Perforators of the Lower Leg: Analysis of Perforator Locations and Clinical Application for Pedicled Perforator Flaps:

A Review of Pedicled Perforator Flaps for Reconstruction of the Soft Tissue Defects of the Leg and Foot

Lower extremity soft tissue defects frequently result from high-energy trauma or oncological resection. The lack of suitable muscle flap options for the distal leg and foot makes defects in these locations especially challenging to reconstruct and free tissue transfer is commonly used. Another option that has become more popular in the past two decades are pedicled perforator flaps. Based on a thorough literature review and the authors’ experience on leg perforator flaps for over a decade, this article presents a historical review, the anatomical basis of common perforator flaps of the leg and foot, patient selection, wound selection, perforator selection, flap design, surgical techniques, refinements, and postoperative care. A review of the clinical outcomes and complications of these flaps was also performed and was noted to be comparable to the outcomes of free tissue transfer with significantly lower total flap failure rate. It is hoped that this review will assist surgeons in the formulation of a comprehensive step-by-step guide in performing pedicled perforator flap reconstruction of the lower extremity.

Posterior Tibial Artery Perforator Flaps Carrying Partial Gastrocnemius Muscle for Repair of Soft Tissue Defects With Dead Space in the Ankle and Foot

BACKGROUND

Soft tissue defects with dead space in the ankle and foot remain a challenge for surgeons. The aim of the study was to evaluate the surgical technique and clinical significance of posterior tibial artery perforator flaps carrying partial gastrocnemius muscle for patients with soft tissue defects with dead space in the ankle area.

METHODS

Between August 2015 and August 2017, 14 patients (2 women and 12 men) between 20 and 58 years old (median age, 42 years) were hospitalized in The First Affiliated Hospital of Soochow University. All injuries involved damage to the ankle area and formation of soft tissue defects with dead space. In all patients, posterior tibial artery perforator flaps carrying partial gastrocnemius muscle were transplanted to cover soft tissue defects with dead spaces.

RESULTS

Hospitalization duration ranged from 10 to 20 days (mean, 16 days). All flaps survived and healed well. At follow-up after 6 to 24 months, all cases had recovered successfully in terms of aesthetic and functional aspects.

CONCLUSIONS

Posterior tibial artery perforator flaps carrying partial gastrocnemius muscle can be an optimal reconstruction method for repairing soft tissue defects with dead space in the ankle and foot.

[Application of composite tissue flaps pedicled with distal perforating branch of posterior tibial artery for repairing distal leg defects]

Objective

To investigate the clinical application and effectiveness of the composite tissue flaps pedicled with perforating branch of posterior tibial artery for repairing distal leg defects.

Methods

Between September 2014 and August 2017, 12 patients with skin and bone defects of distal leg were repaired with the composite tissue flaps pedicled with perforating branch of posterior tibial artery. There were 8 males and 4 females with an average age of 41.3 years (range, 25-66 years). The causes of injury included traffic accident injury in 7 cases, heavy crushing injury in 2 cases, tibial osteomyelitis with soft tissue ulcer and necrosis in 2 cases, and bone and soft tissue defect after resection of bone tumor in 1 case. Eight patients underwent primary repair, and 4 patients underwent second-stage repair. The size ranged from 6 cm×4 cm to 10 cm×7 cm in skin flap, from 4.0 cm×2.5 cm to 8.0 cm×6.0 cm in muscle flap, and from 4 cm×2 cm×2 cm to 5 cm×4 cm×4 cm in tibial bone flap. Tibial defects of the donor region were repaired by autologous iliac bone grafting, and the wounds were sutured directly in 7 cases and repaired by autologous skin grafting in 5 cases.

Results

All composite tissue flaps survived and both the recipient and the donor wounds healed primarily. All patients were followed up 6-12 months, with an average of 10.8 months. The appearance, color, texture of the composite tissue flaps and ankle function were satisfactory. X-ray films showed that the bone flap at the tibia defect and the ilium graft at the donor site both healed well at 6 months after operation.

Conclusion

The composite tissue flaps pedicled with perforating branch of posterior tibial artery has abundant blood, and it is a good donor region for repairing the distal leg defects combined with circumscribed bone defect.

Posterior tibial perforator-based flaps for leg and foot defects: Indications, limitations, and technical considerations

BACKGROUND

Covering defects at the lower leg and foot is a common challenge in reconstructive surgery. A flap is often required, and free flaps are widely used. The posterior tibial perforator-based flap constitutes a valuable option in this situation. The objectives of this study were to evaluate the reliability of the posterior tibial perforator-based flap, report any complications, and describe the outcomes, with the goal of defining the indications of this flap in the treatment of lower limb defects.

HYPOTHESIS

The posterior tibial perforator-based flap is a useful and reliable option for soft-tissue defect reconstruction at the leg and foot.

MATERIAL AND METHOD

Patients managed using a posterior tibial perforator-based flap to cover soft-tissue defects of the leg and foot were reviewed retrospectively. A physical examination was performed and radiographs obtained at the last postoperative follow-up visit.

RESULTS

Thirteen patients with a mean age of 46.9 years (range: 25-73 years) were reviewed after a mean follow-up of 19.5 months (range: 16-63 months). The tissue defects were due to compound fractures in 10 patients and to postoperative complications in 3 patients. Mean flap size was 12.3cm by 6.2cm. The donor site was covered by a skin graft in 12 patients and closed primarily in 1 patient. The procedure was successful in 11 (85%) patients.

DISCUSSION

The posterior tibial perforator-based flap is a method of choice for covering soft-tissue defects at the leg and foot. Careful patient selection and flawless technique contribute to minimise the failure rate.

