MINISTRY OF EDUCATION AND TRAINING

MINISTRY OF NATIONAL DEFENSE

108 INSTITUTE OF CLINICAL MEDICAL AND
PHARMACEUTICAL SCIENCE

NGUYEN QUANG VINH

ANATOMICAL AND CLINICAL INVESTIGATION OF
THE FREE SENSORY FASCIOCUTANEOUS DELTOID
FLAP FOR SOFT TISSUE DEFECTS RECONSTRUCTION
OF THE FOOT WEIGHT-BEARING AREA

Specialty: Orthopaedic Trauma and Reconstructive Surgery
Code: 62720129

MEDICAL DOCTORAL THESIS SUMMARY

HANOI 2019


THE WORK HAS BEEN COMPLETED
AT 108 MILITARI CENTRAL HOSPITAL

Scientific instructors: Prof., Dr. of Science. Nguyen The Hoang

Reviewer 1: Prof., PhD. Le Gia Vinh
Reviewer 2: Assoc. Prof., PhD. Pham Dang Ninh
Reviewer 3: Assoc. Prof., PhD. Lam Khanh

The dissertation defense will take place in front of 2nd dissertation
committee in 108 Institute Of Clinical Medical And Pharmaceutical
Science at hour: DD/MM/YYYY

This Study available at:
1. National Library of Viet Nam.
2. Library of 108 Institute Of Clinical Medical And Pharmaceutical
Science.


1
BACKGROUND
The weight-bearing area of the foot has unique physiological and
anatomy features (characteristics) to adapt to the role of bearing gravity.
Until now, the reconstruction of the weigth bearing area of the foot has
always been a challenge due to the lack of comparable replacement
materials. The skin grafts are a simple method, however skin graft has no
bearing gravity. The local random flaps are only suitable for small
defects. The local neurovascular island flaps have treated a lot of defects
in the weight-bearing area of the foot, but the applicability of local
neurovascular island flaps was limited by the size and sometimes these
flaps were not available. If using crossflaps, cylinder flaps, the patient
has to undergo many surgeries, suffering from long-term restrictive
posture.
The reconstruction by free flaps has been successful since the 70s
of last century and has flourished for more than last four decades.
Overcoming the initial challenges of covering defects only for the
purpose of wound healing, the present challenge is the increasing
functional and aesthetic requirements. For defects in the weight-bearing
area of the foot, covering is required a thin flap, good perfusion ability,

sensation to protect the flap, size of the flap is large, hairless and possibly
minor donor-site comorbidities. The fasciocutaneous deltoid free flap is
one of the few flaps that can meet most of the above criteria.
The fasciocutaneous deltoid free flap was discovered by Franklin
J.D in 1984. Later, many authors applied this flap to cover the defects of
the hands, feet and face. Overall, the fasciocutaneous deltoid free flap
was found to be suitable for covering defects in the weight-bearing area
of the foot by the authors. However, the anatomical studies on flap has
been less informed. These studies also did not mention much about the
anatomical characteristics of the Posterior circumflex humeral vascular
bundles and the sensory nerve branches of the flap. About the thickness
of this flap and especially the size of blood vessels of this flap on the
body has not been mentioned by any author.


2
In Vietnam, the sensory deltoid free flap has been used in Military
Central Hospital 108 since 2005. The initial results of using flap to treat
defects in the weight-bearing area of the foot are encouraging. However,
there is currently no systematic study linking the anatomy study of the
flap with clinical applications. For all above reasons, we studied
"Anatomical and clinical investigation of the free sensory
fasciocutaneous deltoid flap for soft-tissue defects reconstruction of the
foot weight-bearing area ". Our goals were:
1. Research on anatomical characteristics of fasciocutaneous
deltoid free flap in Vietnamese adults.
2. Assess the results of clinical application to treat soft-tissue
defects in the weight-bearing area of the foot.
Our contribution
1. Using ultrasound to measure the thickness of the

fasciocutaneous deltoid flap: In Vietnam, this is the first time this method
has been performed. The results show that this method is reliable,
practical and scientific.
2. Determine the length, diameter and three-dimensional image of
arterial system blood- supplying for deltoid flap on the living organism
through CTA-320. For deltoid flap, this is the first time this method has
been used.
3. Detecting anatomical abnormalities related to the original types,
course of the posterior circumflex humeral artery and cutanous branch
artery. This finding gives surgeons more confidence in using deltoid free
flap on clinically.
4. Determine the participation of deltoid flap in walking through
footprint: In Vietnam, this is the first time this method has been applied.
5. Currently, the deltoid flap is rarely used and reported in the
literature. This study contributes to affirming that deltoid flap is a
suitable and reliable material when choosing flaps that cover expose
tendons, bone, joint defects ... in weight-bearing area of the foot.


