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Nava CM, Martineau J, Suva D, Kalbermatten DF, Oranges CM. Distally based peroneus brevis flap: Reconstruction of complex soft-tissue defects with bony infection of the lateral malleolus. J Plast Reconstr Aesthet Surg 2024; 95:207-215. [PMID: 38936331 DOI: 10.1016/j.bjps.2024.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Revised: 06/02/2024] [Accepted: 06/06/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Managing wounds of the lateral malleolus is challenging owing to limited nearby tissues and possibly injured or inadequate vessels for free flaps, especially in case of underlying infections. Moreover, free flaps require specialized skills and are not suitable for every patient. Therefore, identifying reliable local alternatives is crucial. This retrospective study investigated the efficacy and safety of the distally based peroneus brevis muscle flap in treating complex and infected soft-tissue defects of the lateral malleolus. MATERIALS AND METHODS A retrospective medical chart review of all patients who underwent a distally based peroneus brevis muscle flap reconstruction in the context of an infected lateral malleolus defect at Geneva University Hospitals between October 2020 and January 2024 was performed. RESULTS Ten patients underwent lateral malleolus reconstruction using a distally based peroneus brevis muscle flap primarily to address post-traumatic infections. Flap coverage was performed within 4 weeks of infection onset for post-traumatic cases, alongside antibiotic treatment. The defects were moderate in size, with a median width of 2.5 cm and length of 5.5 cm. There were no complete or partial flap failures. All patients regained the ability to walk within 5 days after surgery. CONCLUSIONS The distally based peroneus brevis muscle flap was efficient in managing complex and infected soft-tissue defects of the lateral malleolus, with control of infection in all patients and minimal donor-site morbidity.
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Affiliation(s)
- Caterina M Nava
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Geneva University Hospitals, Geneva University, 1205 Geneva, Switzerland; Department of Surgery, HFR Fribourg Cantonal Hospital, 1708 Fribourg, Switzerland
| | - Jérôme Martineau
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Geneva University Hospitals, Geneva University, 1205 Geneva, Switzerland
| | - Domizio Suva
- Department of Orthopaedic Surgery, Bone Infection Unit, Geneva University Hospitals, Geneva University, 1205 Geneva, Switzerland
| | - Daniel F Kalbermatten
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Geneva University Hospitals, Geneva University, 1205 Geneva, Switzerland
| | - Carlo M Oranges
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Geneva University Hospitals, Geneva University, 1205 Geneva, Switzerland.
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Tweel M, Dow T, Greene B, Leblanc M. Anatomy, surgical techniques, and clinical outcomes for the medial arm flap: A systematic review. J Plast Reconstr Aesthet Surg 2024; 92:130-144. [PMID: 38518625 DOI: 10.1016/j.bjps.2024.02.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 02/19/2024] [Accepted: 02/22/2024] [Indexed: 03/24/2024]
Abstract
BACKGROUND The medial arm flap (MAF) has been used as a pedicle flap and free flap to reconstruct various deformities, including those of the head and neck, axilla, elbow, chest, and hand. This study reviews the anatomy of the flap, the technique of flap harvest, its clinical applications, and a systematic review of the current published literature. METHODS An online systematic review of MEDLINE, EMBASE, PubMed, and The Cochrane Library from inception to September 30, 2023, was completed. Studies that investigate the anatomy, technique or clinical outcomes of medial arm flaps were included. Clinical data extracted includes patient, defect, flap characteristics, complications, and take-back procedures. Anatomic data extracted includes anatomical variations, and vascular characteristics and patterns. RESULTS Between 1980 and 2023, 50 papers were published outlining the medial arm flap. Anatomic studies detail the anatomy of 384 medial arms, and outcomes are reported for 283 MAFs (75 free flaps and 208 pedicle flaps). The superior ulnar collateral artery is most commonly cited as the dominant arterial supply to the middle third of the medial arm. The majority of patients required reconstruction post-burn (39.2%), trauma (17.7%), and tumor excision (12.4%). MAFs were mostly used to reconstruct defects of the head and neck (41.7%), the hand and wrist (21.9%), and the elbow (16.3%). Eleven flaps (4.1%) suffered partial flap failure, and two flaps (0.7%) suffered total flap failure. CONCLUSION This manuscript demonstrates that the MAF is a reliable and underutilized flap option with a well-hidden donor scar and a low complication rate.
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Affiliation(s)
- Madeline Tweel
- Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Todd Dow
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Dalhousie University, Halifax, Nova Scotia, Canada.
| | - Bradley Greene
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Martin Leblanc
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
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Gatto A, Giacomini G, Cavalli EM, Pajardi GE, Marchesi A. Immediate Soft Tissue Reconstruction in Lower Limb Traumas Using Propeller Perforator Flaps. Ann Plast Surg 2023; 91:590-596. [PMID: 37823624 DOI: 10.1097/sap.0000000000003696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
BACKGROUND Open bone fractures represent a demanding clinical condition that can be life- or limb-threatening. For small- to medium-size soft tissue defects of the lower extremity, propeller perforator flaps are a viable option for reconstruction. We report our experience in Gustilo IIIB open fractures treatment with immediate coverage through propeller-based perforator flaps performed in acute setting. METHODS Between 2019 and 2022, 94 Gustilo III fractures were admitted to our trauma center, and 28 were Gustilo IIIB fractures. Five patients were eligible for an immediate perforator-based propeller flaps reconstruction. The mean age of the patients was 33.8 years. All of them were male. One of them was a heavy smoker (15 cigarettes per day). No other comorbidities were present. RESULTS The mean operating time, including fracture reduction and fixation time, was 106 minutes. The length of the defect varied between 5 and 7 cm and the width between 3 and 4 cm. We reported no major complications, and none of the patients required a surgical revision of the flap. A patient with smoking habit reported a superficial flap necrosis. The mean follow-up was 5.5 months. No cases of nonunion or osteomyelitis have developed so far. CONCLUSIONS The use of perforator-based propeller flaps, in acute trauma setting, has not been reported in literature so far. In our experience, propeller perforator flaps are a viable reconstructive option in immediate reconstruction during the acute management of open fractures.
