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The posterior tibial artery free flap for head and neck reconstruction. Curr Opin Otolaryngol Head Neck Surg 2022; 30:358-362. [PMID: 36004793 DOI: 10.1097/moo.0000000000000843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE The posterior tibial artery free flap (PTAFF) has been a mainstay of lower extremity reconstruction. Over the past 30 years, it has been intermittently used for head and neck reconstruction with recent renewed interest given its versatility. RECENT FINDINGS Use of the PTAFF in head and neck reconstruction is expanding along with the continued evolution of microvascular techniques. Differences in overall health, incidence of smoking, and body habitus can impact the utility of this flap and should be taken into consideration when choosing to use it. SUMMARY The PTAFF for head and neck reconstruction is a useful tool for the head and neck/reconstructive surgeon. Understanding the potential pitfalls and caveats to use of the PTAFF is important for successful use of this versatile flap.
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Tsukuura R, Yamamoto T. Free medialis tarsus flap transfer for reconstruction of toe necrosis: A case report. Microsurgery 2021; 41:671-675. [PMID: 34156111 DOI: 10.1002/micr.30780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 01/12/2021] [Accepted: 05/28/2021] [Indexed: 10/21/2022]
Abstract
The medial tarsal area is a commonly used donor site for skin grafts to the digits and toes, with good color and texture match as well as a concealable donor site scar. Yet, there has been no report as a perforator free flap donor site. The purpose of this report is to present a new perforator flap harvested from medial tarsal region. We present a case of a soft tissue defect of the fifth toe due to essential thrombocythemia (ET), successfully treated with a free medialis tarsus flap (MTF) transfer. A 62-year-old male with ET suffered from the right fifth toe necrosis caused by digital artery thrombosis. After the manifestation of the necrosis, necrotic tissue was completely debrided, which resulted in a 3 × 1.5 cm skin defect with exposure of the tendon and the phalangeal bone. Sixth days after debridement, a 4.5 × 1.7 cm MTF was harvested transversely and inferiorly to the right medial ankle, locating the preoperatively detected posterior tibial artery perforator (PTAP) in the flap. Perforator-to-perforator anastomosis was done using the dorsal metatarsal artery perforator and the subcutaneous vein as recipient vessels. The donor site was closed primarily. Postoperative course was uneventful, and the reconstruction preserved the toe length and functions of extension and flexion at 9 months postoperatively. The patient could walk with conventional shoes by himself. MTF may be an option for small skin defect in the digits and toes where skin graft is not indicated.
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Affiliation(s)
- Reiko Tsukuura
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Takumi Yamamoto
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
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Liu X, Sun Y, Jia Y, Hong SM, Xu J, Wang C, Wen G, Lineaweaver WC, Chai Y. Free extended posterior tibial artery perforator flap with the neurovascular plexus of a saphenous nerve branch for large soft tissue and sensory reconstruction: Anatomic study and clinical application. Microsurgery 2020; 41:133-139. [PMID: 33165984 DOI: 10.1002/micr.30675] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 10/10/2020] [Accepted: 10/16/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND The posterior tibial artery perforator (PTAP) flap is a useful tool for reconstruction of soft tissue defects in the leg. However, the size and reliability of the flap largely depends on the quality of the perforator by which the flap is supplied, and the sensory recovery of the flap is limited. In this study, the anatomy of the saphenous nerve branches and their accompanying vessels was investigated, and a free extended PTAP flap with the neurovascular plexus of a saphenous nerve branch was designed for large soft tissue and sensory reconstruction in a series of clinical cases. METHODS Sixteen adult cadaveric legs perfused with red latex in the femoral artery were dissected. The number and location of the saphenous nerve branches and the features of their accompanying vessels were dissected and studied. From January 2016 to December 2017, six patients with soft tissue defects ranged from 8 × 2.5 cm to 21 × 4 cm were repaired by the free extended PTAP flap. The patients' average age was 48 years. The causes of the defects included machine injuries in three patients and traffic injuries in the other three. The defects located at the hand in three cases, foot in two cases, and ankle in one case. The flap was designed based on the perforators of the posterior tibial artery and included a branch of saphenous nerve. The perforator pedicle and the nerve branch were connected to the vessels and nerve in the recipient site, respectively. RESULTS The saphenous nerve gave off 5.8 ± 1.1 branches, with a relatively constant one issuing 8.1 ± 0.7 cm distal to the medial femoral condyle. Every nerve branch had an accompanying vessel, which connected with the PTAPs and supplied the skin. The size of the flap ranged from 10 × 3.5 cm to 23 × 5 cm. All of the flaps survived completely without complications. Follow-up varied from 6 to 12 months. All the patients obtained cold/hot sensation and pain sensation. The results of Semmes-Weinstein monofilament test ranged from 4.31(2 g) to 5.46 (26 g), and the 2-point discrimination test varied from 20 to 35 mm. CONCLUSION The free extended PTAP flap, containing the saphenous nerve branch and its accompanying vessels, may be an alternative for large soft tissue reconstruction with improved sensation recovery.
