The hand has been regarded as one of the most crucial organs for daily activities; thus, hand injuries are very common in the clinic. With the development of industrialization and with the presence of frequent accidents such as traffic accidents, hand injuries are currently increasing daily in society. Such injuries often result in the loss and necrosis of skin and soft tissue to different extents and are often accompanied by tendon exposure, nerve injury and bone defects. Hand reconstruction is challenging due to the unique functions and appearance of the hand; above all, skin reconstruction in order to restore the function of the hand is always difficult in the clinic .
Since abdominal flaps were first reported by McGregor and Jackson et al in 1972, they have gradually become ideal workhorse flaps for skin and soft tissue replacement in the hand. Abdominal flaps have many advantages, such as their consistent vessel anatomy, flexible design, harvesting simplicity, rapid postoperative recovery, and limited complications and wound infections . However, in addition to their advantages, these flaps also have limitations as well as disadvantages because if multiple finger injuries occur, the traditional surgical procedure used is often to artificially form syndactylia using an abdominal pedicled flap; this involves a secondary surgery for cutting the vascular pedicle and separating the fingers. Because of the long-term passive position, joint stiffness, discomfort position and unexpected flap avulsion often occur [14, 15].
For decades, with the continuous development of microsurgery techniques and tools, supermicrosurgery, a technique involving the dissection and anastomosis of small vessels ranging from 0.3 to 0.8 mm in size, has revolutionized the field of vessel reconstruction, allowing the possibility of perforator flaps with thinner calibers . The concept of a perforator flap was first presented by Koshim and Soeda in 1989, and this flap roughly experienced three substantial processes of development: pedicle flap-free flap-perforator flap[15, 16].
The perforator flap is a kind of flap that survives due to the blood supply from perforator vessels with small diameters (approximately 0.5 mm). Unlike other traditional flaps, the perforator flap does not depend on muscle or deep fascia and reduces the morbidity of the donor area to the minimum. Therefore, the use of this flap is an inevitable trend in the field of hand trauma and represents an opportunity for microsurgery to solve complex reconstructive problems. In recent years, various types of perforator flaps have been reported, such as the paraumbilical, anterolateral thigh, lateralthoracic, superficial circumflex iliac and gluteal artery perforator flaps.
In 2004, Koshima et al. first established the concept of the SCIP flap, constituting the dissection of a groin flap based on the superficial circumflex iliac artery (SCIA) . The SCIP flap is pliable, thin and reliable, and is one of the most demanding flaps with long vascular pedicles. This flap has many advantages by not only obtaining an aesthetic effect and functional outcome but also minimizing donor site morbidity with concealment of the scar, reducing the surgical time, and achieving one-stage surgical reconstruction.
The SCIP flap is one of the most advantageous flaps because it enables the reconstruction of multiple lesions with one source vessel. It can be designed with a lobulated appearance in order to repair two or more wounds simultaneously by anastomosing one group of blood vessels.
In recent years, with the development of perforator flaps, many studies have reported that these flaps can be successfully applied in many fields. The SCIP flap was widely used since it was first described in 2004 by Koshima et al, soon afterwards, Lita T and his colleague demonstrated success of the SCIP flap in reconstructive of head and neck defects . It has been reported in many department listed as follows: reconstructions of hand, breast, lower extremity, penis, limbs (Hong JP et al., 2013), urethral reconstruction (Yoo KW et al., 2012), oral maxillofacial reconstruction (Yue He et al., 2016) [18–20] and so on.
The SCIP flap plays an important role in clinical microsurgery due to its remarkable aesthetic and functional merits. Perforator flap surgery is relatively complicated mainly because of the short arterial pedicle, arterial anatomical variability and tiny caliber of the vessels. Due to these difficulties, the performer should be experienced instead of microsurgically novice.
Meanwhile, preoperative imageological examination and anatomical assessment of vascular mapping were important for the successful flap transfer. Diversified anatomical variations of dominant vasculature in the groin area especially SCIA have been reported in previous study . So preoperative CDS mapping and CTA combined with three-dimensional volume-rendered reconstruction were performed to identify the location, the whole vessel stream, vascular trunk and side branch of SCIA. Following the tiny branches, the main trunk of the SCIA was detected, and then the projection lines was marked on body surface with gentian violet pen.
The SCIP flap is crucial for hand reconstruction not only in adult patients but also in pediatric patients. Previous relevant studies have mainly focused on adults, and few studies have reported the use of perforator flaps in pediatric patients. To be certain, vascular anastomosis in pediatric patients certainly poses a unique clinical challenge.
Children's fingers are smaller than adults’ fingers, while the vascular caliber of the traditional flap is wider, which makes the anastomotic process more laborious. The SCIP flap, with its small caliber, flexibility, minimal donor site morbidity, and scar concealment, is highly suitable for pediatric patients. This flap can be designed with alobulated appearance to repair two or more wounds in order to avoid the inconsistencies in caliber and the risk of a second-stage operation. To our knowledge, the relevant study of pediatric patients is not common, this study is the first to conduct a free single-pedicle bilobed SCIP flap for multifinger defect reconstruction in pediatric patients.