LEVEL OF EVIDENCE

IV, retrospective study.

Pedicled Peroneal Artery Perforator Flap for Knee Defect Reconstruction: Case Presentation and Literature Discussion

There have been very limited data on the use of pedicled peroneal artery perforator flaps in knee soft-tissue reconstruction, especially for anterior and medial defects. Here, we present a case of proximally based peroneal artery perforator flap for knee soft-tissue reconstruction in a defect that included lateral, anterior, and medial surfaces of the knee presenting the technical challenges associated with this flap. A 15-year-old girl presented with extruded knee implant after osteosarcoma resection of femur. The defect involved the whole knee with the anterior and mostly the lateral knee surfaces. Her medical condition precluded the use of free tissue transfer. During her previous surgery, gastrocnemius muscles were detached with injured vascular pedicled and posterior tibial artery. Successful single-stage coverage was achieved using a large proximally based pedicled peroneal artery perforator flap. There are only few reports that described the use of peroneal artery flaps for knee soft-tissue coverage. The reach of a proximally based flap can be increased when it is raised on a distal perforator or when peroneal artery has a proximal takeoff. Furthermore, removing the fibula can facilitate the dissection and the reach of the flap till the most medial aspect of the knee. Pedicled peroneal artery perforator flap provides superior soft-tissue coverage with limited morbidity for knee soft-tissue reconstruction; however, flap reach is usually affected by anatomic variation. Preoperative planning can help to determine the reach of the flap and ease the dissection.

Non-microsurgical skin flaps for reconstruction of difficult wounds in distal leg and foot

PURPOSE

To express the versatility of a variety of non-microsurgical skin flaps used for coverage of difficult wounds in the lower third of the leg and the foot over 4 years period. Five kinds of flaps were used. Each flap was presented with detailed information regarding indication, blood supply, skin territory and technique.

METHODS

Altogether 26 patients underwent lower leg reconstruction were included in this study. The reconstructive procedures applied five flaps, respectively distally based posterior tibial artery perforator flap (n = 8), distally based peroneal artery perforator flap (n = 4), distally based sural flap (n = 6), medial planter artery flap (n = 2) and cross leg flaps (n = 6).

RESULTS

In all cases, there were no signs of osteomyelitis of underlying bones or discharge from the undersurface of the flaps. Fat necrosis occurred at the distal end of posterior tibial artery perforator flap in one female patient. The two cases of medial planter artery flap showed excellent healing with closure of donor site primarily. One cross leg flap had distal necrosis.

CONCLUSION

Would at lower third of leg can be efficiently covered by posterior tibial, peroneal artery and sural flaps. Heel can be best covered by nearby tissues such as medial planter flap. In presence of vascular compromise of the affected limb or exposure of dorsum of foot, cross leg flap can be used.

[The fascio-cutaneous fibular island flap]

The perforators of the fibular artery provide a well vascularised supra fascial network which allows to raise a proximally or a distally based island fascio cutaneous flap with an adipo-fascial pedicle. We present a short series of five cases of this flap for coverage of soft tissue defects involving the region of the knee, the distal third of the leg and the lateral aspect of the heel. All flaps healed entirely without venous congestion. The advantages of the fascio cutaneous fibular island flap are the supine operative position, the preservation of the sural nerve and the lesser saphenous vein and a pivot point which can be located at the middle third of the leg. According to our experience, the fascio cutaneous fibular island flap is especially indicated for repairing defects of the distal leg.

Perforator Propeller Flaps for the Coverage of Middle and Distal Leg Soft-tissue Defects

Background:

Local propeller flaps preserve the main vascular arteries of the lower extremity and muscle function, avoiding the need for a microsurgical anastomosis and the benefit of providing a “like with like” coverage. Our goal in this study was to demonstrate the versatility, safety, and complications of the local propeller flaps for lower extremity reconstruction.

Methods:

We present a series of 28 patients in whom we used local propeller flaps to restore small-to-medium soft-tissue defects of the lower limb in different hospitals of Managua, Nicaragua.

Results:

Flap average dimensions were of 48 cm². Flap rotation was performed in 180 degrees in 85% of the cases. The propeller flaps were based on a single perforator, from the posterior tibial artery in 50%, anterior tibial artery in 39.3%, and peroneal artery in 10.7% of the cases. Complications occurred in 14% of the propeller flaps performed, with 3 partial necrosis of less than 15% of the flap transposed. Complications of the patients occurred in both sex groups; however, for the female group, there was a 75% of complications with a tendency toward statistical significance of P = 0.038. Donor site of the flap was closed primarily in 85.7% (24) of the cases.

Conclusions:

In our opinion, the availability and safety of local propeller flaps, justifies its use in cases where microsurgical techniques are not an option for the reconstruction of the middle and distal extremity, in small-to-medium defects of soft-tissue coverage of the lower limb.

[The sural medial perforator flap: Anatomical bases, surgical technique and indications in head and neck reconstruction]

INTRODUCTION

The medial sural artery perforator (MSAP) flap is defined as a thin cutaneo-adipose perforator flap harvested on the medial aspect of the leg. The aims of this study were to describe the anatomical basis as well as the surgical technique and discuss the indications in head and neck reconstructive surgery.

MATERIAL AND METHODS

We harvested 10 MSAP flap on 5 fresh cadavers. For each case, the number and the location of the perforators were recorded. For each flap, the length of pedicle, the diameter of source vessels and the thickness of the flap were studied. Finally, we performed a clinical application of a MSAP flap.