3
STRUCTURE OF THE THESIS

Total page: 127
- Introduction: 2 pages
- Chapter 1. Overview: 31 pages
- Chapter 2. Method: 29 pages
- Chapter 3. Result: 28 pages
- Chapter 4. Discussion: 34 pages
- Conclusion: 2 pages
- Include: 13 tables, 2 figures, 67 photos

- References: 144 (Vietnamese: 29, Foreign languages: 115)
- 3 reports related to our study has been announced.
Chapter 1: OVERVIEW
1.1. Anatomy and physiological characteristics of weight- bearing
area of the foot
1.2. Treatment of defects in weight-bearing area of the foot
1.2.1. Skin grafts method
1.2.2. The local random flaps
1.2.3. The local neurovascular island flaps
1.2.4. The flaps moves from afar
1.2.4.1. The flaps moves from afar without vascular anastomosis
1.2.4.2. The free flaps
a. The muscle flaps recontruction of soft-tissua defects in the weightbearing area of the foot.
b. The fasciocutaneous flap and role of sensation when recontruction
of defects in the weight- bearing area of the foot.
In 1990, Meland studied free flaps reconstruction in the weightbearing area of the foot and synthesized literature, showing the following
trends in the choice of fasciocutaneous flaps. Initial, the largest number
used were the tensor fascia lata flaps. They were reported early in the
literature and had a high minor and major complication rate of 20-47%,
respectively. Eleven of these flaps were also innervated with a 36%
ulceration rate despite adequate return of two-point discrimination in the


4
25-30mm. Because of the thickness of this flap and its inability to
withstand the stress forces of ambulation, most authors have now
abandoned it. Of particular interest is the noted success of the relatively
more recently described, thin fasciocutaneous flaps that may provide
sensory innervation (i.e., the radial forearm, dorsalis pedis, and the
deltoid flap). This review included 24 of these flaps, all with very minor

complications that responded well to local, conservative therapy. The
only major complication was an infection that required debridement in
one radial forearm flap. All of the innervated flaps eventually developed
two-point discrimination in the 20-30 mm range and the flaps seemed to
hold up very well to the stresses of ambulation. They most certainly
showed improved results when compared to the early, thicker
fasciocutaneous flaps studied including the tensor fascia lata,
scapular/parascapular, and groin flaps.
Summary: There are many options for recontruction of soft-tisue
defects in the weight-bearing area of the foot. Skin grafting is usually
only considered a temporary solution. The Cross-flap is only applied to
save limbs in special cases. Most commonly used in reconstruction in the
weight-bearing area of the foot is local neurovascular flaps and free flaps.
With limit size defects is local neurovascular flaps is often chosen.
Nowadays, with the advancement of microsurgical techniques, along
with the increasing demands on functional and aesthetic reconstruction,
free flaps are increasingly more widely assigned. The free flaps are often
used to cover in the weight-bearing area of the foot is the free sensory
fasciocutaneous flap and muscle flaps. Because of the thickness of the
flap, skin grafts must be grafted onto the surface and there is no sensation
so muscle flaps only really fit deep cavities, osteoarthritis. The free
sensory fasciocutaneous flap, especially thin flaps such as the anterior
thigh flap, radial forearm flap, lateral arm flap and deltoid flap are the
preferred ones, even with large imperfections, with shallow bone
damage, superficial osteitis.


5
1.3. The fasciocutaneous deltoid flap
1.3.1. Anatomy research situation of fasciocutaneous deltoid flap

1.3.1.1. In the world
The fasciocutaneous deltoid free flap was discovered by Franklin
J.D in 1984. The flap is the skin covering the deltoid muscle and
posterolateral arm. The axis of the flap is the path connecting acromion
and medial epicondyle. The flap is dominated sensation by the lateral
brachial cutaneous nerve separated from axilary nerve. The pedicle
consists of cutaneous vascular bundles separated from Posterior
circumflex humeral vascular bundles. According to Franklin, the pedicle
has a length of about 6 - 8cm, posterior circumflex humeral artery has a
diameter of about 2 - 4mm, cutaneous branch artery has a diameter of
about 1mm and usually has two dependent.
Posterior circumflex humeral artery (PCHA) and cutaneous branch
artery’course and branch distribution: According to Franklin, from
original in axillary artery, PCHA runs back through Velpeau quadrangle
space and then go around the surgical neck of the humerus. The PCHA is
divided into several branches, including: the branch connected to the
deltoid branch of the deep arm artery, the branch connected to the
anterior humeral circumflex artery, the branches supply blood to the
deltoid muscle and the cutaneous branch artery supply blood to the
deltoid flap. Cutaneous branch artery travels within the deltoid-triceps
muscles wall to enter the flap. Russell (1985) and Strauch (1993)
described a bifurcation of cutaneous branch artery in the muscular
septum, and the case of a branch going through the deltoid muscle.
However, both authors did not give statistial ratios.
Pedicle position enters the flap: According to Franklin, the pedicle
position enters the flap at the back of point A (the intersection of the axis
of the deltoid flap and the back edge of the deltoid muscle) and the
average distance from point A is 2cm. This distance according to Wang
is 1.86cm and according to Meltem is 1.5cm.



6
In 2003, Wang was dissection the vascular network of deltoid flap
at 21 cadavers. The skin vascular network of deltoid flap consists of five
layers and the vascular network of deep fascia is the most dense with
96.5 ± 14 artery branch / mm2. Through the continuity of the vascular
network from the cutaneous branch artery to the vascular network from
multiple musculocutaneous perforators, from the brachial artery, the
transverse cervical artery, the thoracoacromial artery helps the flap to be
well perfected and the flap blood supply area is expanded. Wang is also
the only author who mentioned the anatomical features of PCHA, and
described this artery only penetrates the quadrangular space in 90 percent
of cases, the remaining case it arose from the arch of the brachialis and
profunda brachii and did not penetrate the quadrangular space.
1.3.1.2. In Vietnam
In 2013, dissection in 43 deltoid regions on formalin storage
corpses, Nguyen Duc Nghia described the cutaneous branch artery
always present and always derived from PCHA. The cutaneous branch
artery split 2 branches at 74.42% (32/43 templates), in 5/43 templates
(11.63%), after the split there was a branch that went through the deltoid
muscle to enter the flap. The author did not describe the posterior
circumflex humeral bundle.
In general, the anatomy researchs on deltoid flap of authors in the
country as well as in the world has focused mainly on the description of
cutaneous branch bundle. The research results show that deltoid flap has
dense vascular network with lots of rich connections. The anatomical
characteristics of posterior circumflex humeral bundle have not been
described. According to the documents we found, the authors did not
dissect deeply into the Velpeau quadrangle space to describe the
anatomical characteristics of Posterior circumflex humeral bundle, as

well as the sensory nerve branch of the flap. The size of the pedicled
deltoid flap has also been described by some authors, but the data are still
very different. The determination of the length and diameter of the
pedicled deltoid flap on living organism has not been mentioned.