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Affiliation(s)
- Xuanzhe Liu
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Yi Sun
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Yachao Jia
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Sung Min Hong
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jia Xu
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Chunyang Wang
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Gen Wen
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | | | - Yimin Chai
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
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Perry WC, Masadeh S, Thione A. The Distally Based Posterior Tibial Artery Flap. Clin Podiatr Med Surg 2020; 37:671-680. [PMID: 32919597 DOI: 10.1016/j.cpm.2020.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Soft tissue defects to the distal leg and hindfoot are challenging with only the smallest defects closed primarily without tissue transposition. These defects to the distal leg and hindfoot can lead to tendon desiccation, damaged neurovascular structures, and exposed joint surfaces. These wounds can be the result of postoperative dehiscence and exposed orthopedic hardware, with high susceptibility to infection. Pedicled fasciocutaneous flaps of the medial leg provide an excellent solution with good outcomes that do not require microanastomosis and have similar outcomes as compared with free flap reconstruction in the lower extremity.
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Affiliation(s)
- William C Perry
- Cincinnati Veteran Affairs Medical Center, 3200 Vine Street, Cincinnati, OH 45220, USA.
| | - Suhail Masadeh
- Cincinnati Veteran Affairs Medical Center, 3200 Vine Street, Cincinnati, OH 45220, USA
| | - Alessandro Thione
- Department of Plastic Surgery and Burns, Hospital Universitari i Politecnic La Fe, 106 Avinguda de Fernando Abril Martorell, Valencia E-46026, Spain
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Liu J, Lu D, Deng D, Wang J, Gan W, Zou J, Chen F, Yang H. Free posterior tibial artery perforator flap for 2-stage tracheal reconstruction in patients after resection of well-differentiated thyroid carcinoma invading the trachea. Head Neck 2019; 41:2249-2255. [PMID: 30729609 PMCID: PMC6618072 DOI: 10.1002/hed.25675] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 12/09/2018] [Accepted: 01/15/2019] [Indexed: 02/05/2023] Open
Abstract
Background The present study was conducted to explore the efficacy of using a free posterior tibial artery perforator flap (FPTAPF) for trachea reconstruction after resection of well‐differentiated thyroid carcinoma (WDTC) invading the trachea. Methods We retrospectively collected and analyzed clinical and surgical data from 14 patients who underwent tracheal reconstruction using a FPTAPF after resection of WDTC invading the trachea between August 2014 and July 2017. Results Satisfactory tracheal structure and functional recovery were obtained in 11 of the 14 patients. One patient had breathing difficulties after tracheostomy closure tests because of bilateral recurrent laryngeal nerve damage caused by disease invasion. Tracheostomy incision was not closed in 2 patients because they received postoperative adjuvant radioactive iodine 131 treatment. Conclusion Satisfactory tracheal reconstruction results were achieved in patients with resection of WDTC invading the trachea, indicating that a FPTAPF is a safe and reliable choice for management.