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Affiliation(s)
| | - Giorgio Giacomini
- Plastic, Reconstructive and Aesthetic Surgery, University of Rome "La Sapienza," Rome
| | - Erica Michela Cavalli
- From the Department of Plastic Surgery, Hand Surgery and Reconstructive Microsurgery, Fondazione IRCCS San Gerardo dei Tintori, Monza
| | - Giorgio Eugenio Pajardi
- Reconstructive Microsurgery Service, University Department of Hand Surgery and Rehabilitation, San Giuseppe Hospital, IRCCS MultiMedica Group, Milan, Italy
| | - Andrea Marchesi
- From the Department of Plastic Surgery, Hand Surgery and Reconstructive Microsurgery, Fondazione IRCCS San Gerardo dei Tintori, Monza
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Laitonjam M, Khan MM, Krishna D, Cheruvu VPR, Minz R. Reconstruction of Foot and Ankle Defects: A Prospective Analysis of Functional and Aesthetic Outcomes. Cureus 2023; 15:e40946. [PMID: 37378308 PMCID: PMC10292190 DOI: 10.7759/cureus.40946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2023] [Indexed: 06/29/2023] Open
Abstract
INTRODUCTION Reconstruction of foot and ankle defects requires selecting an appropriate durable and aesthetically appealing option. From the different options, the procedure's choice depends on the defect's size, location, and donor area's availability. Patients' main goal is to have an acceptable biomechanical outcome. MATERIALS AND METHODS In this prospective study, we have included patients who had undergone reconstruction of the ankle and foot defects between January 2019 and June 2021. Patient demographics, location and size of the defect, different procedures, complications, sensory recovery, ankle hindfoot score, and satisfaction score were recorded. RESULTS 50 patients with foot and ankle defects were enrolled in this study. All flaps survived except one free anterolateral thigh flap. Five locoregional flaps developed minor complications, and all skin grafts healed well. The Ankle Hindfoot Score outcome has no significant relation with the anatomical location of the defects and the reconstructive procedure. All patients reconstructed using random local flap and with free flap were satisfied with the aesthetic outcome. CONCLUSIONS Because of limited soft tissue, local flap availability is restricted to small defects. Satisfaction rates are high in local and free flaps and are best suited for reconstructing the weight-bearing part of the foot. Bulky flaps should be avoided over the dorsum and ankle region.
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Affiliation(s)
- Michael Laitonjam
- Plastic and Reconstructive Surgery, Shija Hospital and Research Institute, Imphal, IND
| | - Manal M Khan
- Department of Burns and Plastic Surgery, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
| | - Deepak Krishna
- Department of Burns and Plastic Surgery, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
| | - Ved Prakash Rao Cheruvu
- Department of Burns and Plastic Surgery, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
| | - Reena Minz
- Department of Burns and Plastic Surgery, All India Institute of Medical Sciences, Bhubaneswar, Bhubaneswar, IND
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Zhou JD, Zhang XF, Xu TL, Yang WB, Xu YJ. Super-thin anterolateral thigh flap for reconstruction of the medial plantar artery perforator flap donor site. J Orthop Surg (Hong Kong) 2023; 31:10225536231181706. [PMID: 37268597 DOI: 10.1177/10225536231181706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND The medial plantar artery perforator (MPAP) flap is widely used to reconstruct the weight-bearing area of the foot. Traditionally, its donor site is closed using a skin graft, which is associated with several complications, including walking disability. This study aimed to examine our experience with using a super-thin anterolateral thigh (ALT) flap to reconstruct the MPAP flap donor site. METHODS We examined 10 patients who underwent reconstruction of the MPAP flap donor site using a super-thin ALT flap between August 2019 and March 2021. The vascular pedicle was anastomosed to the proximal end of the medial plantar vessels or the end of the posterior tibial vessels. RESULTS All reconstruction flaps survived and all patients were satisfied with the aesthetic appearance. No blisters, ulcerations, hyperpigmentation, or contractures occurred. All patients gained protective sensation in the super-thin ALT flap. The average visual analog scale score for the aesthetic appearance of the reconstructed foot was 8.5 ± 0.7 (range, 8-10). All patients were able to ambulate without aids and could wear regular shoes. The average revised Foot Function Index score was 26.4 ± 4.1 (range, 22-34). CONCLUSION Reconstruction of the MPAP flap donor site using a super-thin ALT flap is reliable and provides satisfactory functional recovery, aesthetic appearance, and protective sensation while minimizing postoperative morbidity.