Seven pediatric patients who underwent the reconstruction of finger defect with free single-pedicle bilobed SCIP perforator flaps were collected, all flaps survived well and with no complications except one child with scar contracture of interphalangeal joint, finger function recovered well after release surgery and postoperative systematic rehabilitation training, the flaps had a satisfactory appearance, motor function and protective sensation, and the donor area is sutured primarily and with well-concealed scar.
In spite of these advantages, Our study is limited with the small sample size and lack of objective monitoring index. Also the longstanding operation and difficulties in harvesting flap are apparent limitations. Further studies with larger sample should be conducted to consolidate this research and develop more practical variations.
Mkono ni muhimu sana katika shughuli za kila siku, na kwa hivyo, majeraha ya mikono ni ya kawaida sana. Pamoja na maendeleo ya viwanda na uwepo wa ajali za mara kwa mara kama vile ajali za barabarani, majeraha ya mkono kwa sasa yanaongezeka kila siku katika jamii. Majeraha kama hayo mara nyingi husababisha hasara na necrosis ya ngozi na tishu laini kwa kiwango tofauti na mara nyingi huambatana na mfiduo wa tendon, majeraha ya neva na kasoro za mifupa. Ujenzi wa mkono ni changamoto kwa sababu ya kazi ya kipekee na kuonekana kwa mkono; juu ya yote, ujenzi wa ngozi ili kurudisha kazi ya mkono ni daima vigumu katika kliniki. Tangu flaps tumbo walikuwa kwanza aliripotiwa na McGregor na Jackson et al katika 1972, wao hatua kwa hatua kuwa flaps kazi farasi bora kwa ajili ya ngozi na tishu laini badala katika mkono. Flaps ya tumbo ina faida nyingi, kama vile anatomy yao ya mto thabiti, muundo rahisi, upole wa kuvuna, uponyaji wa haraka baada ya upasuaji, na matatizo ya kupunguzwa na maambukizi ya jeraha. Hata hivyo, pamoja na faida zao, flaps hizi pia zina mapungufu na hasara kwa sababu kama majeraha ya vidole vingi hutokea, utaratibu wa upasuaji wa jadi hutumiwa mara nyingi kuunda syndactylia kwa kutumia flap ya tumbo ya tumbo; hii inahusisha upasuaji wa sekondari wa kukata pedicle ya mishipa na kutenganisha vidole. Kwa sababu ya hali ya muda mrefu ya kutokuwa na shughuli, mara nyingi kuna ugumu wa viungo, hali ya kutokuwa na furaha na kutoweka kwa flap isiyotazamiwa. Kwa miongo kadhaa, kwa maendeleo ya kuendelea ya mbinu na zana za upasuaji mdogo, upasuaji mdogo, mbinu inayohusisha kupasuliwa na anastomosis ya mishipa midogo ya 0.3mm hadi 0.8mm, imebadilisha uwanja wa ujenzi wa mishipa, ikiruhusu uwezekano wa flaps perforator na calibers nyembamba. "Kushikilia kwa flipper ni mfano wa flipper ya kawaida ya kawaida, ambayo kwa kawaida huitwa ""flipper ya pedicle,"" ambayo ni flipper ya kawaida ya flipper." Flipper ya perforator ni aina ya flipper ambayo huishi kutokana na usambazaji wa damu kutoka kwa mishipa ya perforator yenye kipenyo kidogo (karibu 0.5mm). Tofauti na flaps nyingine za jadi, flap perforator haitegemei misuli au fascia ya kina na hupunguza ugonjwa wa eneo la wafadhili hadi kiwango cha chini. Kwa hiyo, matumizi ya flap hii ni mwelekeo unaoepukika katika uwanja wa majeraha ya mkono na inawakilisha fursa ya microsurgery kutatua matatizo magumu ya ujenzi. Katika miaka ya hivi karibuni, aina mbalimbali za perforator flaps wamekuwa taarifa, kama vile paraumbilical, anterolateral paja, lateraltoracic, uso circumflex iliac na gluteal artery perforator flaps. Mwaka 2004 Koshima na wenzake walifanya utafiti. "Kama ilivyoelezwa hapo juu, ""Scipial Flap"" ni sehemu ya sehemu ya chini ya mshipa wa iliac (SCIA)." Flip ni rahisi, nyembamba na kuaminika, na ni moja ya flip zaidi ya mahitaji na pedicles muda mrefu vascular. Flap hii ina faida nyingi kwa kupata athari ya urembo na matokeo ya kazi tu, lakini pia kupunguza ugonjwa wa eneo la wafadhili kwa