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Affiliation(s)
- Jun Liu
- Department of Otorhinolaryngology, Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Dan Lu
- Department of Otorhinolaryngology, Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Di Deng
- Department of Otorhinolaryngology, Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Ji Wang
- Department of Otorhinolaryngology, Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Weigang Gan
- Department of Otorhinolaryngology, Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jian Zou
- Department of Otorhinolaryngology, Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Fei Chen
- Department of Otorhinolaryngology, Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Hui Yang
- Department of Otorhinolaryngology, Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China
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Redefining Vascular Anatomy of Posterior Tibial Artery Perforators: A Cadaveric Study and Review of the Literature. Ann Plast Surg 2017; 76:705-12. [PMID: 25003444 DOI: 10.1097/sap.0000000000000258] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Reconstruction of Moderate-Sized Hand Defects Using a Superficial Lateral Sural Artery Perforator Flap. Ann Plast Surg 2017; 78:412-416. [DOI: 10.1097/sap.0000000000000898] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Özalp B, Aydınol M. Perforator-based propeller flaps for leg reconstruction in pediatric patients. J Plast Reconstr Aesthet Surg 2016; 69:e205-11. [DOI: 10.1016/j.bjps.2016.07.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 06/24/2016] [Accepted: 07/16/2016] [Indexed: 10/21/2022]
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Hupkens P, Westland PB, Schijns W, van Abeelen MH, Kloeters O, Ulrich DJ. Medial lower leg perforators: An anatomical study of their distribution and characteristics. Microsurgery 2016; 37:319-326. [DOI: 10.1002/micr.30076] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 04/07/2016] [Accepted: 05/04/2016] [Indexed: 11/06/2022]
Affiliation(s)
- Pieter Hupkens
- Department of Plastic and Reconstructive Surgery; Radboud University Medical Center (Radboudumc); Geert Grooteplein-Zuid 10 Nijmegen GA 6525 the Netherlands
| | - Pèdrou B. Westland
- Department of Plastic and Reconstructive Surgery; Radboud University Medical Center (Radboudumc); Geert Grooteplein-Zuid 10 Nijmegen GA 6525 the Netherlands
| | - Wendy Schijns
- Department of Plastic and Reconstructive Surgery; Radboud University Medical Center (Radboudumc); Geert Grooteplein-Zuid 10 Nijmegen GA 6525 the Netherlands
| | - Marjolijn H.A. van Abeelen
- Department of Plastic and Reconstructive Surgery; Radboud University Medical Center (Radboudumc); Geert Grooteplein-Zuid 10 Nijmegen GA 6525 the Netherlands
| | - Oliver Kloeters
- Department of Plastic and Reconstructive Surgery; Radboud University Medical Center (Radboudumc); Geert Grooteplein-Zuid 10 Nijmegen GA 6525 the Netherlands
| | - Dietmar J.O. Ulrich
- Department of Plastic and Reconstructive Surgery; Radboud University Medical Center (Radboudumc); Geert Grooteplein-Zuid 10 Nijmegen GA 6525 the Netherlands
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Free and pedicle flaps in lower extremity trauma. EUROPEAN JOURNAL OF PLASTIC SURGERY 2015. [DOI: 10.1007/s00238-014-1056-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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A study of the perforating arteries of the leg derived from the anterior tibial, posterior tibial and peroneal arteries. J ANAT SOC INDIA 2014. [DOI: 10.1016/j.jasi.2014.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Chen F, Liu J, Wang L, Lv D, Zhu Y, Wu Q, Li G, Zheng H, Tao X. Free posterior tibial flap reconstruction for hypopharyngeal squamous cell carcinoma. World J Surg Oncol 2014; 12:163. [PMID: 24884631 PMCID: PMC4038592 DOI: 10.1186/1477-7819-12-163] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Accepted: 05/09/2014] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES The aim of this article was to determine outcomes in patients with squamous cell carcinoma of the hypopharynx (SCCHP) in whom the free posterior tibial flap was used for primary reconstruction of hypopharynx defects after cancer resection. SUBJECTS AND METHODS Between August 2009 and February 2012, 10 patients with SCCHP underwent posterior tibial flap reconstruction for hypopharynx defects. The corresponding clinical data were retrospectively collected and analyzed. RESULTS Despite the multistep and time-consuming procedure, the posterior tibial flap survival rate was 100%. Operation-induced complications did not occur in four patients. Six patients developed postoperative hypoproteinemia, four patients developed postoperative pulmonary infections, and four patients developed pharyngeal fistula. The pharyngeal and laryngeal functions of all patients were preserved. CONCLUSION Our experience demonstrates that the posterior tibial flap is a safe and reliable choice for the reconstruction of hypopharynx defects.
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Affiliation(s)
| | | | | | | | | | | | - Guojun Li
- Department of Head and Neck Surgery, the University of Texas, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA.