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Affiliation(s)
- Jian-Dong Zhou
- Department of Foot and Ankle Surgery, Wuxi 9th People's Hospital, Affiliated to Soochow University, Wuxi, China
| | - Xing-Fei Zhang
- Department of Foot and Ankle Surgery, Wuxi 9th People's Hospital, Affiliated to Soochow University, Wuxi, China
| | - Tong-Long Xu
- Department of Foot and Ankle Surgery, Wuxi 9th People's Hospital, Affiliated to Soochow University, Wuxi, China
| | - Wen-Bo Yang
- Department of Orthopaedic Surgery, Nanjing 1st Hospital, Nanjing, China
| | - Ya-Jun Xu
- Department of Foot and Ankle Surgery, Wuxi 9th People's Hospital, Affiliated to Soochow University, Wuxi, China
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Abdelfattah U, Elbanoby T, Elmofty AM, Hassan A, Mohammed AS, Roshdy S, Salah M. The durability of thin superficial circumflex iliac artery perforator flap in sole reconstruction: Clinical experience with 18 cases. Microsurgery 2022; 42:800-809. [PMID: 36134728 DOI: 10.1002/micr.30960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 08/30/2022] [Accepted: 09/09/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND The superficial circumflex iliac artery perforator flap's overall success in the reconstruction of the lower limb has been acceptable, but the sole of the foot remains more challenging. The purpose of this article is to report our experience employing the SCIP flap and evaluate its durability in reconstructing different units of the foot's sole, heel, middle, and forefoot. PATIENTS AND METHODS This retrospective study reviewed 18 patients with sole defect reconstructed with free SCIP flap from 2017 to 2019. 18 free SCIP flaps were harvested depending on the superficial branch of SCIA (n = 16) or deep branch (n = 2). All flaps were thin and elevated above the scrapa's fascia. The heel (n = 10), middle foot sole (n = 5), forefoot sole (n = 2), and combined heel and midfoot in one patient were among the defect locations. Sole defects were caused by trauma in 10 patients (55.5%), while the rest of the causes were melanoma (three patients, 16.7%), diabetic ulcer (three patients, 16.7%), and unstable scar (one patient), and calcaneal osteomyelitis (one patient). The defect size ranged from 24 to 230 cm2 . RESULTS The flap dimensions ranged from 6 × 4 to 18 × 11 cm. Mean follow-up observations were 42.5 months. 72.2% of our patients developed protective sensation between 12-18 months. No ulcerations were observed, and all of the patients had successful functional recoveries with satisfying cosmetic outcomes. CONCLUSION The SCIP flap can be an optimal durable skin flap for weight-bearing sole reconstruction. SCIP flap has the advantage of being thin minimizing the problem of shearing, the need for secondary procedures, and the faster recovery of protective sensation that could prevent ulceration.
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Affiliation(s)
- Usama Abdelfattah
- Plastic and Reconstructive Surgery Department, Al-Azhar University, Cairo, Egypt
| | - Tarek Elbanoby
- Plastic and Reconstructive Surgery Department, Al-Azhar University, Cairo, Egypt
| | - Ahmed Maged Elmofty
- Plastic and Reconstructive Surgery Department, Al-Azhar University, Cairo, Egypt
| | - Ali Hassan
- Plastic and Reconstructive Surgery Department, Al-Azhar University, Cairo, Egypt
| | | | - Samir Roshdy
- Plastic and Reconstructive Surgery Department, El-Nile Insurance Hospital, Cairo, Egypt
| | - Mohamed Salah
- Plastic and Reconstructive Surgery Department, El-Nile Insurance Hospital, Cairo, Egypt
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Stiles ZE, Lohman RF, Mann GN. Plastic Surgery Reconstruction of Sarcoma Resection Defects. Surg Clin North Am 2022; 102:583-599. [DOI: 10.1016/j.suc.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Short- and Long-Term Complications of Free Anterolateral Thigh Flap Reconstructions: A Single-Centre Experience of 92 Consecutive Cases. Surg Res Pract 2022; 2022:2122956. [PMID: 35299587 PMCID: PMC8923785 DOI: 10.1155/2022/2122956] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 02/08/2022] [Accepted: 02/16/2022] [Indexed: 11/18/2022] Open
Abstract
Background. The anterolateral thigh (ALT) flap has been amongst the most versatile components of the reconstructive surgeon’s armamentarium. The authors utilise these flaps for a variety of reconstructive procedures including lower limb reconstruction; postsarcoma excision; and open fractures. Few studies have discussed the extent of recipient site morbidity and subsequent revisional procedures. We will report our experience of the ALT flap in 92 consecutive reconstructions with focus on recipient site complications and revisional procedures. Methods. Retrospective data collection was done from 92 patients who underwent ALT flap reconstruction—for various large soft tissue defects—at our unit at the Royal Free Hospital, London. We evaluated primary recipient site complications and the requirements for secondary operations after flap transfer. Results. All flaps survived with the exception of 3 cases (97% survival rate) in which irreversible venous thrombosis was encountered. 16 of 92 patients (17%) required a second recipient site operation for the following: 7 patients experienced major recipient site complications that warranted early return to theatre and 9 patients required a secondary revision thinning procedure(s). 8 of the 16 patients (50%) requiring second operations had construction on their lower leg/ankle/feet (p value = 0.10). Conclusions. Our data demonstrated effective use of the ALT flap in the management of soft tissue reconstructive surgery. Partial flap necrosis was the main complication at the recipient site. In future work, secondary thinning procedures, particularly at the ankle/foot, should be separated from flap-specific complications. Furthermore, we demonstrate tailoring ALT thickness can be performed safely without compromising flap viability.