7
Regarding the thickness of deltoid flap, the authors all considered deltoid
flap to be a thin flap, but no author had ever measured the thickness.
1.3.2. Situation of deltoid flap clinical application
1.3.2.1. In the world
2.3.2.2. In Vietnam
Through international and national literature, the deltoid flap is
applied to cover hand defects and especially in the weight-bearing area of
the foot. With the advantage of color, some authors also applied deltoid
flap to recontruction of oral and maxillofacial. In general, the authors
stated that fasciocutaneous deltoid flap is a thin flap, hairless, the
constant vascular pedicle with a convenient length and diameter, safe for
free flap transfer. The deltoid flap has a rich vascular network, good
perfusion, helps to minimize the phenomenon of pressure ulcer caused by
the lack of support and anti-bacterial infection. Statistics of 125 deltoid
flaps covering soft-tissue defects have been reported by 13 authors,
including complex soft-tissue defects and bacterial infections. All deltoid
flap are alive (100%), which helps heal injuries and facilitate patients
both functionally and aesthetically. The deltoid flap has a sensory nerve
branch, can be harvested with a large size, allowing the donor site to be
directly closed, scars are easy to hide and do not affect the function of the
deltoid muscle as well as the shoulder joint after surgery. Disadvantage
factors of the flap are also shown, which is the difficult flap dissection
process due to the multiple branching of the neurovascular pedicle in

Velpeau quadrangle space. In addition, Krishnan and Musharafieh have
recommended that scar donor sites be at risk for hypertrophic, especially
in young patients (two authors did not give specific statistics).
From this fact, we found that the results of deltoid flap application
in the treatment of soft-tissue defects in the weight-bearing area of the
foot were positive. However, thickness and sensory nerve branches of the
flap have not been described. The posterior circumflex humeral bundle
characteristics are just mentioned very briefly. The determination of the
length and diameter of the pedicled deltoid flap on living organims has


8
not been mentioned. In addition, the number of patients of each author is
small (< 20 patients). Some characteristics of reinnervation, the function
of using the flap and the aesthetic problem of the whole tie-receiving
place and donor site have not been specifically described by the authors.
From the above reasons, we believe that the implementation of the
subject: "Anatomical and clinical investigation of the free sensory
fasciocutaneous deltoid flap for soft-tissue defects reconstruction of the
foot weight-bearing area" to have more general conclusions about the
anatomy and results after shaping the flap is needed.
Chapter 2: SUBJECT AND METHODS
2.1. Research on anatomical characteristics of fasciocutaneous
deltoid flap
2.1.1. Measure the thickness of deltoid flap through ultrasound
- Subjects: 72 deltoid areas/36 patients, from 4/2015-12/2017 at
department C7, of Military Central Hospital 108.
- Methods: Using soft tissue ultrasound program with frequency
probe 7-16 MHz on Logiq S8 machine manufactured by GE. The probe
is gently applied to the surface of the skin without subsidence, measuring

the thickness of the deltoid flap in 8 positions: 1 (located on the axis and
below 5cm A point), 2 (point A- intersection of the axis of the flap and
posterior deltoid muscle), 3 (acromion), 4 (located on the axis and on the
acromion 5cm), 5 and 6 (two symmetrical positions via acromion and
5cm from the acromion, position 5 in front and position 6 in the back), 7
and 8 (two symmetrical positions over point A and 5cm from point A,
position 7 in front and position 8 on the back).
- Evaluation criteria: Average thickness at 8 locations on the flap
(mm) and average thickness of flap.
2.1.2. Determination of blood artery system for deltoid flap through
CTA-320
- Subjects: 54 shoulder and arm areas of 27 Vietnames adult
patients, pre-surgical angiography with CT-320 at Diagnostic Imaging
Department of Military Central Hospital 108 from 5/2015 - 5/2017.


9
- Methods: Using CT-320 Aquilion One machine manufactured by
Toshiba, Xenetic® (France) Contrast does not ionize vials of 350mg /
100ml, at a dose of 1.5ml / kg, injected with an automatic syringe into
saphenous vein in leg at 5ml / sec. The time taken after the injection of
contrast material is about 120 - 180 seconds. The following image was
taken in 3-D by Vitrea FX software, Version 6.3 (Toshiba)
- Evaluation criteria: Statistics about origins, paths, branches and
measuring the length and diameter of posterior circumflex humeral artery
as well as cutaneous branch artery.
2.1.3. The characteristics of neurovascular pedicled deltoid flap
through autopsy
2.1.3.1. Subjects: The dissection 54 deltoid regions in 27 Vietnames adult
cadavers (13 males, 14 females) at the Anatomical Department of Ho Chi

Minh Medical University in March 2014 and September 2016. Among
them, there are 16 cadavers preserved by 10% Formol (preserve
cadavers), 11 preserved at -300C (fresh cadavers).
2.1.3.2. Methods
a. Research design: Cross-sectional descriptive research.
b. The technique of dissection on cadaver:
+ Put the cadaver lying prone on the operating table, shoulder
height padded, spread arms 300. Draw the axis of the flap and determine
point A. Draw a center circle A with a radius of 3cm. Draw a line
through A and perpendicular to the axis of the flap to divide the circle
into 4 equal areas. The goal is to locate the pedicle into the flap.
+ Incise skin and deep fascial from between spine of scapula going
up to front to midpoint of clavicle, going outward to deltoid-thoracic
groove, straight down to lateral condyle of humerus, going backwards to
medial condyle of humerus pulling up to the posterior edge of armpit.
Dissect by Franklin's method from the front of the shoulder, along the
flap, to the trunk of the flap at the base of the deltoid-triceps wall.
+ Dissection neurovascular pedicled deltoid flap in the deltoidtriceps wall and Velpeau quadrangle space.