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Chen F, Liu J, Lv D, Wang L, Liu Y. Reconstruction of the oropharynx with free posterior tibial flap after tonsillar cancer extirpation. J Oral Maxillofac Surg 2014; 72:2083-91. [PMID: 25234533 DOI: 10.1016/j.joms.2014.04.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 04/17/2014] [Accepted: 04/21/2014] [Indexed: 02/05/2023]
Abstract
PURPOSE Oropharyngeal reconstruction after tonsillar tumor resection is a great challenge for head and neck surgeons. The aim of the present study was to explore the reconstruction efficacy of the free posterior tibial flap in the primary reconstruction of oropharynx defects after tonsillar squamous cell carcinoma (SCC) ablation. MATERIALS AND METHODS From August 2009 to March 2012, 12 patients with tonsillar SCC underwent oropharynx reconstruction with a free posterior tibial flap at the Department of Otolaryngology Head and Neck Surgery, West China Hospital of Sichuan University. Their clinical and surgical data were retrospectively collected and analyzed. RESULTS Of the 12 patients, 8 were male and 4 were female (age range 41 to 66 years, mean 55.1). The average size of the free posterior tibial flap was 9.2 × 6.3 cm (range 7 × 5 to 12 × 7), the average flap thickness was 1.1 cm (range 0.9 to 1.3), and the average pedicle length was 10 cm (range 7 to 12). Despite the multistep and time-consuming procedure, all patients tolerated oropharynx reconstruction with the free posterior tibial flap. The transferred free posterior tibial flaps survived well. No donor site complications were observed during the follow-up period. All 12 patients acquired satisfactory swallowing and speech function preservation. CONCLUSIONS Satisfactory reconstruction results were achieved for all 12 patients, indicating the free posterior tibial flap should be considered a potential treatment option for reconstruction of oropharynx defects. However, additional prospective studies with a larger sample size are required to validate our results.
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Affiliation(s)
- Fei Chen
- Assistant Professor, Department of Otolaryngology Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jun Liu
- Surgeon, Department of Otolaryngology Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Dan Lv
- Surgeon, Department of Otolaryngology Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Lihong Wang
- Professor, Department of Otolaryngology Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yafeng Liu
- Professor, Department of Otolaryngology Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China.
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Eburdery H, Chaput B, Andre A, Grolleau JL, Chavoin JP, Lauwers F. Can we consider standard microsurgical anastomosis on the posterior tibial perforator network? An anatomical study. Surg Radiol Anat 2014; 36:747-53. [PMID: 24482060 DOI: 10.1007/s00276-014-1261-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 01/17/2014] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Harold Eburdery
- Plastic and Reconstructive Surgery Unit, CHU Toulouse Rangueil, 1 avenue Jean Poulhès, 31400, Toulouse, France,
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Nelson JA, Fischer JP, Brazio PS, Kovach SJ, Rosson GD, Rad AN. A review of propeller flaps for distal lower extremity soft tissue reconstruction: Is flap loss too high? Microsurgery 2013; 33:578-86. [DOI: 10.1002/micr.22134] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Revised: 04/04/2013] [Accepted: 04/17/2013] [Indexed: 11/11/2022]
Affiliation(s)
- Jonas A. Nelson
- Division of Plastic Surgery; Perelman School of Medicine at the University of Pennsylvania; Philadelphia PA
| | - John P. Fischer
- Division of Plastic Surgery; Perelman School of Medicine at the University of Pennsylvania; Philadelphia PA
| | - Philip S. Brazio
- Department of Surgery; University of Maryland School of Medicine; Baltimore MD
| | - Stephen J. Kovach
- Division of Plastic Surgery; Perelman School of Medicine at the University of Pennsylvania; Philadelphia PA
| | - Gedge D. Rosson
- Department of Plastic Surgery; Johns Hopkins Hospital; Baltimore MD
| | - Ariel N. Rad
- Department of Plastic Surgery; Johns Hopkins Hospital; Baltimore MD
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Reconstruction of Distal Limb Defects with the Free Medial Sural Artery Perforator Flap. Plast Reconstr Surg 2013; 131:95-105. [DOI: 10.1097/prs.0b013e3182729e3c] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Xu ZF, Shang DH, Duan WY, Liu FY, Li P, Sun CF. Free posterior tibial artery perforator flap for floor of mouth reconstruction: A case report. Microsurgery 2011; 31:659-61. [DOI: 10.1002/micr.20931] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2010] [Accepted: 05/11/2011] [Indexed: 11/09/2022]
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Boriani F, Bruschi S, Fraccalvieri M, Cipriani R. Leg perforators and leg length: An anatomic study focusing on topography and angiogenesis. Clin Anat 2010; 23:593-605. [PMID: 20544953 DOI: 10.1002/ca.20981] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Filippo Boriani
- Department of Plastic Reconstructive and Aesthetic Surgery, University of Turin, Italy.