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He J, Guliyeva G, Wu P, Yu F, Qing L, Tang J. Reconstruction of Complex Soft Tissue Defects of the Heel With Versatile Double Skin Paddle Anterolateral Thigh Perforator Flaps: An Innovative Way to Restore Heel Shape. Front Surg 2022; 9:836505. [PMID: 35237651 PMCID: PMC8884269 DOI: 10.3389/fsurg.2022.836505] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 01/14/2022] [Indexed: 11/13/2022] Open
Abstract
Background Complex heel defects constitute a significant challenge for plastic surgeons. Objectives In this study, versatilities of free double skin paddle ALT flaps in the reconstruction of complex soft tissue defects of heels were explored. Methods From January 2010 to December 2019, 16 patients (13 male and 3 females) aged 16–74 years underwent double skin paddle ALT flap reconstruction in our department. All the patients had large defects located at the heel, and 5 had a dead space. Underlying structures such as vessels, bones, and tendons were exposed in all cases. Results Flap survival rate was 100% after the reconstruction. Eleven double skin paddle ALT flaps and 5 vastus lateralis muscle-chimeric double skin paddle ALT flaps were used. The size of the skin flap ranged from 9.5 × 4.5 cm2 to 22 × 10 cm2, and the size of a muscle segment ranged from 6 × 3 × 1 cm3 to 10 × 3 × 2 cm3. The mean follow-up was 22.6 months (range: 10–81 months). The wounds healed well, providing reliable soft tissue coverage and good heel contour. All the patients ambulated independently during the follow-up period. Most of them regained protective sensation. The average two-point discrimination was 32.7 mm (range: 27–37 mm). Conclusion Double skin paddle ALT flaps are a feasible option for the reconstruction of complex heel defects, with good functional and aesthetic results. Nonetheless, further studies comparing double skin paddle ALT flaps to other flap techniques are needed.
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Affiliation(s)
- Jiqiang He
- Xiangya Hospital, Central South University, Changsha, China
| | - Gunel Guliyeva
- The Johns Hopkins Hospital, Johns Hopkins Medicine, Baltimore, MD, United States
| | - Panfeng Wu
- Xiangya Hospital, Central South University, Changsha, China
| | - Fang Yu
- Xiangya Hospital, Central South University, Changsha, China
| | - Liming Qing
- Xiangya Hospital, Central South University, Changsha, China
| | - Juyu Tang
- Xiangya Hospital, Central South University, Changsha, China
- *Correspondence: Juyu Tang
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Mehmood Hashmi P, Musaddiq A, Hashmi A, Zahid M. Comparison of distally based sural artery and supramalleolar flap for coverage of dorsum of foot and ankle defects; a cross-sectional study of 53 patients. Ann Med Surg (Lond) 2021; 73:103109. [PMID: 34917350 PMCID: PMC8669369 DOI: 10.1016/j.amsu.2021.103109] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 11/20/2021] [Accepted: 11/21/2021] [Indexed: 11/18/2022] Open
Abstract
Background Soft tissue defects over the foot and ankle region are most challenging in reconstructive surgery. Sural artery and supramalleolar flaps have been commonly used for the reconstruction of non-weight-bearing surfaces of the foot. This article aimed to evaluate the long-term outcome comparisons between a sural artery and Supramalleolar flap in the reconstruction of extensive defects of foot and ankle only. Methods Between 1996 and 2020, a retrospective analysis of 53 fasciocutaneous flaps (27 sural and 26 Supramalleolar) used for reconstruction of soft tissue defects of foot and ankle were reviewed in this study. The parameters included were demographics data, causes, site and size of the defect, flap size, hospital stay, complications, and outcomes in a pre-structured proforma. The clinical outcome was assessed by a Self-Designed Tool based on flap survival, coverage of defect, weight-bearing status, functional activities of daily living, and cosmetic appearance. Data were analyzed through SPSS version 25. Results Among 53 flaps, the major cause of the defect was Trauma (60.4%). The maximum flap size harvested was 25*10 for sural and 20*8 cm for supramalleolar. Complications were seen in 8 (15%) cases in both flaps. Flap tip necrosis and venous congestion were seen in 4 cases. 2 each in Supramalleolar whereas 1 partial necrosis, 1 venous congestion, and 2 infections were seen in the sural artery flap. The flap survival rate in both flaps was 96.2%. Based on the self-designed Tool, flaps were graded Excellent in 43, Good in 8, and Fair in 2 cases. There was no case of Poor in both flaps. Conclusion Compared with the sural artery flap, the lateral supramalleolar flap demonstrated higher rates of functional outcomes although flap tip necrosis was higher in Supramalleolar. The comparative long-term clinical and functional outcomes of Sural and Supramalleolar flap is based on defect coverage, cosmetic appearance of surgical limb and activity of daily living. Compared with the sural artery flap, the lateral Supramalleolar flap is more reliable and exhibit higher rates of functional outcomes. Outcomes of Supramalleolar Flap was better than Sural artery flap as it was much more vascular and robust.
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Affiliation(s)
| | | | | | - Marij Zahid
- Aga Khan University Hospital, Karachi, Pakistan
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Sakarya AH, Tsai KY, Hsu CC, Chen SH, Do NK, Anggelia MR, Lin CH, Lin CH. Free tissue transfers for reconstruction of weight-bearing heel defects: Flap selection, ulceration management, and contour revisions. J Plast Reconstr Aesthet Surg 2021; 75:1557-1566. [PMID: 34969626 DOI: 10.1016/j.bjps.2021.11.095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 05/20/2021] [Accepted: 11/15/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Soft tissue defects in the weight-bearing heel represent a reconstructive challenge because of tissue complexity and lack of local/regional coverage. This study presents our reconstruction outcomes of different defect aetiologies, reconstruction timing, and flap selection. METHODS Patients with weight-bearing heel defects who underwent free tissue transfer from 2003 to 2014 and with at least 6 months of follow-up were retrospectively reviewed. Flap types (fasciocutaneous vs muscle/musculocutaneous), timing of reconstruction (early vs subacute vs delayed), and defect aetiology were compared in terms of flap failure, vascular complications, and ulceration. RESULTS Seventy-four flaps were used to reconstruct weight-bearing heel defects in 70 patients. Defect aetiology included trauma in 53 patients (75%), chronic wound in 12 patients (17%), and tumour resection in 6 patients (8%). Flap survival was 97% (72/74). There was no significant difference in flap failures between muscle and fasciocutaneous flaps. The timing of reconstruction showed no difference in flap survival. There was a significant difference in ulceration rate between the trauma and non-trauma groups (p = 0.001). Twenty-eight ulcers (39%) developed, 12 (43%) of which presented 3 years postoperatively, while only 6 cases (21%) presented within one year postoperatively. CONCLUSION Our experience represents one of the highest survival rates reported regarding free flap weight-bearing heel reconstruction. The anterolateral thigh flap was our first choice for extensive heel defects. Ulceration incidence was directly related to trauma and tends to develop 3 years after reconstruction. Delayed reconstruction was at least as safe as early or subacute reconstruction though with less need for debulking.