10
+ Determination of blood supply area: 500ml of 1% Methylene
blue solution is suspended 1.5m above the flap and infused at maximum
speed into the cutaneous branch artery on fresh cadavers for 30 minutes,
then measure the size of infusion area.
+ Measurement of the distribution of the sensory nerve branch:
Dissection in the soft-tissue of deltoid flap on the preserved 10% Formol
cadavers (under 5X magnifier) to show the path and branching of the
sensory nerve. Measure the distribution of this nerve branch from the
position it enters the flap up and down.

+ Statistics about origins, paths, branches and measuring the length
and diameter of posterior circumflex humeral artery as well as cutaneous
branch artery and accompany veins.
2.2. CLINICAL RESEARCH
2.2.1. Patients: 60 patients with expose tendons, bone, joint defects in
weight-bearing area of the foot, reconstruction using fasciocutaneous
sensory deltoid free flap at Institute of Orthopaedics and Traumatology
of Military Central Hospital 108, from 7/2005 - 12/2017
2.2.2. Methods
Retrospective and prospective, cross-sectional description,
longitudinal monitoring and no control group.
Retrospective group: 18 patients from 7/2005 - 8/2012.
Prospective group: 36 patients from 9/2012 - 12/2017.
2.2.2.1. Surgical procedures
Dissect the deltoid flap: Dissect the pedicle of deltoid flap using
Franklin technique (2008).
Transfer flap into recipient site: Using the suture method to blood
vessels end to end according to harashina and neurorrhaphy by the epi
perinneural - perinneural method.
2.2.2.2. Follow up after surgery
2.2.2.3. Treatment after surgery
2.2.2.4. To guider patients how to care and exercise against for flap:
After 3 weeks of surgery, the flap is pressed and the patient is trained to


11
stand on a foam sheet with pressure and time increasing to the flap. After
2 weeks, give the patient a walker with crutches with increased support to
the flap. patients are instructed to check the flap daily and encourage the
use of shoes and sandals with comfortable sole throughout the life.

2.2.2.5. Evaluation criteria
The examination and evaluation process is conducted every 3
months in the first year and once every 1 year in subsequent years ..
* Evaluation of early results after surgery (≤ 3 months)
+ Ratio of surviving flap: Good (whole flap survives), Fair (partial
necrotic flap) and Bad (failure - total necrotic flap).
+ Results of cover soft-tissue defect: Good: first heal, Moderate:
may require intervention to clear the infection or a skin graft to heal the
wound, with a second heal. Bad: fistula with prolonged inflammation.
* Evaluate long-term results at recipient site and donor site (≥ 9 months)
- Results at recipient site (foot area):
+ Investigation patient satisfaction with flap (Appendix 5): The
results are classified according to Graf P. into 4 levels including: (1):
Very satisfied, (2): Satisfied, (3): Accepted and (4): Not satisfied.
+ Level of sensate recovery was assessed by BMRC (British
Medical Research Council), and was compared with the corresponding
area on the opposite leg on the Kalbermatten. Results are classified into 4
levels: Very Good, Good, Fair and Poor.
+ Restoration of walking ability: assessed according to Rautio:
Very Good, Good, Fair and Poor.
+ The durability of the flap (assessed by Rautio): Very Good,
Good, Fair and Poor.
+ The aesthetic of the flap (assessed by Graf P.): Very Good,
Good, Fair and Poor.
+ General classification of results at the recipient site: Based on
the 5 criteria above, the overall results are classified into 4 corresponding
levels: Very Good, Good, Average and Poor when that level is achieved
at 4/5 criteria.



12
- Comorbity at the donor site: 4 criteria: (1) Patient ’s satisfaction with
scar at the donor site, (2) Deltoid muscle and shoulder joint function, (3)
Scars formed after harvest flap and ( 4) Ability to hide scars.
+ Investigation patient satisfaction with scar at the donor site:
Includes 4 levels: (1): Very satisfied, (2): Satisfied, (3): Accepted and
(4): Not satisfied.
+ Deltoid muscle and shoulder joint function: Very Good, Good,
Fair and Poor.
+ Cosmetic problem of scar after harvest flap: 4 levels: good scar,
spread scar, hypertrophic scar and keloid scar.
+ Ability to hide scars: Very Good, Good, Fair and Poor.
+ General classification of comorbity at the donor site:
Based on the 4 criteria above, the overall results are classified into
4 corresponding levels: Very Good, Good, Average and Poor when that
level is achieved at 3/4 criteria.
Chapter 3: RESULTS
3.1. Anatomical research results fasciocutaneous deltoid flap
3.1.1. Result of thickness of fasciocutaneous deltoid flap
Table 3.1. The thickness of fasciocutaneous deltoid flap.
Data (n=72)
Position 1: 5cm below point A
Position 2: point A
Position 3: acromion
Position 4: 5cm above the acromion
Position 5: in front of the acromion 5cm
Position 6: 5cm behind the acromion
Position 7: in front of point A 5cm
Position 8: 5 cm behind point A
Average thickness of the flap