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Abstract
BACKGROUND Three-dimensional evaluations of cutaneous perforator vessels provide useful clinical information to aid in the design of perforator flaps. By combining three-dimensional digital imaging and angiography, the authors developed a new three-dimensional visualization technique for vascular perforators. Their purpose was to produce a digitized model of the posterior leg to determine the anatomical relationships of perforators in each zone of the posterior leg. METHODS Eight cadavers were injected with a modified lead oxide-gelatin mixture. Two cadavers were selected for three-dimensional reconstruction using a spiral computed tomography scanner and specialized volume-rendering software. Dissection, angiography, and photography of each layer were performed to outline the course of every perforator in the posterior leg. The area of the vascular territory supplied by each source vessel was calculated. Surface areas were measured using Scion Image software. RESULTS The arterial supply to the integument of the posterior leg was divided into proximal, middle, and distal zones. There were 13 +/- 2.3 perforators with diameters of greater than or equal to 0.5 mm; the average external diameter was 0.8 +/- 0.2 mm. Each perforator supplied an average area of 38 +/- 9.0 cm. Perforators from the popliteal artery were large and consistent and supplied an average area of 55 +/- 20 cm; there were multiple anastomoses between perforators from the popliteal, posterior tibial, and peroneal arteries. The distal zone received its arterial supply from two to three smaller septocutaneous perforators, which are arranged longitudinally in one to two parallel chains. CONCLUSIONS The posterior leg is an excellent donor site for local and distant flaps. Perforator flaps could be based in a variety of ways from each zone.
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Current state of the art in perforator flap imaging with computed tomographic angiography. Surg Radiol Anat 2009; 31:631-9. [DOI: 10.1007/s00276-009-0484-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2008] [Accepted: 02/16/2009] [Indexed: 10/21/2022]
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Feinendegen DL, Niederhäuser T, Herrmann G, Abderhalden S, Vögelin E, Banic A, Constantinescu MA. The subcostal artery perforator flap; an anatomical study. J Plast Reconstr Aesthet Surg 2008; 61:1496-502. [DOI: 10.1016/j.bjps.2007.09.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2006] [Revised: 02/14/2007] [Accepted: 09/17/2007] [Indexed: 11/28/2022]
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Perforators of the Lower Leg: Analysis of Perforator Locations and Clinical Application for Pedicled Perforator Flaps. Plast Reconstr Surg 2008; 122:161-170. [PMID: 18594401 DOI: 10.1097/prs.0b013e3181774386] [Citation(s) in RCA: 147] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Masia J, Moscatiello F, Pons G, Fernandez M, Lopez S, Serret P. Our Experience in Lower Limb Reconstruction With Perforator Flaps. Ann Plast Surg 2007; 58:507-12. [PMID: 17452834 DOI: 10.1097/01.sap.0000239841.47088.a5] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The application of Taylor's concept about body angiosomes, referred to tissue transfers, has meant that the development of the perforator flaps and muscles is no longer needed as a carrier of skin flap vascularity. In this paper, we revise 59 lower limb reconstructions with local and free perforator flaps performed in the last 5 years, and a basic reconstructive algorithm is also suggested to help with the management of the lower limb soft tissue reconstruction with perforator flaps. The advantages of the perforator flaps are (1) muscles and their function are preserved; (2) the main vascular trunks are spared; (3) it is possible to make a more specific reconstruction, replacing "like with like" (even performing compound or chimeric flaps); (4) the donor site can often be closed primarily; (5) the general morbidity is reduced; (6) a better cosmetic result can be achieved.
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Affiliation(s)
- Jaume Masia
- Department of Plastic Surgery, Hospital de la Santa Creu i Sant Pau (Universitat Autonoma de Barcelona), Barcelona, Spain.