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Affiliation(s)
- Ahmet H Sakarya
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
| | - Kun-Yu Tsai
- Department of Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
| | - Chung-Chen Hsu
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
| | - Shih-Heng Chen
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
| | - Nicholas K Do
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
| | - Madonna R Anggelia
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
| | - Chih-Hung Lin
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
| | - Cheng-Hung Lin
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan.
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Yildirim T, Unsal SS, Armangil M. Propeller flap: Orthoplastic approach for coverage of distal leg and ankle defects. Foot Ankle Surg 2021; 27:874-878. [PMID: 33339714 DOI: 10.1016/j.fas.2020.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 11/04/2020] [Accepted: 11/27/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Covering soft tissue defects of the distal one-third of the leg and the Achilles tendon region and is a challenging problem for an orthopedic surgeon. With recent advancements in the anatomical knowledge of perforating vessels, perforator-pedicled propeller flaps have become increasingly popular in recent decades. We aimed to evaluate the clinical outcomes of our patients whose soft tissue defects in the distal leg were reconstructed with propeller flaps and assessed association of complications with age, gender, flap size and arc of rotation. METHODS Patients that had a reconstruction with a propeller flap at the ankle from 2013 to 2019 were retrospectively reviewed. The main indications for the propeller flap were small- and medium-sized soft tissue defects of the distal lower limb. 20 propeller flaps were applied to 19 patients (14 male, 5 female) for various lower extremity defects. RESULTS The mean follow-up duration was 2 years (range, 6 months to 6 years). The average flap size was 82 cm2 (range, 48-125 cm2). The flap was rotated 180 degrees in nine patients The source of the perforator vessel was the tibialis posterior artery in 14 cases, the peroneal artery in 4 cases, both the tibialis posterior and peroneal arteries in 1 case. Four complications (20 %) occured postoperatively. Two patients developed partial necrosis at the tip of the flap, and two patients developed superficial epidermolysis. No correlations were found between complications and flap size and the arc of rotation. CONCLUSIONS The propeller flap is a reliable option for reconstruction of small to moderate defects in the lower extremity with good clinical results and minimal donor-site morbidity. It is applicable for orthopedic surgeons who do not have microsurgical experience or an available microscope in the operating room.
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Affiliation(s)
- Tugrul Yildirim
- Ankara University Faculty of Medicine, Department of Orthopaedics and Traumatology, Department of Hand Surgery, Talatpasa Blv No:82 Altindag, Ankara, Turkey.
| | - Seyyid Serif Unsal
- Ankara University Faculty of Medicine, Department of Orthopaedics and Traumatology, Department of Hand Surgery, Talatpasa Blv No:82 Altindag, Ankara, Turkey
| | - Mehmet Armangil
- Ankara University Faculty of Medicine, Department of Orthopaedics and Traumatology, Department of Hand Surgery, Talatpasa Blv No:82 Altindag, Ankara, Turkey
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Reconstruction of Foot and Ankle Defects Using Free Lateral Arm Flap: A Retrospective Review of Its Versatile Application. BIOMED RESEARCH INTERNATIONAL 2021; 2021:4128827. [PMID: 34754880 PMCID: PMC8572601 DOI: 10.1155/2021/4128827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 09/14/2021] [Accepted: 10/05/2021] [Indexed: 11/24/2022]
Abstract
Background Successful reconstruction of the feet and ankles remains challenging due to limited quantities of soft tissue and laxity. The free lateral arm flap (LAF) is an alternative to conventional flaps and has been widely used due to advancements in its flap characteristics. This study is aimed at utilizing the advantages of this flap to validate its increased applications for foot and ankle defects. Methods Twenty patients with various LAF types between May 2011 and May 2020 were enrolled. Clinical data was retrospectively collected, and defect sites were classified according to the subunit principle. We utilized various LAF types, such as LAFs with sensate, extended, osteomyocutaneous, or myocutaneous flaps, as necessary. A two-point discrimination test was performed, and results were statistically compared between flaps. Results Among the diverse etiologies of skin defects, chronic inflammation was the most common cause of defects. Various LAF types, including LAFs with fasciocutaneous, extended fasciocutaneous, musculocutaneous, and osteomyocutaneous flaps, were used. The versatility of free LAF helped successfully cover various defects in all cases. Results of the two-point discrimination test were statistically significant between groups. Conclusions Free LAF is a unique soft tissue free flap that is more versatile than other flaps, allowing flaps to be continuously modified and applied to various foot and ankle defects under different clinical conditions.