Thinnest
(mm)
4,7
6,5
3,2
3,0
3,2
3,4
3,4
4,8

Thickest
(mm)
8,4
11,5
6,5
6,2
6,5
6,8
7,2
8,4

± SD
6,11 ± 0,9
7,87 ± 1,17
4,11 ± 0,76
3,81 ± 0,7
3,99 ± 0,75
4,22 ± 0,78

4,76 ± 0,92
6,03 ± 0,89
5,14 ± 0,81

The average thickness of the flap through ultrasound is: 5.14 ±
0.81mm. The thickest flap at the vascular position enters the flap
(position 2) and thins towards the shoulder (Table 3.1).


13
3.1.2. Artery system results on CTA-320
3.1.2.1. Posterior circumflex humeral artery
Origins and paths: Posterior circumflex humeral artery (PCHA) is
always present, separated from axillay artery in 42/54 cases (77.78%),
separated from subscapular artery in 7/54 cases (12.96%). When
separated from axillay artery or subscapular artery, PCHA always passes
through Velpeau quadrangle space. In 5/54 cases (9.26%) PCHA
separated from brachial artery and did not pass through Velpeau space.
Branches: The posterior circumflex humeral artery divides about
7-10 branches to supply blood to the deltoid area and connects to the
anterior circumflex humeral artery, deep brachial artery.
The length and diameter of posterior circumflex humeral artery:
diameter: 3,38± 0,58mm (2,2-4,5), length: 43,08±6,60mm (27,7 ± 60,2).
3.1.2.2. Cutaneous branch artery
Origins: Cutaneous branch artery is always present in all 54/54
CTA-320 films (100%) and is derived from posterior circumflex humeral
artery.
The length and diameter: length: 44,57 ± 4,83mm (34,5 - 56),
diameter: 1,49 ± 0,28mm (1,1 - 2,5).
Cutaneous branch artery ’s caurse and branches: The image of

skin vascular network of deltoid flap is not shown clearly on CTA-320 in
many cases, so this criterion is not statistically significant.
3.1.3. Result of dissection on cadaver
3.1.3.1. Neurovascular pedicle and blood supply area
a. Artery:
- Posterior circumflex humeral artery (PCHA):
+ Origins and paths: In 45/54 cases (83.33%) PCHA separated
from axillay artery and in 6/54 cases (6.11%) separated from subscapular
artery. In these cases (51/54 cases = 94.44%) PCHA always passes
through Velpeau quadrangle space. In 3/54 cases (5.56%) PCHA was
originally derived from brachial artery and did not cross Velpeau
quadrangle space.


14
+ Branches: PCHA divides about 7-10 branches, include of about
3-5 blood supply branches for deltoid muscle, 1 branch connected to the
deltoid branch of deep brachial artery, 1 branch connected to anterior
circumflex humeral artery, branches for teres minor muscle, teres major
muscle and cutaneous branch artery blood supply to the deltoid flap.
+ The length and diameter: described in table 3.2
Table 3.2. Length and diameter of PCHA and accompany veins.
Data
Cadaver
form
Diameter of
artery
Diameter of
vein 1
Diameter of

vein 2*
Length of
artery
Length of
vein 1

Min (mm)

Max (mm)

PC

FC

PC

FC

2,42

2,48

3,95

3,69

2,17

3,12


4,14

3,82

1,15

2,48

3,25

2,93

32

35

50

45

34

29

46

45

± SD (mm)
PC

n=32
2,98 ±
0,29
3,35 ±
0,32
2,35 ±
0,41
38,75 ±
4,28
40,59 ±
3,87

FC
n=22
3,16 ±
0,26
3,51 ±
0,17
2,62 ±
0,12
39,05
±2,70
40,59
±4,16

p

0,018
0,038
0,045

0,757
0,998

*: n= 17 on preserve cadavers and n=11 on fresh cadavers (28/54
cases have 2 veins). PC: preserve cadavers. FC: fresh cadavers.
- Cutaneous branch artery:
+ Origins: Cutaneous branch artery is always separated from
PCHA (100%).
+ Branches: Cutaneous branch artery is divided into 2 branches in
46/54 cases (85.19%). The branching position may be in the deltoidtriceps muscles wall (31/54 cases = 57.41%), or in the flap (15/54 cases =
27.78%). In 8/54 cases (14.81%), Cutaneous branch artery only creates a
single axis and this circuit always goes towards the acromion.
+ Paths: Cutaneous branch artery goes into deltoid-triceps muscles
wall to enter the blood supply to the flap. In 4/54 cases (7.41%), the
cutaneous branch artery split into 2 branches, including one that passed
through the deltoid muscle to enter the flap.