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Ozdemir R, Kocer U, Sahin B, Oruc M, Kilinc H, Tekdemir I. Examination of the Skin Perforators of the Posterior Tibial Artery on the Leg and the Ankle Region and Their Clinical Use. Plast Reconstr Surg 2006; 117:1619-30. [PMID: 16641734 DOI: 10.1097/01.prs.0000206957.02510.40] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND There are many treatment alternatives for reconstruction of leg and foot defects. One of these treatment alternatives includes local flaps. A detailed understanding of the blood flow of the leg region is essential for producing new alternatives for the reconstruction of defects of this region. METHODS The leg and foot region blood flow was examined on 11 fresh cadavers, and perforators of this region were examined in three zones. Perforator numbers and their diameters were defined at this region. It was determined in cadaver studies that especially zones I and II were more suitable for the planned flaps based on perforators of the posterior tibial artery. In a clinical study that accompanies this anatomical study, eight patients underwent reconstruction by flaps based on the perforators of the posterior tibial artery. RESULTS Patients were followed for 3 to 14 months. In three patients, venous drainage problems had developed, and in one of them, partial flap loss had developed. This partially necrosed region was left to heal by secondary intention. Venous drainage problems resolved in 5 to 7 days in the two remaining patients. No other complications were seen. CONCLUSION Regarding the results of the clinical study, the authors observed that this flap can provide the desired soft-tissue support for defects that expose the bones, tendons, and neural and vascular bundles.
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Affiliation(s)
- Ragip Ozdemir
- Plastic and Reconstructive Surgery Clinic, Ankara Training and Research Hospital, Ankara, Turkey.
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Mardini S, Salgado CJ, Chen HC, Yazar S, Ozkan O, Sassu P. Posterior Tibial Artery Flap in Poliomyelitis Patients with Lower Extremity Paralysis. Plast Reconstr Surg 2006; 117:640-5. [PMID: 16462351 DOI: 10.1097/01.prs.0000197208.29709.83] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Poliomyelitis is a disease that can render affected individuals incapacitated to a variable degree. A normal lifespan is expected and therefore the patients deserve every effort at curative cancer resection and reconstruction. Those with lower extremity paralysis rely heavily on their upper limbs and torso for ambulation; therefore, their compromised limbs may be a better donor site for flaps. METHODS All poliomyelitis patients with lower extremity paralysis over a 20-month period who underwent head and neck reconstruction were selected for a retrospective review. Perioperative complications were noted and outpatient follow-up was performed. RESULTS Three patients underwent reconstruction of defects using the posterior tibial artery flap. Two patients required reconstruction of a buccal defect and one patient required soft palate reconstruction. All patients healed without complications and none required reexploration. At a mean follow-up of 10 months, there was no incidence of donor limb vascular compromise, cold intolerance, or long-term paresthesias. CONCLUSIONS The posterior tibial artery free flap has been used successfully in the past; however, its popularity has been limited because of sacrifice of the posterior tibial artery. Nevertheless, in patients with lower extremity paralysis, this flap may fulfill the requirements of a thin, pliable flap with minimal hair that has a long pedicle and a reliable blood supply. Most importantly, the use of this flap obviates the need to use flaps that fulfill the same requirement, such as forearm flaps, that would be taken from patients' functioning limbs.
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Affiliation(s)
- Samir Mardini
- Department of Plastic Surgery, Da Hospital/I-Shou University, Kaohsiung County, Taiwan
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Guerra AB. Soft-tissue reconstruction after meningococcal septicemia using a posterior tibial artery perforator flap in a 6-year-old boy. Pediatr Surg Int 2005; 21:466-9. [PMID: 15883822 DOI: 10.1007/s00383-005-1427-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/11/2005] [Indexed: 11/30/2022]
Abstract
Fulminant meningococcemia can have life-threatening as well as limb-threatening complications. However, unlike other types of peripheral gangrene, areas of necrosis do not follow known anatomic vascular patterns. Instead, irregular and patchy areas of necrosis are found to exist adjacent to viable tissues. With improved critical care, more patients survive the initial insult and are referred for reconstructive procedures. In this case, a 6-year boy was diagnosed with meningococcemia-induced purpura fulminans. After stabilization, he was transferred to our facility for management of open wounds of both lower extremities and the left elbow. Soft-tissue coverage was accomplished after multiple debridements using various flaps. In particular, a defect of the right midtibia was reconstructed using a posterior tibial artery perforator-based flap with excellent results. This is the first time such a flap has been reported in association with meningococcemia in a patient of this age.
