title: Combined multi-lobed flaps: A series of 39 extensive hand and multi-digit injuries one-staged reconstructions using modified designs of ALT, DPA and chimeric linking flaps.
abstract: BACKGROUND
  The use of multiple small flaps linked in a "chain-linked" flap microanastomosed chimeric system is recommended in distal hand and digital defects reconstruction. The aim of this study is to demonstrates our experience utilizing microsurgical fabrication, multi-lobed and linking combined flaps for the reconstruction of hand degloving injuries with complex multidigit soft tissue defects.
  
  
  METHODS
  Microanastomosed chimeric flap systems using ALT and DPA modified designed flaps were combined in five selections to cover extensive soft tissue defects involving the hands and multiple digits of 39 patients (M:F - 36:3) from October 2009 to February 2013. Five different microsurgical combined chimeric flap systems utilised in extensive hand and multidigit injuries; innervated ALT flaps, multilobed DPA flaps, innervated ALT flap with multilobed DPA flap, innervated ALT flap with sensate ALT flap and bilobed ALT flap with multilobed DPA flap. All DPA donor sites were reconstructed using free ALT flap and anterior tibial artery propeller flap.
  
  
  RESULTS
  Thirty-nine combined free flap extremities reconstructions on 39 patients (M:F - 36:3) with average age 28.5 (18-45) years sustained traumatic degloving injuries, 24 from road traffic accidents and 15 from industrial devices. Five different designs of combined multi-lobed flaps have be successfully used without any peri-operative complications. Average follow-up of 12 months, all flaps survived without complications. Operated extremities showed favorable functional recovery with restoration of the diminished protective sensation on the flap through reinnervation. All flaps survived uneventfully with coverage matching the texture and color of the recipients. Donor sites healed without complication.
  
  
  CONCLUSIONS
  The microsurgical fabrication of chimeric ALT flaps and multilobed DPA flaps is a valuable alternative for the reconstruction of hand degloving injury with complex multidigit soft tissue defects.
  
  
  METHODS
  Level IV, therapeutic study.
authors.affiliation: Department of Repair and Reconstructive Surgery, Department of Plastic Surgery, Hangzhou First People's Hospital and The Affiliated Hospital of Nanjing Medical School, Nanjing University, Hangzhou, Zhejiang 310000, China.
authors.forename: Liang
authors.initials: L
authors.lastname: Tang
authors.affiliation: Academic Plastic Surgery Unit, Queen Mary University of London, London, United Kingdom.
authors.forename: Georgios
authors.initials: G
authors.lastname: Pafitanis
authors.affiliation: Department of Orthopedic Trauma Surgery, Changzheng Hospital, The Second Military Medical University, Shanghai, China.
authors.forename: Peng
authors.initials: P
authors.lastname: Yang
authors.affiliation: Department of Oncology Plastic Surgery, Hunan Province Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan, China.
authors.forename: Zan
authors.initials: Z
authors.lastname: Li
authors.affiliation: Department of Repair and Reconstructive Surgery, Department of Plastic Surgery, Hangzhou First People's Hospital and The Affiliated Hospital of Nanjing Medical School, Nanjing University, Hangzhou, Zhejiang 310000, China.
authors.forename: Ming
authors.initials: M
authors.lastname: Jia
authors.affiliation: Department of Plastic and Reconstructive Surgery, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 1138655, Japan.
authors.forename: Isao
authors.initials: I
authors.lastname: Koshima
authors.affiliation: Department of Oncology Plastic Surgery, Hunan Province Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan, China. Electronic address: johnsondan@163.com.
authors.forename: Dajiang
authors.initials: D
authors.lastname: Song
authors.affiliation: Department of Orthopedic Surgery (Division of Plastic and Hand Surgery), The Second Affiliated Hospital of Wenzhou Medical College, Wenzhou, China. Electronic address: chizhenglinpro@163.com.
authors.forename: Zhenglin
authors.initials: Z
authors.lastname: Chi
mesh_terms: D000328:Adult; D000069836:Degloving Injuries / Q000503:physiopathology / Q000601:surgery*; D004954:Esthetics; D005260:Female; D005500:Follow-Up Studies; D058752:Free Tissue Flaps / Q000098:blood supply*; D006085:Graft Survival / Q000502:physiology*; D006230:Hand Injuries / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D008297:Male; D061525:Perforator Flap / Q000098:blood supply*; D019651:Plastic Surgery Procedures / Q000379:methods; D020127:Recovery of Function / Q000502:physiology*; D016896:Treatment Outcome; D014945:Wound Healing / Q000502:physiology
keywords: Anterolateral thigh flap; Chimeric flap; Dorsalis pedis artery flap; Flow-through; Multi-digit injury; Multi-lobed flap