15
+ The length and diameter: described in table 3.4
Table 3.4. Length and diameter of cutaneous branch artery and
accompany veins.
Data
Cadaver
form
Diameter
of artery
Diameter
of vein 1
Diameter

of vein 2*
Length of
artery
Length of
vein 1

Min (mm)

Max (mm)

PC

FC

PC

FC

1,02

1,08

1,53

1,66

1,21

1,40


1,97

1,85

0,83

1,15

1,59

1,53

35

36

52

60

34

38

53

58

± SD (mm)
PC

n=32
1,26 ±
0,1
1,58 ±
0,17
1,21 ±
0,16
44,56 ±
3,43
44,28 ±
3,91

FC
n=22
1,39 ±
0,13
1,67 ±
0,1
1,37 ±
0,1
45,5 ±
3,91
46,31±
3,52

p

0,00
0,018
0,001

0,355
0,056

*: n= 27 on preserve cadavers and n=16 on fresh cadavers (34/54
cases have 2 veins). PC: preserve cadavers. FC: fresh cadavers.
b. Veins:
- Posterior circumflex humeral vein: There may be 1 or 2
accompanying veins, in 28/54 cases (51.85%) there are 2 veins, in 26/54
cases (48.15%) there are 1 veins. The length and diameter of veins are
described in table 3.2.
- Cutaneous branch vein: In 43/54 cases there were 2 veins
(79.63%), in 11/54 cases (20.37%) there was 1 vein. The veins size is
described in table 3.4.
c. Blood supply area for transfusion of blue Methylene into
cutaneous branch artery: The size of the methylene blue infusion area is
measured vertically: 20.41 ± 1.62cm (17 - 23), measured horizontally:
12.36 ± 1.47cm (9-15).
d. The flap’ sensory nerve: The lateral brachial cutaneous nerve
split from axillary nerve in Velpeau space, with a length of 6.54 ±
0.53cm (5.6 - 7.8), usually with 4-6 bundles and often divided into 2
branches (branches up and branches down) before entering the flap.


16
Dissection in the subcutaneous tissue of the flap on 32 preserve formol
cadavers (5X magnifying), the distribution range of the upper branch: 5.3
- 7.8cm (7.02 ± 0.46), and of the branch down: 4.7 - 7.2cm (6.06 ± 0.61).
e. The secondary pedicle
Although the flap still has a pedicle as the classical description, the
branch connected to the deep brachial artery adds another branch to the

blood supply to the flap. This branch is the secondary peduncle and is
found in 8/54 cases (14.81%). The secondary peduncle also has an artery
with an average diameter: 0.92 ± 0.12mm and 1 vein with an average
diameter: 1.23 ± 0.14mm.
3.1.3.2. Locate the position pedicle enter the flap
In 49/54 cases (90.74%) the position pedicle enter the flap in the
posterosuperior of the circle, in 5/54 cases (9.26%) this position is in the
posteroinferior area. The distance from the pedicle to point A is: 19.3 ±
0.42mm and to the acromion is: 7.87 ± 0.43cm.
3.2. Clinical outcomes
3.2.1. Characteristics of patients studied
60 patients with 60 soft-tisue defects in the weight-bearing area of
the foot, including 46 male and 14 female. The average age of patients is:
33 ± 15 (8 - 74 years). Inside:
+ 5 patients with peripheral nerve damage: 4 patients with lower
limb (due to sequelae of cerebral palsy 2 patients and spinal cord injury 2
patients), 1 patient with diabetes.
+ There are 3 patients who had amputation on the opposite side
because of previous injuries.
3.2.2. Characteristics of soft-tisue defects and deltoid flap
- The cause of soft-tisue defects (n = 60):
+ Ulcers in weight-bearing area of the foot on subparalytic lower
limb patients: 4/60 patients (6.67%).
+ Ulcers caused by cancer: 3/60 patients (5%).
+ Soft-tisue defects caused by trauma: 53/60 BN (83,33%).


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- Location of soft-tisue defects (n = 60): There were 52 soft-tisue
defects in the direct weight-bearing area of the foot (hindfooot and

plantar regions), of which the hindfooot involved in 40/60 defects
(66.67%). There are 8 soft-tisue defects in the indirect weight-bearing
areas (5 in dorsum and 3 in posterio calcaneus of the foot).
- Size of soft-tisue defects and flap (n = 60):
The soft-tisue defects in this study have an average size: 111.8
cm2 (32 - 231cm2). The flaps are also taken with the same size, the
average length of flaps is: 12.95 ± 4.06cm (7 - 22cm), the average width
is: 8.23 ± 1.79cm (4 - 12cm). Of the flaps used, the smallest flap is 8 x
4cm and the largest is 21 x 11cm.
- The reconstruction methods was used (n=60): 8/60 soft-tisue
defects were reconstruction with sural flap or medial plantar flap, but the
ulcer continued to recur.
- Infection status and grow bacteria result (n=60): In this study,
there are 11 soft-tisue defects which are bad scars that are sterile. Of the
remaining 49 soft-tisue defects, 27 were subacute (wound) and 22
chronic (ulcers). Twelve soft-tisue defects were grown bacteria, the
common bacteria were P. Aeruginosa (6 cases) and S. Aureus (4 cases),
the rest were S. Epidermidis (1 cases) and Proteus sp. (1 cases).
- Characteristics of soft-tisue defects and associated lesions(
n=60): All soft-tisue defects after incise have tendon and bone exposed.
There were 21/60 cases (33.3%) with cordinate lesions including: 7
patients with metatarsal fractures, 8 patients with heel fractures, 5
patients with partial loss of achille, 1 patients completely lost anterio
tibial tendon and extensor digitorum longus tendon.
- Pathology (n=21): Of the 21 patients who had a biopsy, 17
patients were chronically infected, 1 benign tumor and 3 patients with
squamous cell carcinoma (T3N0M0) all 3 patients were still alive.
3.2.3. Results soon after surgery (n=60)
3.2.3.1. Ratio flap ’s surviving and results of cover soft-tissue defect