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Yen YH, Lo SL, Liu SP, Pu CM. Eccentric free muscular perforator flaps in the proximal lateral leg for hand and foot reconstruction. Microsurgery 2021; 41:726-733. [PMID: 34617329 DOI: 10.1002/micr.30821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 05/25/2021] [Accepted: 09/17/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND We aimed to introduce our modifications by using eccentrically located muscular perforators to shorten the distance between the recipient vessels and the flap pedicle for overcoming the "short pedicle" drawback of the proximal lateral leg perforator (PLLP) flap. PATIENTS AND METHODS A retrospective review of 12 cases undergoing free PLLP flap for hand and foot regions reconstruction during 2010 and 2019. The mean age was 43.3 years. Most defects resulted from burn and trauma injuries. The dimensions of defects ranged from 8 × 1.5 cm2 to 12 × 6.5 cm2 . Muscular perforators were designed eccentrically 1-3 cm away from the central point of the flap to shorten the distance between the recipient vessels and the pedicle. The flap was designed to be 0.5-1 cm larger than the defect. RESULTS The flap size ranged from 9 × 2 cm2 to 15 × 6 cm2 . All pedicles were long enough to ensure an appropriate anastomosis without tension. The post-operative course in all cases was uneventful. All flaps survived without complications. Primary repair of the donor sites was performed in all patients. Donor leg function was not hampered by flap harvesting. All patients were satisfied with the scar after at least 1 year of follow-up. CONCLUSION Based on our experience, selection of the eccentric locations of the musculo-cutaneous perforators were effective methods to overcome the short pedicle length of this flap type. Using our modifications, thin PLLP flaps can be used in foot and hand reconstruction with minimal donor site morbidity and a high success rate.
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Affiliation(s)
- Yu-Hsiu Yen
- Division of Plastic Surgery, Department of Surgery, Sijhih Cathay General Hospital, New Taipei, Taiwan.,School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Shih-Lun Lo
- Division of Plastic Surgery, Department of Surgery, Cathay General Hospital, Taipei, Taiwan
| | - Shih-Pi Liu
- Division of Plastic Surgery, Department of Surgery, Cathay General Hospital, Taipei, Taiwan
| | - Chi-Ming Pu
- School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan.,Division of Plastic Surgery, Department of Surgery, Cathay General Hospital, Taipei, Taiwan
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He J, Qing L, Wu P, Zhou Z, Yu F, Tang J. Large wounds reconstruction of the lower extremity with combined latissimus dorsi musculocutaneous flap and flow-through anterolateral thigh perforator flap transfer. Microsurgery 2021; 41:533-542. [PMID: 33988868 DOI: 10.1002/micr.30754] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 04/24/2021] [Accepted: 05/06/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Management of large wounds of the lower extremities remains a challenge for plastic and reconstructive surgeons. Herein, a surgical technique and clinical algorithm using the combined transfer of a latissimus dorsi (LD) musculocutaneous flap and flow-through anterolateral thigh (ALT) perforator flap for the treatment of extensive soft-tissue defects is described. METHODS From January 2012 to September 2018, 12 patients (six men and six women) aged 6-37 years, sustained injuries in road traffic accidents with large soft-tissue defects in the lower extremities. Seven cases were Gustillo Anderson type IIIB open fractures and two cases were Gustillo Anderson type IIIC open fractures. Two wounds were located in the knee joint, four in the calf, and six in the ankle and foot. The skin defect size ranged from 25 × 20 cm2 to 36 × 25 cm2 . All patients in this series underwent reconstruction using combined transfer of the LD musculocutaneous flap and flow-through ALT perforator flap, wherein the LD was attached through its pedicle to the distal continuation of the ALT flap. RESULTS The size of the flow-through ALT perforator flaps ranged from 13.5 × 6.5 cm2 to 31 × 8.5 cm2 . The size of the LD musculocutaneous skin paddle ranged from 25 × 6 cm2 to 34 × 7 cm2 , and that of the muscle paddle ranged from 13 × 3.5 cm2 to 30 × 11 cm2 . One patient experienced postoperative thrombosis of the venous pedicle, and the flap was salvaged after emergency re-exploration and thrombectomy. No other complications were observed postoperatively. The mean follow-up period was 26.8 months. All patients were able to ambulate independently at the end of the follow-up period. CONCLUSIONS The combined transfer of the LD musculocutaneous flap and flow-through ALT perforator flap ensured adequate surface coverage, making it a feasible procedure for large soft-tissue defects.
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Affiliation(s)
- Jiqiang He
- Department of Hand and Microsurgery, Xiangya Hospital of Central South University, Changsha, Hunan Province, China.,Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Liming Qing
- Department of Hand and Microsurgery, Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Panfeng Wu
- Department of Hand and Microsurgery, Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Zhengbing Zhou
- Department of Hand and Microsurgery, Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Fang Yu
- Department of Hand and Microsurgery, Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Juyu Tang
- Department of Hand and Microsurgery, Xiangya Hospital of Central South University, Changsha, Hunan Province, China
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Luo Z, Ni J, Lv G, Wei J, Liu L, Peng P, Dong Z. Distally Based Sural Fasciocutaneous Flaps for Reconstructing Soft Tissue Defects Proximal and Distal to the Tarsometatarsal Joints: A Comparative Analysis. INT J LOW EXTR WOUND 2021; 22:251-258. [PMID: 33856240 DOI: 10.1177/15347346211002333] [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: 11/16/2022]
Abstract
Distally based sural fasciocutaneous (DBSF) flaps are widely used for reconstructing soft tissue defects of the foot. The purpose of this paper was to compare the clinical efficacy of the use of flaps to repair defects in areas proximal and distal to the level of the tarsometatarsal joints in a relatively large number of patients and to analyze the effects of factors on the risk of developing partial necrosis of the flaps. Between April 2001 and December 2019, a total of 355 DBSF flaps were utilized to cover soft tissue defects in the foot. According to the furthest location of the defects reconstructed with the flaps, the flaps were divided into the proximal foot group (n = 260) and the distal foot group (n = 95). The partial necrosis rates, their influencing factors, and the clinical outcomes of the procedure were compared between the two groups. In the proximal foot group, the partial necrosis rate (6.2%, 16 of 260) was significantly lower than that in the distal foot group (14.7%, 14 of 95) (P < .05). The proportion of successful coverage of the defects using the flaps alone or in combination with a simple salvage treatment was comparable between the groups (P > .05). The ratio of unfavorable conditions in the distal foot group was higher than that in the proximal foot group (P < .05). DBSF flaps can be effectively utilized to repair defects in the proximal and distal areas of the foot. The use of a DBSF flap to repair defects in the proximal areas of the foot is superior to the use of DBSF flaps for repairing defects in the distal areas of the foot in terms of reliable survival of the flap.