RESULTS

A total of 23 perforators with a diameter superior than 1mm were dissected on 10 legs. The medial sural artery provided between 1 and 4 musculocutaneous perforators. Perforators were located in average at 10.3cm±2cm from the popliteal fossa and at 3.6cm±1cm from the median line of the calf. The mean pedicle length was 12.1cm±2.5cm. At its origin, the source artery diameter was 1.8mm±0.25mm and source veins diameters were 2.45mm±0.9mm in average. There was no complication in our clinical application.

DISCUSSION

This study confirms the reliability of previous anatomical descriptions of the medial sural artery perforator flap. This flap was reported as thin and particularly adapted for oral cavity reconstruction and for facial or limb resurfacing. Sequelae might be reduced as compared to those of the radial forearm flap with comparable results.

Perforators of the fibular artery and suprafascial network

INTRODUCTION

Soft tissue defect on lower limb can result in an intractable wound. Surgeons resort in flaps to cover these injuries. Including fascia as in the case of a fasciocutaneous flap increases survey of the flap. Rising a perforator flap avoids to sacrifice a major vessel whence the nourishing perforator artery is born. We wanted to explore suprafascial distribution of the fibular skin perforator arteries supposing possible to find out a vascular axis composed of anastomoses of the fibular perforator vessels.

MATERIALS AND METHODS

Systematic observation was carried out on ten injected legs about the fibular perforator distribution, and especially their suprafascial course.

RESULTS

Dissection allowed us to raise in all specimens a large fasciocutaneous paddle including a fine arteriolar vessel connecting fibular perforators. Perforators were isolated along from the leg and we found suprafascial arteriole connecting all perforators from the fibular head to the lateral malleolus. There were a total number of 126 perforators for 10 legs. The mean length of the fibula was 32.9 cm. No perforator was located at more than 2 cm from fibular posterior border. Proximal perforators were closer to posterior fibular side than distal perforators. We found that fibular perforators clustered in the middle and upper third of the leg.

CONCLUSION

This study proves the real existence of a microvascular suprafascial axis formed by fibular perforator anastomoses and stretching over the entire length of the fibula, from the fibular head to the distal tip of the lateral malleolus. This suprafascial vascular axis could be an anatomical basis for a fasciocutaneous fibular flap.

Redefining Vascular Anatomy of Posterior Tibial Artery Perforators: A Cadaveric Study and Review of the Literature

INTRODUCTION

Perforator flaps whether in a free or pedicled form are essential in leg reconstruction, requiring meticulous dissection based on a detailed understanding of vascular topographic anatomy. Numerous investigators have addressed this issue. However, the directionality of their fascial exit has not been greatly discussed in the literature. Subfascial course of the perforating vessel is a crucial determinant for optimal perforator selection especially when the propeller perforator flap option is considered, because an angulated fascial penetration would eventually result in perforator kinking which would additionally compromise vascular patency. The aim of the current study was to investigate the vascular anatomy of posterior tibial artery evaluating a wide range of parameters, including perforators' subfascial directionality, to precisely determine constant reliable perforator sites, in relation to surface landmarks on the medial aspect of the lower leg.

MATERIAL AND METHODS

Dissections in 30 lower legs from 25 fresh cadavers were performed. The lower leg was divided into 3 equal vascular zones. Measurements were taken in reference to anatomical landmarks. Perforator clusters to 5-cm intervals from medial malleolus were recorded and analyzed. Vessels with external diameter less than 0.5 mm were excluded. Data regarding the number, distribution, type, external diameter, length from posterior tibial artery, distance, and subfascial directionality were collected and treated.

RESULTS

A total of 155 perforators were identified (average number, 5 per leg; average diameter, 1.0 mm). Septocutaneous (127/155) perforators predominated, followed by musculocutaneous (19/155) and septomusculocutaneous (9/155). Most was concentrated in the middle (73/155) and distal (64/155) tertile. There were no septomusculocutaneous perforators at the distal third of the leg, whereas septocutaneous perforators were encountered into all vascular tertiles. An average of 2 comitant veins accompanied each perforator. Length and diameter related to the perforators' location. There was a significant association between perforator length and type. Cluster analysis revealed that reliable perforators were identified within the 21 to 25, 26 to 30, and 16 to 20 cm intervals.

CONCLUSIONS

Clinically optimal perforators for the first time were precisely located in relation to subfascial directionality, vascular diameter, and length from the source artery. Continuous improving details of vascular anatomy will further evolve perforator flaps' applications.

Using a Thermal Imaging Camera to Locate Perforators on the Lower Limb

Reconstruction of the lower limb presents a complex problem after skin cancer surgery, as proximity of skin and bone present vascular and technical challenges. Studies on vascular anatomy have confirmed that the vascular plane on the lower limb lies deep to the deep fascia. Yet, many flaps are routinely raised superficial to this plane and therefore flap failure rates in the lower limb are high. Fascio-cutaneous flaps based on perforators offer a better cosmetic alternative to skin grafts. In this paper, we detail use of a thermal imaging camera to identify perforator 'compartments' that can help in designing such flaps.

Photo Epilation with Intense Pulsed Light for Thinning of Anterior Hairline after Hairline Correction Surgery in East Asians

Background

Thin hairs are critical to achieve natural result in female hairline correction surgery. However, there are few studies on the usefulness of hair thinning by intense pulsed light (IPL) after hairline correction surgery in East Asian females.

Methods

Hair thinning using IPL was performed in 54 women who had complained about thick hairs along the frontal hairline after hairline correction surgery. Patient mean age was 31.2 years old and patients were an average of 2.1 years post-hairline correction surgery. Initial treatment used 10 J, while second and third sessions were conducted with 10 to 15 J according to responsiveness to treatment.