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* Ratio flap ’s surviving (n=60): Whole flap survives: 59/60
(98,33%). Total necrotic flap: 1/60 (1,67%).
* Results of cover soft-tissue defect (n=59): Good (first heal):
55/59 patients (93,22%). Moderate (second heal): 4/59 patients (6,78%).
3.2.3.2. Early complications and management results
Vascular congestion: encountered in 2 cases, of which 1 case saved
the flap. Infection: 1 case.
3.2.4. The long-term results (≥ 9 months, n = 58)
There were 60 patients with 60 deltoid free flaps, of which 59 flaps
lived completely and 1 necrosis. The number of flaps evaluated for longterm results was 58/59 flaps. The longest follow-up was 12 years and 3
months, the shortest was 9 months, the average was 51.7±45 months.
3.2.4.1. Results at recipient site (foot area):
a. Investigation patient ’s satisfaction (Appendix 5): Very satisfied:
32/58 patients (55,2%), Satisfied: 24/58 patients (41,4%), Accepted: 2/58
patients (3,4%).
b. Result of sensate recovery:
* Patients without peripheral neuropathy (n = 53):
+ Good (S3+): 45/53 patients (84,9%).
+ Fair (S3): 8/53 patients (15,1%).
* Patients group with peripheral neuropathy (n = 5, including 4
subparalytic lower limb patients and 1 diabetic patient): Before surgery
there were 3 patients: S2 and 2 patients: S1. After surgery: 2 patients at
S2 and 3 patients at S1.
c. Restoration of walking ability (n = 58):
- Of the 52 patients with soft-tisue defects in the direct weightbearing area of the foot, 46 patients had foot prints. The picture shows
that all flaps are involved in the compression of the soles when walking.
- Result of restoration of walking ability:
+ Group A: No sequelae of subparalytic lower limb, opposite legs

were healthy (n = 51): Very Good: 29/51 (56,9%), Good: 20/51 (39,2%),
Fair: 2/51 BN (3,9%), Poor: 0 BN.


19
+ Group B: Have sequelae of subparalytic lower limb, or have
amputated on the opposite side: 7/7 patients (100%).
d. The durability of the flap (n = 58):
- Group flaps reconstructed in the direct weight-bearing area of the
foot (n = 50): Very good: 31/50 patients (62%), Good: 15/50 patients
(30%), Fair: 4/50 Patient (8% - ulcerated flap).
- Group flaps reconstructed in the indirect weight-bearing area of
the foot (n=8): Very good: 8 cases.
- In this study, the patients with a good sense of conserve flap also
had better results on the durability of flap (p <0.001, Fisher's exact test).
e. Result of aesthetic at the flap recipient site (n=58): Very good:
38/58 (65,52%), Good: 15/58 (25,86%), Fair: 5/58 (8,62%).
There were 2 female patients who had debulking surgery and the
results improved clearly.
f. The results of general classification at the recipient site (n=58):
Based on the 5 criteria above, the overall results are classified: Very
good: 26/58 (44,8%), Good: 30/58 (51,7%), Fair: 2/58 BN (3,5%).
3.2.4.2. The results of comorbity at the donor site (deltoid area, n=58)
a. The investigation results of patient ’s satisfaction with scar at the
donor site (n=58): Very satisfied: 25/58 (43,1%), Satisfied: 25/58 BN
(43,1%), Accepted: 8/58 BN (13,8%), Not satisfied: 0.
b. The function of deltoid muscle and shoulder joint (n=58):
In all patients (100%), after deltoid flap is harvested, the function
of deltoid muscle and shoulder joint is completely normal (very good).
c. The cosmetic problem of scar after harvest flap (n=58): Good scar:

14/58 (24,14%), spread scar: 31/58 (53,45%), hypertrophic scar: 12/58
(20,69%), keloid scar: 1/58 (1,72%). There are 2 patients with scar repair.
After the surgery, cosmetic scar is completely acceptable for patients.
d. Ability to hide scars (n=58): Very good: 29/58 (50%), Tốt: 27/58
(46,6%), Fair: 2/58 (3,4%), Poor: 0/58.
e. General classification results of comorbity at the donor site (n=58):
Very good: 26/58 (44,7%), Good: 27/58 (46,7%), Fair: 5/58 BN (8,6%).


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Chapter 4: DISCUSSION
4.1. Anatomical study of deltoid flap through ultrasound, CTA-320
and dissection on cadaver
4.1.1. How to determine the thickness of deltoid flap and clinical
significance
During the application of deltoid flap, we found that the thickness
of flap is unequal in positions. We tried to measure the thickness of the
flap with a Palmer ruler. However, this method is not reliable because
when cut off the adjacent tissue, the flap immediately shrinks.
Through the world literature review, there have been several
reports of ultrasound, X-ray or PET-CT applications to determine the
thickness of flaps before or after reconstruction. In particular, to measure
thickness at many places on the flap, ultrasound is an easy method to
perform, has a lower cost and still ensures accuracy. In this study, when
using ultrasound to measure the deltoid flap thickness, the ultrasound
transducer was perpendicular to the skin surface, the pressure applied to
the skin was just enough to contact without skin subsidence to minimize
errors. The results showed that the thickest position was the pedicle
position and the flap was thinner towards the shoulder. From this result,
the deltoid flap has been harvested towards the shoulders to achieve an

optimal thinness.
4.1.2. Consistency of artery system for blood supply to deltoid flap
The results of this study are similar to those previously reported in
the literature, that there is always a pedicle separated from the posterior
circumflex humeral bundle to supply blood for deltoid flap.
4.1.3. Comments on the value of anatomical research through
dissection on cadaver and CTA-320
4.1.3.1. Advantages and disadvantages of dissection on cadaver method
The dissection process on cadaver has revealed all the components
of the pedicle including arteries, veins and nerves. Blue methylene
solution may be infused into cutaneous branch artery (on fresh cadarvers)
to determine area of blood supply. The dissection process on cadaver also