kuficha kidonda, kupunguza muda wa upasuaji, na kufikia ujenzi wa upasuaji wa hatua moja. Flip ni moja ya flip bora zaidi kwa sababu inawezesha ujenzi wa majeraha mengi na chombo kimoja cha chanzo. Inaweza kubuniwa na kuonekana lobulated ili kurekebisha majeraha mawili au zaidi wakati huo huo kwa anastomosing kundi moja la mishipa ya damu. Katika miaka ya hivi karibuni, na maendeleo ya flaps perforator, masomo mengi wameripoti kwamba flaps hizi inaweza kutumika kwa mafanikio katika nyanja nyingi. Flip ya SCIP ilitumiwa sana tangu ilipoelezwa kwa mara ya kwanza mnamo 2004 na Koshima et al. Muda mfupi baadaye, Lita T na mwenzake walionyesha mafanikio ya Flip ya SCIP katika ujenzi wa kasoro za kichwa na shingo. Upasuaji wa mkono, kifua, viungo vya chini, penis, viungo (Hong JP et al., 2013), urekebishaji wa mkojo (Yoo KW et al., 2012), urekebishaji wa mdomo wa maxillofacial (Yue He et al., 2016) [18]. Flip ya SCIP ina jukumu muhimu katika upasuaji mdogo wa kliniki kwa sababu ya sifa zake za kushangaza za urembo na kazi. Upasuaji wa perforator flap ni ngumu sana hasa kwa sababu ya pedicle fupi ya mshipa, kutofautiana kwa anatomical ya mshipa na caliber ndogo ya mishipa. Kwa sababu ya matatizo haya, mtendaji anapaswa kuwa na uzoefu badala ya microsurgically novice. Wakati huo huo, uchunguzi wa picha kabla ya upasuaji na tathmini ya anatomical ya ramani ya mishipa ilikuwa muhimu kwa uhamisho wa flap uliofanikiwa. Utafiti wa awali unaonyesha kwamba kuna tofauti kubwa katika mfumo wa mishipa ya damu katika sehemu ya kiuno, hasa katika sehemu ya chini ya kiuno. Kwa hivyo, ramani ya CDS ya kabla ya upasuaji na CTA pamoja na ujenzi wa kiasi cha tatu ulifanywa ili kutambua eneo, mkondo mzima wa chombo, shina la mishipa na tawi la upande wa SCIA. Baada ya kuonekana kwa matawi madogo, shina kuu la SCIA liligunduliwa, na kisha mistari ya kutazama ilitambuliwa kwenye uso wa mwili kwa kalamu ya rangi ya zambarau. Flip ya SCIP ni muhimu kwa ajili ya ujenzi wa mkono si tu katika wagonjwa wazima lakini pia katika wagonjwa wa watoto. Uchunguzi wa awali umekuwa ukielekezwa kwa watu wazima, na utafiti mdogo umeripoti matumizi ya flaps za perforator kwa wagonjwa wa watoto. Kwa hakika, anastomosis ya mishipa ya damu katika wagonjwa wa watoto bila shaka ni changamoto ya kipekee ya kitiba. Vidole vya watoto ni vidogo kuliko vidole vya watu wazima, wakati caliber ya mishipa ya flap ya jadi ni pana, ambayo hufanya mchakato wa anastomotic kuwa ngumu zaidi. Flip ya SCIP, na caliber yake ndogo, kubadilika, kiwango cha chini cha ugonjwa wa tovuti ya wafadhili, na kuficha kidonda, inafaa sana kwa wagonjwa wa watoto. Flap hii inaweza kubuniwa na kuonekana alobulated kurekebisha majeraha mawili au zaidi ili kuepuka kutofautiana katika caliber na hatari ya hatua ya pili ya upasuaji. Kwa habari yetu, utafiti husika wa wagonjwa wa watoto haujapatikana kwa kawaida, utafiti huu ni wa kwanza kufanya bure single-pedicle bilobed SCIP flap kwa ajili ya ujenzi wa kasoro ya vidole vingi katika wagonjwa wa watoto. Matibabu ya watoto saba waliopitia urekebishaji wa kasoro ya kidole na bure single-pedicle bilobed SCIP perforator flaps walikusanywa, flaps zote ziliokoka vizuri na bila matatizo isipokuwa mtoto mmoja na contracture ya kidonda cha pamoja ya interphalangeal, kazi ya kidole ilipata vizuri baada ya upasuaji wa kuachiliwa na mafunzo ya ukarabati wa utaratibu wa baada ya upasuaji, flaps walikuwa na muonekano wa kuridhisha, utendaji wa motor na hisia ya kinga, na eneo la wafadhili ni sutured hasa na na scar well-kufichwa. Licha ya faida hizi, utafiti wetu ni mdogo na ukubwa mdogo wa sampuli na ukosefu wa index ya ufuatiliaji wa lengo. Pia operesheni ya muda mrefu na matatizo katika kuvuna flap ni mapungufu dhahiri. Mafunzo zaidi na sampuli kubwa inapaswa kufanywa ili kuimarisha utafiti huu na kuendeleza tofauti zaidi za vitendo.