Results

Mean thickness of individual hairs assessed before the procedure was 78.86 µm. The mean number of procedures was 1.6 per patient. Forty of 54 subjects (74%) achieved satisfactory hair thinning with only one procedure from 78.01 to 66.14 µm after treatment. The measured thickness was 66.43 µm at the end of the first year in patients who were satisfied after one procedure. Thirteen cases achieved satisfactory hair thinning after two sessions. Mean thickness was 74.44 µm and 67.51 µm, before and after the second session. One case required a third session with 15J, thinning from 89.00 to 66.50 µm.

Conclusions

Hair thinning by IPL is a very useful method to provide a natural look after hairline correction surgery in East Asians, who have naturally thick hair.

Peroneal Flap: Clinical Application and Cadaveric Study

Background

The goal of this study was to investigate the anatomy of the peroneal artery and its perforators, and to report the clinical results of reconstruction with peroneal artery perforator flaps.

Methods

The authors dissected 4 cadaver legs and investigated the distribution, course, origin, number, type, and length of the perforators. Peroneal artery perforator flap surgery was performed on 29 patients.

Results

We identified 19 perforators in 4 legs. The mean number of perforators was 4.8 per leg, and the mean length was 4.8 cm. Five perforators were found proximally, 9 medially, and 5 distally. We found 12 true septocutaneous perforators and 7 musculocutaneous perforators. Four emerged from the posterior tibia artery, and 15 were from the peroneal artery. The peroneal artery perforator flap was used in 29 patients. Retrograde island peroneal flaps were used in 8 cases, anterograde island peroneal flaps in 5 cases, and free peroneal flaps in 16 cases. The mean age was 59.9 years, and the defect size ranged from 2.0 cm×4.5 cm to 8.0 cm×8.0 cm. All the flaps survived. Five flaps developed partial skin necrosis. In 2 cases, a split-thickness skin graft was performed, and the other 3 cases were treated without any additional procedures.

Conclusions

The peroneal artery perforator flap is a good alternative for the reconstruction of soft tissue defects, with a constant and reliable vascular pedicle, thin and pliable skin, and the possibility of creating a composite tissue flap.

Management of Gustilo Anderson III B open tibial fractures by primary fascio-septo-cutaneous local flap and primary fixation: The 'fix and shift' technique

BACKGROUND

Open fractures of tibia have posed great difficulty in managing both the soft tissue and the skeletal components of the injured limb. Gustilo Anderson III B open tibial fractures are more difficult to manage than I, II, and III A fractures. Stable skeletal fixation with immediate soft tissue cover has been the key to the successful outcome in treating open tibial fractures, in particular, Gustilo Anderson III B types. If the length of the open wound is larger and if the exposed surface of tibial fracture and tibial shaft is greater, then the management becomes still more difficult.

MATERIALS AND METHODS

Thirty six Gustilo Anderson III B open tibial fractures managed between June 2002 and December 2013 with "fix and shift" technique were retrospectively reviewed. All the 36 patients managed by this technique had open wounds measuring >5 cm (post debridement). Under fix and shift technique, stable fixation involved primary external fixator application or primary intramedullary nailing of the tibial fracture and immediate soft tissue cover involved septocutaneous shift, i.e., shifting of fasciocutaneous segments based on septocutaneous perforators.

RESULTS

Primary fracture union rate was 50% and reoperation rate (bone stimulating procedures) was 50%. Overall fracture union rate was 100%. The rate of malunion was 14% and deep infection was 16%. Failure of septocutaneous shift was 2.7%. There was no incidence of amputation.

CONCLUSION

Management of Gustilo Anderson III B open tibial fractures with "fix and shift" technique has resulted in better outcome in terms of skeletal factors (primary fracture union, overall union, and time for union and malunion) and soft tissue factors (wound healing, flap failure, access to secondary procedures, and esthetic appearance) when compared to standard methods adopted earlier. Hence, "fix and shift" could be recommended as one of the treatment modalities for open III B tibial fractures.

Fibula osteofascial flap with proximal skin paddle for intraoral reconstruction

BACKGROUND

the fibula free flap has become a workhorse in intraoral reconstruction. However, its skin paddle has multiple drawbacks. The aim of this report is to establish the applicability of the fibula osteofascial flap in intraoral reconstruction.

METHODS

prospectively maintained database was performed in 15 patients who underwent fibula osteofascial flap for intraoral reconstruction. Mandibular reconstruction was the main location (13 patients). Ten flaps were done following tumor resection, three due to osteoradionecrosis and two following mandible fracture/bone loss. A standard fibula flap dissection performing an anterior approach was done, adding a distal fascial flap isolated on the distal perforators (for intraoral reconstruction) and a proximal skin paddle (for external soft tissue reconstruction).

RESULTS

One flap was lost due to hypercoagulable state. Fourteen flaps survived with complete oral mucosalization, resembling physiological intraoral bone coverage by 7 weeks (range: 6-8 weeks). One patient presented with delayed donor-site wound healing. The mean follow-up was 14.4 months (range: 2-33 months). Thirteen patients (87%) were without tracheotomy at last follow-up, and 14 patients (93%) were taking at least some nutrition by mouth.

CONCLUSION

Fibula osteofascial flap can be safely used for intraoral reconstruction. This flap provides a stable, thin, and vascularized fascia over the fibula with minimal donor-site complications. © 2016 Wiley Periodicals, Inc. Microsurgery, 2016. © 2016 Wiley Periodicals, Inc. Microsurgery 37:276-281, 2017.