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Affiliation(s)
- Aldo Benjamin Guerra
- Aesthetic Surgical Associates, 3601 Houma Boulevard, Suite 300, Metairie, LA, 70006, USA.
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29
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Kim JT. New nomenclature concept of perforator flap. ACTA ACUST UNITED AC 2005; 58:431-40. [PMID: 15897023 DOI: 10.1016/j.bjps.2004.12.009] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2003] [Accepted: 12/15/2004] [Indexed: 10/25/2022]
Abstract
Confusion regarding the perforator flap concept has arisen partly from the use of ill-defined nomenclature without consistency; flaps have been named according to either the proximal vessel, the location harvested or the muscle dissected. Since, a variety of conflicting terms can distort the exact understanding of the flap and the true perforator concept, a precise and scientific system of nomenclature is promptly needed. In order to remedy such confusion, the author reviewed 54 recently published articles and 38 abstracts for vague or inaccurate nomenclatures, and compared the perforator flaps with the conventional flaps. A new nomenclature was then drawn up according to three perforator types: direct cutaneous, septocutaneous and musculocutaneous perforator. Even though only musculocutaneous perforators were considered to be true perforators in the initial concept, some perforator flaps have subsequently been added based on septocutaneous or direct cutaneous perforators. Discrimination is necessary and made possible by use of the following nomenclature: a perforator flap based on a musculocutaneous perforator is named according to the name of the muscle perforated, and perforator flaps based on other types of perforators, are named according to the name of the proximal vessel. The term 'perforator based' further defines those flaps harvested without sacrificing the proximal vessel. This new nomenclature concept would be a great help in discriminating among the various patterns of perforator flaps and also in preventing confusion arising from the misnaming of new perforator flaps in the future. Furthermore, the perforator pattern used in the flap can easily be comprehended, and especially in extremities, various perforator flaps, based on the musculocutaneous or septocutaneous perforator, can plainly be distinguished with this new nomenclature concept.
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Affiliation(s)
- Jeong Tae Kim
- Department of Plastic and Reconstructive Surgery, College of Medicine, Hanyang University, Haengdang-Dong 17, Seongdong-Gu, Seoul 133-792, South Korea.
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Wolff KD, Hölzle F, Nolte D. Perforator Flaps from the Lateral Lower Leg for Intraoral Reconstruction. Plast Reconstr Surg 2004; 113:107-13. [PMID: 14707628 DOI: 10.1097/01.prs.0000095936.56036.cd] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Perforator flaps are based on cutaneous, small-diameter vessels that originate from a main pedicle and perforate fascia or muscle to reach the skin. Although these flaps have recently become popular for soft-tissue reconstructions in nearly all regions of the body, the systematic application of perforator flaps with short, small-caliber pedicles for intraoral reconstruction has not been reported. Experience with the use of 10 consecutive perforator flaps from the lateral lower leg for intraoral defect coverage is reported. In 10 cases, a 4- to 6-cm-long septocutaneous or myocutaneous perforating vessel from the peroneal artery, with a diameter of 1 to 2 mm, could be identified in the proximal one-half of the lateral lower leg. The thin, pliable skin paddles, measuring up to 6 x 8 cm, were used for defect coverage after resection of squamous cell carcinomas of the floor of the mouth (five cases), soft palate (one case), tongue (two cases), or buccal mucosa (two cases). Anastomoses were performed to the lingual artery and concomitant vein. Except for one case, all perforator flaps healed without complications and the functional results were satisfying. At the donor site, which was always closed directly, an approximately 15-cm-long scar resulted, without functional impairments. The peroneal artery was regularly preserved. Perforator flaps from the lateral lower leg might have many applications for intraoral soft-tissue reconstruction, especially because of their minimal donor-site morbidity.
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Affiliation(s)
- Dominik L Feinendegen
- Department of Hand and Plastic Surgery, Friedrich-Alexander University Hospital, Erlangen, Germany.
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