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Affiliation(s)
- Zhaobiao Luo
- 70566The Second Xiangya Hospital, Central South University, Changsha, People's Republic of China
| | - Jiangdong Ni
- 70566The Second Xiangya Hospital, Central South University, Changsha, People's Republic of China
| | - Guohua Lv
- 70566The Second Xiangya Hospital, Central South University, Changsha, People's Republic of China
| | - Jianwei Wei
- 70566The Second Xiangya Hospital, Central South University, Changsha, People's Republic of China
| | - Lihong Liu
- 70566The Second Xiangya Hospital, Central South University, Changsha, People's Republic of China
| | - Ping Peng
- 70566The Second Xiangya Hospital, Central South University, Changsha, People's Republic of China
| | - Zhonggen Dong
- 70566The Second Xiangya Hospital, Central South University, Changsha, People's Republic of China
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Parikh RP, Ha A, Tung T. Free Flap Reconstruction of Traumatic Pediatric Foot and Ankle Defects: An Analysis of Clinical and Functional Outcomes. J Reconstr Microsurg 2021; 37:783-790. [PMID: 33853128 DOI: 10.1055/s-0041-1727187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Traumatic lower extremity injuries involving the foot and ankle can have devastating consequences and represent a complex reconstructive challenge. To date, there are limited reports on microsurgical reconstruction for foot and ankle defects in children. This study aims to evaluate clinical and functional outcomes of free flaps for pediatric foot and ankle injuries. METHODS This is a retrospective review of patients undergoing free flaps for traumatic foot and ankle defects at a pediatric trauma center between 2000 and 2015. Patients with less than 5-year follow-up were excluded. Demographics, clinical characteristics, and postoperative outcomes were evaluated. RESULTS Thirty patients undergoing 30 flaps were analyzed. The mean age was 11.9 years (range: 2 to 17 years). Muscle flaps (n = 21, 70%) were more common than fasciocutaneous flaps (n = 9, 30%). Limb salvage with functional ambulation was achieved in 96.7% of patients (n = 29). The complication rate was 33.3% (n = 10), with wound breakdown (n = 6, 20.0%) as most common feature. There were no significant differences in limb salvage, total or partial flap loss, fracture union, and donor-site complications based on flap type. Fasciocutaneous flaps were more likely to require revision procedures for contour compared with muscle flaps (55.6 vs. 9.5%, p = 0.013). Mean follow-up was 8.5 years. CONCLUSION Microsurgical reconstruction of pediatric foot and ankle defects results in high rates of limb salvage. A defect- and patient-centered approach to reconstruction, emphasizing durable coverage and contour, is critical to facilitating ambulation and ensuring favorable long-term functional outcomes.
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Affiliation(s)
- Rajiv P Parikh
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, Missouri.,Department of Plastic and Reconstructive Surgery, MedStar Washington Hospital Center/Georgetown University School of Medicine, Washington, District of Columbia
| | - Austin Ha
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Thomas Tung
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, Missouri
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Luo Z, Ni J, Lv G, Wei J, Liu L, Peng P, Dong Z. Utilisation of distally based sural fasciocutaneous flaps in lower extremity reconstruction: a single-centre experience with 88 paediatric patients. J Orthop Surg Res 2021; 16:52. [PMID: 33441179 PMCID: PMC7805089 DOI: 10.1186/s13018-021-02206-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 01/04/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND No large series have analysed distally based sural fasciocutaneous (DBSF) flaps in paediatric patients. The aims of this study were to assess the reliability and analyse the potential risk factors for these flaps and to describe complications in the donor site and the functional follow-up results. METHODS Between June 2002 and November 2017, 88 DBSF flaps were used to reconstruct soft tissue defects in paediatric patients. Potential risk factors, reconstruction outcomes, and complications in the donor site of the flaps were analysed. RESULTS Among the 88 flaps, partial necrosis developed in 8 flaps (9.1%). The partial necrosis rate was significantly higher in flaps with the top edge located in the 9th zone (26.1%), with a length-width ratio (LWR) ≥ 5:1 (28.6%), and with a dimension of the skin island ≥ 100 cm2 (22.7%). Partial necrosis did not occur in flaps with a dimension of the skin island < 80.0 cm2 or with a skin-island width < 7.0 cm. The reconstruction outcomes in most paediatric patients were evaluated as "excellent" or "good". The incidence of obvious scarring was higher in the donor site. CONCLUSIONS Partial necrosis of DBSF flaps will significantly increase when the top edge of the flap is located in the 9th zone, when the LWR of the flap is ≥ 5:1, or when the dimension of the skin island is ≥ 100.0 cm2. Flaps with a skin-island width < 7.0 cm or with a dimension of the skin island < 80 cm2 are relatively safe and reliable.