Advances in imaging technologies for planning breast reconstruction

The role and choice of preoperative imaging for planning in breast reconstruction is still a disputed topic in the reconstructive community, with varying opinion on the necessity, the ideal imaging modality, costs and impact on patient outcomes. Since the advent of perforator flaps their use in microsurgical breast reconstruction has grown. Perforator based flaps afford lower donor morbidity by sparing the underlying muscle provide durable results, superior cosmesis to create a natural looking new breast, and are preferred in the context of radiation therapy. However these surgeries are complex; more technically challenging that implant based reconstruction, and leaves little room for error. The role of imaging in breast reconstruction can assist the surgeon in exploring or confirming flap choices based on donor site characteristics and presence of suitable perforators. Vascular anatomical studies in the lab have provided the surgeon a foundation of knowledge on location and vascular territories of individual perforators to improve our understanding for flap design and safe flap harvest. The creation of a presurgical map in patients can highlight any abnormal or individual anatomical variance to optimize flap design, intraoperative decision-making and execution of flap harvest with greater predictability and efficiency. This article highlights the role and techniques for preoperative planning using the newer technologies that have been adopted in reconstructive clinical practice: computed tomographic angiography (CTA), magnetic resonance angiography (MRA), laser-assisted indocyanine green fluorescence angiography (LA-ICGFA) and dynamic infrared thermography (DIRT). The primary focus of this paper is on the application of CTA and MRA imaging modalities.

A novel method to correctly place the fasciotomy incision for decompression of the anterior and peroneal compartments of the leg

Incorrectly placed fasciotomy incisions can lead to catastrophic complications in compartment syndrome. Two distinctly different techniques are widely practiced to decompress the anterior and peroneal compartments. In one technique the anterior compartment is decompressed directly, and then the peroneal via the inter-muscular septum, avoiding the peroneal perforators. The second technique relies on surface anatomy landmarks to place the skin incision immediately over the inter-muscular septum, and then the respective fascial envelopes are incised separately. A study in healthy active volunteers was conducted to explore the feasibility of a new technique for the placing the incision very accurately over the inter-muscular septum and so avoiding perforator vessels. Hypothesis The inter-muscular septum can be reliably identified using hand-held ultrasound, and confirmed with MRI.

METHODS

Fourteen healthy active volunteers underwent hand-held ultrasound to identify the antero-lateral inter-muscular septum in the left lower limb, which was then marked using cod liver oil capsules. The positions of the anterior, septal and peroneal perforators were then identified using hand-held Doppler, and marked in the same way. MRI was then used to measure the relationship between the surface land marks, the septum (compared to its US position), and the relationship of the perforators themselves.

RESULTS

Hand held ultrasound was successful in identifying the position of the inter-muscular septum in healthy volunteers, as confirmed on MRI scanning. The position and number of peroneal and anterior perforators proved very variable. Direct decompression of the anterior compartment would result in the loss of all anterior perforators in all subjects. Decompression with the skin incision over the inter-muscular septum would not jeopardise any peroneal muscular perforators.

CONCLUSION

This new technique enables decompression both the anterior and peroneal compartments through an accurately placed incision, sparing the greatest number of perforators. Two brief case histories in which the technique was used are presented.

Distally Based Saphenous Neurocutaneous Perforator Flap: A Versatile Donor Site for Reconstruction of Soft Tissue Defects of the Medial Malleolar Region

Repair of both simple and complex defects in the medial malleolar region continues to be a challenging task for surgeons because of the local paucity of soft tissue available for transfer. The popular neurocutaneous flap has provided a reliable and less technically demanding method for resurfacing defects of the lower extremities. We present our experience with the versatile design of the distally based saphenous neurocutaneous perforator flap to provide coverage of complex post-traumatic medial malleolar defects by harvesting multiple tissue components in various combinations. Our series included 11 patients (8 males [72.7%] and 3 females [27.3%]); mean age 39.2 (range 22 to 58) years, who were followed for a mean duration of 13.3 (range 9 to 18) months. Three flaps (27.3%) were harvested with massive subcutaneous tissue to obliterate dead space. The procedure was uneventful in 10 patients (90.9%). Venous congestion was noted in 1 patient (9.1%), in whom secondary healing was achieved with conservative treatment.

Lateral calcaneal artery perforator-based skin flaps for coverage of lower-posterior heel defects

BACKGROUND

Perforator-based flaps have been explored across almost all of the lower leg except in the Achilles tendon area. This paper introduced a perforator flap sourced from this area with regard to its anatomic basis and clinical applications.

METHODS

Twenty-four adult cadaver legs were dissected to investigate the perforators emerging along the lateral edge of the Achilles tendon in terms of number and location relative to the tip of the lateral malleolus, and distribution. Based on the anatomic findings, perforator flaps, based on the perforator(s) of the lateral calcaneal artery (LCA) alone or in concert with the perforator of the peroneal artery (PA), were used for reconstruction of lower-posterior heel defects in eight cases. Postoperatively, subjective assessment and Semmes-Weinstein filament test were performed to evaluate the sensibility of the sural nerve-innerved area.

RESULTS

The PA ended into the anterior perforating branch and LCA at the level of 6.0 ± 1.4 cm (range 3.3-9.4 cm) above the tip of the lateral malleolus. Both PA and LCA, especially the LCA, gave rise to perforators to contribute to the integument overlying the Achilles tendon. Of eight flaps, six were based on perforator(s) of the LCA and two were on perforators of the PA and LCA. Follow-up lasted for 6-28 months (mean 13.8 months), during which total flap loss and nerve injury were not found. Functional and esthetic outcomes were good in all patients.

CONCLUSION

The integument overlying the Achilles tendon gets its blood supply through the perforators of the LCA primarily and that of through the PA secondarily. The LCA perforator(s)-based and the LCA plus PA perforators-based stepladder flap is a reliable, sensate flap, and should be thought of as a valuable procedure of choice for coverage of lower-posterior heel defects in selected patients.

