lu J, Jing Y, et al. Global epidemiology of diabetic foot ulceration: a systematic review and meta-analysis^?. Ann Med, 2017, 49(2): 106-116.
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24.	周鑫, 宋達疆, 鄒永根. 游離胸背動脈穿支皮瓣聯合旋髂淺動脈穿支皮瓣移植修復下肢大面積環周軟組織缺損一例. 中國修復重建外科雜志, 2021, 35(3): 399-400.
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28.	胡瑞斌, 周丹亞, 王欣, 等. 游離胸背動脈穿支皮瓣整復面部亞單位大面積瘢痕的臨床效果. 中華燒傷雜志, 2020, 36(7): 586-589.
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1. Ibrahim A. IDF clinical practice recommendation on the diabetic foot: A guide for healthcare professionals. Diabetes Res Clin Pract, 2017, 127: 285-287.
2. Armstrong DG, Boulton AJM, Bus SA. Diabetic foot ulcers and their recurrence. N Engl J Med, 2017, 376(24): 2367-2375.
3. Zhang P, Lu J, Jing Y, et al. Global epidemiology of diabetic foot ulceration: a systematic review and meta-analysis^?. Ann Med, 2017, 49(2): 106-116.
4. Wukich DK, Raspovic KM. Assessing health-related quality of life in patients with diabetic foot disease: Why is it important and how can we improve? The 2017 Roger E Pecoraro award lecture. Diabetes Care, 2018, 41(3): 391-397.
5. Ragnarson Tennvall G, Apelqvist J. Health-economic consequences of diabetic foot lesions. Clin Infect Dis, 2004, 39 Suppl 2: S132-S 139.
6. Alavi A, Sibbald RG, Mayer D, et al. Diabetic foot ulcers: Part Ⅱ. Management. J Am Acad Dermatol, 2014, 70(1): 21.e1-e24.
7. Boulton AJ, Vileikyte L, Ragnarson-Tennvall G, et al. The global burden of diabetic foot disease. Lancet, 2005, 366(9498): 1719-1724.
8. Everett E, Mathioudakis N. Update on management of diabetic foot ulcers. Ann N Y Acad Sci, 2018, 1411(1): 153-165.
9. Wang A, Lv G, Cheng X, et al. Guidelines on multidisciplinary approaches for the prevention and management of diabetic foot disease (2020 edition). Burns Trauma, 2020, 8: tkaa017. doi: 10.1093/burnst/tkaa017.
10. Lee ZH, Daar DA, Stranix JT, et al. Free-flap reconstruction for diabetic lower extremity limb salvage. J Surg Res, 2020, 248: 165-170.
11. Suh HS, Oh TS, Lee HS, et al. A new approach for reconstruction of diabetic foot wounds using the angiosome and supermicro-surgery concept. Plast Reconstr Surg, 2016, 138(4): 702e-709e.
12. Tukiainen E, Kallio M, Lep?ntalo M. Advanced leg salvage of the critically ischemic leg with major tissue loss by vascular and plastic surgeon teamwork: Long-term outcome. Ann Surg, 2006, 244(6): 949-957.
13. Meloni M, Izzo V, Giurato L, et al. Peripheral arterial disease in patients with renal-diabetic foot ulcers. J Wound Care, 2021, 30(8): 660-664.
14. Prompers L, Huijberts M, Apelqvist J, et al. High prevalence of ischaemia, infection and serious comorbidity in patients with diabetic foot disease in Europe. Baseline results from the Eurodiale study. Diabetologia, 2007, 50(1): 18-25.
15. Bus SA, Lavery LA, Monteiro-Soares M, et al. Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2019 update). Diabetes Metab Res Rev, 2020, 36 Suppl 1: e3269. doi: 10.1002/dmrr.3269.
16. Kotha VS, Fan KL, Schwitzer JA, et al. Amputation versus free flap: Long-term outcomes of microsurgical limb salvage and risk factors for amputation in the diabetic population. Plast Reconstr Surg, 2021, 147(3): 742-750.
17. Fitzgerald O’Connor EJ, Vesely M, Holt PJ, et al. A systematic review of free tissue transfer in the management of non-traumatic lower extremity wounds in patients with diabetes. Eur J Vasc Endovasc Surg, 2011, 41(3): 391-399.
18. 劉安銘, 歐昌良, 周鑫, 等. 胸背動脈穿支皮瓣在修復手背軟組織缺損中的臨床應用. 中華顯微外科雜志, 2020, 43(2): 176-178.
19. 莊加川, 張振偉, 李敏姣, 等. 胸背動脈穿支皮瓣修復手部皮膚缺損的臨床應用. 中華手外科雜志, 2018, 34(3): 161-163.
20. 黃廣濤, 魏在榮, 黃麗, 等. 二縱三橫法在胸背動脈穿支皮瓣穿支定位及深度創面修復中的臨床應用效果. 中華燒傷與創面修復雜志, 2022, 38(2): 165-169.
21. 肖海濤, 王懷勝, 劉勇, 等. 胸背動脈穿支皮瓣修復燒傷后嚴重手背瘢痕攣縮畸形. 中國修復重建外科雜志, 2019, 33(6): 717-720.