21
helps determine the course and pedicle's anatomical implications with
muscles, bones, joints and with anatomical landmarks like acromion, Apoint, deltoid-triceps muscles wall....
However, the dissection on cadaver method also has
disadvantages, that the size of the pedicle measured on the cadaver does
not reflect the size of the pedicle on the living body.
4.1.3.2. Advantages and disadvantages of CTA-320 method
CTA-320 images through many 3D-generated slices objectively
show the original structure of the pedicle with anatomical implications
with muscles, bones, joints in 3-dimensional space. Furthermore, the
diameter of the arteries measured on CTA-320 is the diameter of arteries
on the living body, which is larger than the diameter of arteries measured
on cadaver and close to the actual clinical application.
4.1.4. The value of anatomical research serves clinical applications
4.1.4.1. Pedicle abnormalities and precautions when Incise flap
The posterior circumflex humeral artery (PCHA) 's origin and

course abnormalities, the numerous branching of PCHA and the
accompanying veins are the real difficulties when incise flap. The case of
cutaneous branch artery for a branch passing through the deltoid flap is
also a point of attention, because the trans-muscular branch is often
ligated, affecting the blood level of the flap. Author Russell encountered
a case of a cutaneous branch artery that split into two branches in the
deltoid-triceps muscles wall, a branch through the muscle that was
accidentally cut while the incise flap and flap were partially necrotic.
4.1.4.2. The position pedicle enter the flap
4.1.4.3. The blood supply area
In this study, the blood supply area when infusing blue methylene
into the cutaneous branch artery averaged 20.41 x 12.36 cm. When
studying the vascular network of the deltoid area, Wang, Edizer and
Nguyen Duc Nghia have shown that this area has a very rich vascular
network. Through the continuity of the vascular network from the
cutaneous branch artery to the vascular network from multiple


22
musculocutaneous perforators, from the brachial artery, the transverse
cervical artery, the thoracoacromial artery helps the flap to be well
perfected and the flap blood supply area is expanded. Clinically, Russell
took the deltoid flap to size: 33 x 13cm and the flap lived completely. We
have also taken flap to size 21 x 11cm and the flap lives completely.
4.1.4.4. The flap’s sensory nerve branch
In 11/54 cases (20.37%), the flap’s sensory nerve branch split 2
branches early. Although both sensory nerve branches dominate the
sensation of the flap, however, the upward branch is the branch that
follows the axis of flap should be preferred.
4.2. Clinical application deltoid flap

4.2.1. Patients and characteristics of soft-tissue defects
4.2.2. The challenges when changing deltoid flap cover in weightbearing area of the foot
4.2.3. The deltoid flap and the ability to adapt with the weight-bearing
area of the foot
4.2.3.1. The recovery of sensation problem
The result of flaps' s sensate recovery in our study is similar to the
results of Kalbermateen, Santanelli and other authors using
fasciocutaneous sensory flap cover in weight-bearing area of the foot.
The sensory is early recover, in the first 6 months has restored tactile
sensation (level S3 +) and recovered quickly in the first year.
In comparative studies between two flap groups with and without
sensitive nerve coaptation when cover in weight-bearing area of the foot,
Santanelli and Kalbermateen concluded that the coaptation sensory nerve
group had sensate recovery earlier and faster, sensate recovery is also at a
higher level. The early and quick recovery of sensory contributes to help
the patients return to work early.
4.2.3.2. The deltoid flap 's adaptability to walking
According to Milanov and many authors, the walking ability of
patients, who are reconstructed deltoid flap in weight-bearing area of the
foot, depends heavily on the strength of the flap. The stability and sensate


23
recovery of the flap not only helps patients feel the integration of the flap
with the body, but also helps them feel the stability of the foot when
walking. These factors also help counter shear forces and reduce the
feeling of slippery when pressure on the flap. According to
Kalbermateen, when reconstructed with thick flap and no sensation,
patients are afraid to press against the flap and often feel unfriendly to the
flap. The patients in our study did not complain about this.

4.2.3.3. The flap’s durability
So far, the flap’s durability cover in weight- bearing area is still of
great interest to many authors. According to Rautio (1991), Meland
(1994), Potparic (1997), the condition of the bone surface under the flap,
the thickness of the flap, sensate recovery and especially the sense of
keeping the flap of the patients are factors affecting durability of flap.
4.2.4. Comorbity at the donor site
Although did not give specific statistics, Krishnan cautioned that
scars on the donor site deltoid flap are at risk of hypertrophy in young
patients. In this study, 12/58 cases (20.7%) of donor sites formed
hypertrophic scars, of which 9/12 cases were under 30 years old (75%).
To limit the effects of scarring, unlike the author Meltem who often
harvests deltoid flap towards the elbow, we harvested deltoid flap
towards the shoulders to achieve an optimal thinness. This has the
advantage of being able to incise wide about the two edges of the
incision, mobilizing the skin flap from the chest and back to seal the first
incision. In addition, harvested deltoid flap towards the shoulders also
makes it easy for patients to hide scars with short-sleeved shirts.
Moreover, because the scar formed after harvested flap often coincides
with the groove in the posterio deltoid flap, it is less observed.
Unlike the warnings of Franklin and Krishnan, in this study, there
was no case that the funtion of deltoid muscle and shoulder joint was
affected. We believe that understanding the anatomical and meticulous
dissection techniques of surgeons are crucial factors to help ensure the
success of surgery.