Propeller Flap for Complex Distal Leg Reconstruction: A Versatile Alternative when Reverse Sural Artery Flap is Not Feasible

Reverse sural artery fasciocutaneous flap has become a workhorse for the reconstruction of distal leg soft tissue defects. When its use is not feasible, perforator-based propeller flap offers a better, easier, faster, and cheaper alternative to free flap. We present our experience with two men both aged 34 years who sustained Gustilo 3B injuries from gunshot. The donor area for reversed sural artery flap was involved in the injuries. They had early debridement, external fixation, and wound coverage with perforator-based propeller flaps. The donor sites were covered with skin graft. All flaps survived. There were minor wound edge ulcers due to the pressure of positioning that did not affect flap survival and the ulcers healed with conservative management. Perforator-based propeller flap is a versatile armamentarium for reconstruction of soft tissue defects of the distal leg in resource-constrained settings, especially when the donor area for a reverse flow sural flap artery is involved in the injury.

Large heel soft tissue defects managed successfully with reverse medial crural fasciocutaneous flap: a 7-year single-center experience with 21 consecutive cases

The medial crural fasciocutaneous flap is a reliable cutaneous flap that can be used for soft tissue reconstruction in the extremities. The purpose of this article is to evaluate the application and clinical significance of this surgical technique in the reconstruction of heel soft tissue defects. Twenty-one cases of heel soft tissue defect between March 2005 and March 2012 were included in this study. Wound sizes varied from 5.0 × 5.5 to 7.5 × 10.0 cm. All cases were managed with a reverse medial crural fasciocutaneous flap. Patient demographics and case information were analyzed and are reported. The sizes of the reverse medial crural fasciocutaneous flap varied from 6.5 × 10.0 to 9.0 × 15.0 cm; the average size was 7.7 × 13.8 cm. Out of the 21 consecutive cases, 20 flaps survived intact and one flap underwent partial necrosis. Follow-up observations were conducted for 6-36 months. The cosmetic results were satisfactory, without apparent bulkiness; the weight-bearing outcomes were satisfactory. The donor site can be closed primarily or by skin graft. Reverse medial crural fasciocutaneous flap transfer is appropriate for the reconstruction of heel soft tissue defects. The method is safe and can cover large heel defects.

Posterior tibial artery perforator flaps for coverage of Achilles region defects

BACKGROUND

Defects of the Achilles tendon region still represent a tricky issue in lower limb surgery. Among the several reconstructive possibilities, local propeller perforator flaps have gained popularity in the last decade.

MATERIALS AND METHODS

We report our experience with eight patients affected by small-to-moderate soft-tissue defects of the Achilles tendon region, who underwent surgical reconstruction with local flaps based on posterior tibial perforator branches.

RESULTS

All patients healed successfully in terms of aesthetic and functional aspect. In only one case a transient venous congestion was observed and this resolved spontaneously.

CONCLUSIONS

Although the surgical technique requires much care and skill, including an extremely gentle dissection of perforator vessels, local propeller flaps should be considered the first-line choice for reconstruction in small-to-medium size soft-tissue defects in the Achilles region.

The vascularized sural nerve graft based on a peroneal artery perforator for reconstruction of the inferior alveolar nerve defect

The sural nerve has been described for nerve reconstruction of the maxillofacial region since it provides many advantages. We report a case of a vascularized sural nerve graft based on a peroneal artery perforator for immediate reconstruction after the removal of intraosseous neuroma originating in the inferior alveolar nerve. The patient had a neuroma caused by iatrogenic injury to the inferior alveolar nerve. A 4-cm long neuroma existed in the inferior alveolar nerve and was resected. A peroneal perforator was chosen as the pedicle of the vascularized sural nerve graft for the nerve gap. The graft including the skin paddle for monitoring the perfusion supplied by this perforator was transferred to the lesion. The nerve gap between the two stumps of the inferior alveolar nerve was repaired using the 6-cm long vascularized sural nerve. The perforator of the peroneal artery was anastomosed to the branch of the facial artery in a perforator-to-perforator fashion. There was no need to sacrifice any main arteries. The skin paddle with 1 cm × 3 cm in size was inset into the incised medial neck. Perceptual function tests with a Semmes-Weinstein pressure esthesiometer and two-point discrimination in the lower lip and chin at 10 months after surgery showed recovery almost to the level of the normal side. This free vascularized sural nerve graft based on a peroneal artery perforator may be a good alternative for reconstruction of inferior alveolar nerve defects.

Distally based perforator propeller sural flap for foot and ankle reconstruction: a modified flap dissection technique

BACKGROUND

Distally based perforator propeller sural flaps that pedicled on an isolated perforator from the peroneal artery or posterior tibial artery are a versatile local reconstructive option for defects of the foot and ankle region. However, flap venous congestion is yet a difficult problem after operation. We hypothesize that containing some adipofascial tissues around the axial perforator can preserve some tiny venous return routes, improve venous drainage, and ultimately enhance flap safety in distally based sural flaps.

METHODS

A prospective case series of 12 patients undergoing distally based perforator sural flaps for foot and ankle coverage were included in this study from January 2008 to December 2010. There were 7 posterior tibial artery perforator flaps from the posteromedial sural region and 5 peroneal artery perforator flaps from the posterolateral sural region. After identifying the proper viable perforator during operation as the pivot point, the whole flap was designed in an eccentric propeller shape. The proximal larger blade was a fasciocutaneous flap, whereas the distal smaller blade was a subdermal vascular plexus flap, preserving at least a quarter area of adipofascial tissue intact around the perforator. Postoperatively, flap swelling was classified into a 5-grade assessment scale. Flap survival, complications, and patient functional recovery were evaluated.