22. Kim SW, Sung IH, Kim YH. Reconstruction of severe atherosclerotic and obstructive diabetic feet using thoracodorsal artery perforator flaps with long vascular pedicles. Microsurgery, 2018, 38(3): 287-294.
23. 王曉峰, 李學淵, 丁文全, 等. 胸背動脈穿支皮瓣的顯微解剖及臨床應用. 中華顯微外科雜志, 2020, 43(5): 481-485.
24. 周鑫, 宋達疆, 鄒永根. 游離胸背動脈穿支皮瓣聯合旋髂淺動脈穿支皮瓣移植修復下肢大面積環周軟組織缺損一例. 中國修復重建外科雜志, 2021, 35(3): 399-400.
25. 徐廣琪, 李志宇, 霍然, 等. 軀干部穿支皮瓣在胸部創面修復中的應用. 中華整形外科雜志, 2020, 36(9): 1024-1028.
26. 任振虎, 范騰飛, 游元和, 等. 胸背動脈穿支皮瓣在頭頸部缺損修復中的臨床應用. 中華耳鼻咽喉頭頸外科雜志, 2021, 56(9): 914-918.
27. Kim EJ, Lee KT, Lim SY, et al. Reconstructing facial contour deformities using stereoscopic thoracodorsal artery perforator adipofascial flaps. Microsurgery, 2017, 37(4): 300-306.
28. 胡瑞斌, 周丹亞, 王欣, 等. 游離胸背動脈穿支皮瓣整復面部亞單位大面積瘢痕的臨床效果. 中華燒傷雜志, 2020, 36(7): 586-589.
29. Sung IH, Jang DW, Kim SW, et al. Reconstruction of diabetic lower leg and foot soft tissue defects using thoracodorsal artery perforator chimeric flaps. Microsurgery, 2018, 38(6): 674-681.
30. 魏在榮. 影響皮瓣成活的血管因素分析. 中國美容整形外科雜志, 2014, 25(3): 129-131.
31. 常樹森, 莫小金, 魏在榮, 等. 遵義縫合法在股前外側皮瓣供區縫合中的應用研究. 中國修復重建外科雜志, 2021, 35(4): 477-482.
32. Taylor GI, Miller GD, Ham FJ. The free vascularized bone graft. A clinical extension of microvascular techniques. Plast Reconstr Surg, 1975, 55(5): 533-544.
33. Draznin B, Aroda VR, et al. 12. Retinopathy, neuropathy, and foot care: Standards of medical care in diabetes-2022. Diabetes Care, 2022, 45(Suppl 1): S185-S194.
34. American Diabetes Association Professional Practice Committee. 10. Cardiovascular disease and risk management: Standards of medical care in diabetes-2022. Diabetes Care, 2022, 45(Suppl 1): S144-S174.
35. Chiu CC, Huang CL, Weng SF, et al. A multidisciplinary diabetic foot ulcer treatment programme significantly improved the outcome in patients with infected diabetic foot ulcers. J Plast Reconstr Aesthet Surg, 2011, 64(7): 867-872.
36. Kim JY, Lee YJ. A study of the survival factors of free flap in older diabetic patients. J Reconstr Microsurg, 2007, 23(7): 373-380.
37. Ohta M, Ikeda M, Togo T, et al. Limb salvage of infected diabetic foot ulcers with free deep inferior epigastric perforator flaps. Microsurgery, 2006, 26(2): 87-92.
38. Ozkan O, Co?kunfirat OK, Ozgenta? HE. Reliability of free-flap coverage in diabetic foot ulcers. Microsurgery, 2005, 25(2): 107-112.
39. Moucharafieh RS, Saghieh S, Macari G, et al. Diabetic foot salvage with microsurgical free-tissue transfer. Microsurgery, 2003, 23(3): 257-261.
40. Oh TS, Lee HS, Hong JP. Diabetic foot reconstruction using free flaps increases 5-year-survival rate. J Plast Reconstr Aesthet Surg, 2013, 66(2): 243-250.
41. Suh HS, Oh TS, Hong JP. Innovations in diabetic foot reconstruction using supermicrosurgery. Diabetes Metab Res Rev, 2016, 32 Suppl 1: 275-280.
42. Ducic I, Attinger CE. Foot and ankle reconstruction: pedicled muscle flaps versus free flaps and the role of diabetes. Plast Reconstr Surg, 2011, 128(1): 173-180.
43. Illig KA, Moran S, Serletti J, et al. Combined free tissue transfer and infrainguinal bypass graft: an alternative to major amputation in selected patients. J Vasc Surg, 2001, 33(1): 17-23.
44. Endara M, Ducic I, Attinger C. Free tissue transfer for limb salvage in high-risk patients: Worth the risk. Adv Wound Care (New Rochelle), 2013, 2(2): 63-68.
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Chinese Journal of Reparative and Reconstructive Surgery

Clinical application of microdissected thin thoracodorsal artery perforator flaps for repair of diabetic foot ulcers

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