RESULTS

The proximal fasciocutaneous flap measured 4 × 8 to 6 × 18 cm (mean, 57.8 cm), and the distal subdermal cutaneous flap measured 2 × 2 to 4 × 4 cm (mean, 9.2 cm). The flaps were rotated 160 to 180 degrees. Postoperatively, flap swelling was noted under grade 2 in 9 cases, grade 3 in 2, and grade 4 in 1 with some distal superficial skin necrosis, which occurred in the largest flap in our series. All flaps survived uneventfully. After a mean of 13 months of follow-up, the wounds were cured successfully. All patients recovered walking and shoe wearing function.

CONCLUSION

Keeping a quadrant adipofascial tissue around the distal pivot perforator to form a perforator-adipofascial-pedicle can preserve more venous return routes and relieve flap swelling. This technique should be recommended in distally perforator-pedicled propeller flaps because it enhances flap safety yet does not increase the difficulty of 180-degree rotation.

The second dorsal metacarpal artery chain-link flap: an anatomical study and a case report

PURPOSE

The purpose of this study was to discuss the distribution characteristics and the anatomical angioarchitecture of cutaneous branches arising from the second dorsal metacarpal artery for the repair of small tissue defects in the hand or fingers using the second dorsal metacarpal artery chain-link flap.

METHODS

Fifteen fresh human cadaveric hands were studied using three methods: latex perfusion for microanatomical analysis, denaturation of material and vinyl chloride mixed packing for cast specimens, and latex perfusion creating pellucid specimens. Cutaneous perforators with a diameter of 0.2 mm or greater were evaluated using statistical analysis. Cluster analysis was conducted to determine the overall distribution of the perforators.

RESULTS

Two main clusters of perforators distributed at a relative distance of 40.8 and 68.6% from the second web space edge to the midpoint of the second metacarpal bone as a unit. The Chi-square analysis revealed no significant differences in either the radial or ulnar side distribution of the cutaneous perforators from the second dorsal metacarpal artery (p = 0.779). Chain-links formed among adjacent perforators were parallel to the axis of the second metacarpal bone on the dorsum of the hand. Based on the anatomic characteristic, we designed the second dorsal metacarpal artery chain-link flap to recover the defect in the index finger. As a result, the patient was satisfied with the appearance and function.

CONCLUSION

This study indicates that there are two main clusters of arterioles in the distal second dorsal metacarpal artery that can be helpful for the second dorsal metacarpal artery pedicle cutaneous chain-link perforator flaps in the repair of defects in the fingers.

Gluteal-fold adipofascial perforator flap transposition for rectourethral fistula reconstruction

If a rectourinary fistula does not close spontaneously, it requires surgical closure. We present our experience of rectourethral fistula reconstruction using a gluteal-fold perforator flap, resulting in a successful outcome. The patient was a 64-year-old man with prostate cancer who underwent radical prostatectomy. However, he developed rectourinary fistula, which required surgical closure. A dissection was undertaken to divide the fistula tract, and the rectal and urethral defect were closed. A 12.0×3.0 cm gluteal-fold adipofascial perforator flap was harvested and placed in the space between the rectum and urethra. The viability of lap was favourable, without infection or necrosis. The patient could walk the next day, and was discharged 2 weeks later without fecaluria or liquid stool. We conclude that the gluteal-fold adipofascial perforator flap offers excellent functional advantages in rectourethral fistula reconstruction with minimal morbidity at the donor site.

Are there risk factors for complications of perforator-based propeller flaps for lower-extremity reconstruction?

BACKGROUND

Conventional pedicled flaps for soft tissue reconstruction of lower extremities have shortcomings, including donor-site morbidity, restricted arc of rotation, and poor cosmetic results. Propeller flaps offer several potential advantages, including no need for microvascular anastomosis and low impact on donor sites, but their drawbacks have not been fully characterized.

QUESTIONS/PURPOSES

We assessed (1) frequency and types of complications after perforator-based propeller flap reconstruction in the lower extremity and (2) association of complications with arc of rotation, flap dimensions, and other potential risk factors.

METHODS

From 2007 to 2012, 74 patients (44 males, 30 females), 14 to 87 years old, underwent soft tissue reconstruction of the lower extremities with propeller flaps. General indications for this flap were wounds and small- and medium-sized defects located in distal areas of the lower extremity, not suitable for coverage with myocutaneous or muscle pedicled flaps. This group represented 26% (74 of 283) of patients treated with vascularized coverage procedures for soft tissue defects in the lower limb during the study period. Minimum followup was 1 year (mean, 3 years; range, 1-7 years); eight patients (11%) were lost to followup before 1 year. Complications and potential risk factors, including arc of rotation, flap dimensions, age, sex, defect etiology, smoking, diabetes, and peripheral vascular disease, were recorded based on chart review.

RESULTS

Twenty-eight of 66 flaps (42%) had complications. Venous congestion (11 of 66, 17%) and superficial necrosis (seven of 66, 11%) occurred most frequently. Eighteen of the 28 complications (64%) healed with no further treatment; eight patients (29%) underwent skin grafting, and one patient each experienced total flap failure (2%) and partial flap failure (2%). In those patients, a free anterolateral thigh flap was used as the salvage procedure. No correlations were found between complications and any potential risk factor.

CONCLUSIONS

We were not able to identify any specific risk factors related to complications, and future multicenter studies will be necessary to determine which patients or wounds are at risk of complications. Propeller flaps had a low failure rate and risk of secondary surgery. These flaps are particularly useful for covering small- and medium-sized defects in the distal leg and Achilles tendon region and are a reliable and effective alternative to free flaps.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Vulvar reconstruction should be performed using gluteal-fold perforator flap because of less morbidities and complications

The authors present a case of bilateral vulvar defects after abrasion of malignant skin neoplasm, reconstructed with a gluteal-fold perforator flap, resulting in a successful outcome.

Distally based perforator flaps for reconstruction of post-traumatic defects of the lower leg and foot. A review of the anatomy and clinical outcomes

STUDY AIMS

To report the surgical anatomy of the perforator arteries at the lower leg, analyse clinical outcomes in previous studies, and forward methodological recommendations for future studies of post-traumatic perforator flap reconstructions.

METHODS

A study sample of 640 human patients drawn from 24 clinical reports was included for review. The sample comprised of four subsets: sural flap reconstructions (n=257), saphenous flaps (n=122), supramalleolar flaps (n=92), and propeller flaps (n=169).

RESULTS

Statistical analysis of samples from anatomical studies documents significant differences in the perforator distribution from the tibial and peroneal artery; peroneal perforator arteries are randomly organised whereas tibial artery perforators are clustered at three definite levels. The failure rates in clinical studies ranged from 0% to 6%, being lowest for supramalleolar flap reconstructions and highest for saphenous flaps; however, differences between the four subsets were not statistically significant at the 95% confidence level. Due to methodological flaws, outcome comparisons in the actual study sample should be interpreted cautiously; in most clinical studies both risk variables and outcome indicators are poorly defined. The outcome of Dynamic Infrared Thermography imaging of post-transposition changes of flap perfusion is reported.

SUMMARY

Fasciocutaneous perforator flaps seem to have high survival rates and represent a feasible approach to post-traumatic reconstructions, especially in low-resource settings. A template for data gathering is recommended for higher accuracy in future comparative studies, and for scientific analysis of success and risk factors. New imaging techniques indicate a promising potential of micro-circular angiogenesis during the first two weeks after flap transpose.

Can we consider standard microsurgical anastomosis on the posterior tibial perforator network? An anatomical study

PURPOSE

The main vessels in an injured leg can be spared with perforator-to-perforator anastomosis. However, supermicrosurgery is not a routine procedure for all plastic surgeons. Our objective was to establish if the diameter of the perforators of the leg could allow anastomosis with standard microsurgical procedures.

METHODS

Twenty lower legs harvested from ten fresh cadavers were dissected. Arterial and venous vessels were injected with colored latex. The limbs were then dissected in a suprafascial plane. All the perforating arteries of a diameter >0.8 mm were located and their external diameter, the number and external diameter of the venae comitantes were reported.

RESULTS

We found at least three tibial posterior artery perforators with diameters >0.8 mm per leg with a mean external diameter of 1.1 mm and one vena comitans in almost all cases (96 %). The vena comitans was usually bigger than the perforating artery with a mean diameter of 1.6 mm. After statistical analysis, we were able to locate two main perforator clusters: at the junctions of the upper two-thirds of the leg and of the lower two-thirds of the leg.

CONCLUSION

The low-morbidity concept of perforator-to-perforator anastomosis can apply to posterior tibial artery perforators without using supermicrosurgical techniques. This is of high interest for open leg fractures where main vessels could be injured. We hope that the results of our study will incite surgeons to consider sparing of main vessels for coverage of open leg fractures whether surgical teams master supermicrosurgery or not.

Surgical Reconstruction of Radiation Injuries

Significance: Patients with cancer receive benefits from radiation therapy; however, it may have adverse effects on normal tissue such as causing radiation-induced ulcer and osteoradionecrosis. The most reliable method to treat a radiation ulcer is wide excision of the affected tissue, followed by coverage with well-vascularized tissue. As usual, radiation-induced skin ulcers are due to therapeutic irradiation for residual cancer or lymph nodes; the locations of radiation ulcers are relatively limited, including the head, neck, chest wall, lumbar, groin, and sacral areas. Thus, suitable reconstructive methods vary according to functional and aesthetic conditions. I reviewed the practices and surgical results for radiation ulcers over the past 30 years, and present the recommended surgical methods for these hard-to-heal ulcers. Recent Advances: At a minimum, flaps are required to treat radiation ulcers. Surgeons can recommend earlier debridement, followed by immediate coverage with axial-pattern musculocutaneous and fasciocutaneous flaps. Free flaps are also a useful soft tissue coverage option. The choice of flap varies with the location and size of the wounds. Critical Issues: The most crucial procedure is the complete resection of the radiation-affected area, followed by coverage with well-vascularized tissue. Future Directions: Recent developments in perforator flap techniques, which are defined as flaps with a blood supply from isolated perforating vessels of a stem artery, have allowed the surgeons to successfully resurface these difficult wounds with reduced morbidity.

Freestyle propeller flaps from the lower abdomen: a valuable reconstructive option for proximal thigh defects

The concepts of freestyle flap design allows for flap creation from virtually every place in the body. Descriptions of named flaps based on their arterial origin are commonly described in the literature, allowing for predictable flap design. However, in certain cases, isolating a flap based on a Doppler signal and retrograde perforator dissection will allow for appropriate flap creation and wound coverage. We describe a 52-year-old female with a chronic open wound that failed wound care and local soft tissue rearrangement. This led to detection of a strong perforator signal in the lower lateral abdomen prompting the use of a freestyle propeller flap. The patient recovered without complication. Twelve-month follow-up demonstrated trunk and lower extremity mobility without impairment. We describe a successful and novel use of a rare, unnamed perforator from the lower, lateral abdomen by employing the freestyle propeller flap for coverage of a proximal thigh wound.