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Affiliation(s)
- Zhaobiao Luo
- Department of Spine Surgery, The Second Xiangya Hospital, Central South University, Changsha, 410011, People's Republic of China
| | - Jiangdong Ni
- Department of Orthopaedics, The Second Xiangya Hospital, Central South University, Changsha, 410011, People's Republic of China
| | - Guohua Lv
- Department of Spine Surgery, The Second Xiangya Hospital, Central South University, Changsha, 410011, People's Republic of China
| | - Jianwei Wei
- Department of Orthopaedics, The Second Xiangya Hospital, Central South University, Changsha, 410011, People's Republic of China
| | - Lihong Liu
- Department of Orthopaedics, The Second Xiangya Hospital, Central South University, Changsha, 410011, People's Republic of China
| | - Ping Peng
- Department of Orthopaedics, The Second Xiangya Hospital, Central South University, Changsha, 410011, People's Republic of China
| | - Zhonggen Dong
- Department of Orthopaedics, The Second Xiangya Hospital, Central South University, Changsha, 410011, People's Republic of China.
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Bulla A, Delgove A, De Luca L, Pelissier P, Casoli V. The esthetic outcome of lower limb reconstruction. ANN CHIR PLAST ESTH 2020; 65:655-666. [PMID: 32800462 DOI: 10.1016/j.anplas.2020.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 07/17/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND In recent years, the progress of anatomical knowledge and microsurgical techniques, in particular the development of perforator flaps, has risen the number of flaps available for lower leg reconstruction. The esthetic consequences of flap choice and harvest do have an impact on patients' quality of life. Nowadays, more researchers evaluate the esthetic changes following lower limb reconstruction. OBJECTIVES This review aims to summarize the available evidence on the esthetic outcome of lower limb reconstruction. DATA SOURCES A systematic review was planned to identify the most relevant indexed articles on this subject. The search was performed on Pubmed database without date of publication limits. STUDY ELIGIBILITY CRITERIA All papers about reporting information about the esthetic outcome of lower limb reconstruction were selected. Case reports and the articles not including specific information about complications, secondary procedures, and outcomes were excluded. The articles were categorized according to their topic and date of publication. The full texts of all the articles were obtained and read thoroughly. The references for each article were screened to identify articles that were eventually left outside our database search. PARTICIPANTS, AND INTERVENTIONS One hundred and eight articles were retained for the definitive review. Eleven review articles were kept because they represented a good source of information. Thirty-three articles were added after reading the full texts. The articles appear highly heterogeneous and at, this stage, only a critical and qualitative analysis could be performed. RESULTS We found information about 7895 lower reconstructions, 1295 local flaps, 6546 free flaps. LIMITATIONS The esthetic evaluation is intrinsic subjective. Many psychological and cultural factors influence both the patient and the surgeon. There is not a validated assessment tool for the esthetic outcome of lower leg reconstruction. Therefore, no quantitative analysis was performed. CONCLUSIONS Some ancient techniques are today obsolete, like the rectus abdominis free muscle flaps and perhaps free forearm flap, others are always useful, like gracilis and latissimus dorsi free flap. ALT flap is the most versatile perforator flap today available, but the SCIP flap is gaining the favor of a growing number of surgeons. Local flaps will be always performed with success but their indications should not be pushed beyond the medium-size defects. The best cosmetic outcome for each patient cannot necessarily be obtained neither with the easiest techniques nor with the most technically demanding ones. It is necessary to develop validated tools to assess the cosmetic outcome of lower limb reconstruction.
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Affiliation(s)
- A Bulla
- Department of Plastic and Reconstructive Surgery, Hand Surgery, Burns Unit, F.X.-Michelet Center, University Hospital Bordeaux, place Amélie-Raba-Léon, 33076 Bordeaux, France.
| | - A Delgove
- Department of Plastic and Reconstructive Surgery, Hand Surgery, Burns Unit, F.X.-Michelet Center, University Hospital Bordeaux, place Amélie-Raba-Léon, 33076 Bordeaux, France
| | - L De Luca
- Department of Plastic and Reconstructive Surgery, Hand Surgery, Burns Unit, F.X.-Michelet Center, University Hospital Bordeaux, place Amélie-Raba-Léon, 33076 Bordeaux, France
| | - P Pelissier
- Department of Plastic and Reconstructive Surgery, Hand Surgery, Burns Unit, F.X.-Michelet Center, University Hospital Bordeaux, place Amélie-Raba-Léon, 33076 Bordeaux, France
| | - V Casoli
- Department of Plastic and Reconstructive Surgery, Hand Surgery, Burns Unit, F.X.-Michelet Center, University Hospital Bordeaux, place Amélie-Raba-Léon, 33076 Bordeaux, France
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20
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Yang X, Fang Z, Liu M, Zhang Y, Chen Q, Tao K, Han J, Hu D. Reconstruction of Deep Burn Wounds Around the Ankle With Free Fascia Flaps Transfer and Split-Thickness Skin Graft. J Burn Care Res 2019; 40:763-768. [PMID: 31106818 DOI: 10.1093/jbcr/irz078] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
We aimed to introduce a technique by combining free fascia flaps transfer with split-thickness skin graft for the reconstruction of deep burn wounds at the ankle. Fifteen patients from 2009 to 2016 were enrolled in this study. Patients in this series suffered from a deep burn injury around the ankle, which was accompanied with exposure of tendon and medial or lateral malleolus exposure due to severe soft-tissue defects (N = 15). All the 15 wounds were repaired combining free fascia flaps with split-thickness skin graft operations, including nine anterolateral thigh fascia lata flaps (ATFL flaps) and six superficial temporal fascia flaps (STF flaps). All the fascia flaps completely survived. Two patients showed partial grafting skin necrosis due to either wound infection or subcutaneous hematoma infection, and this was eventually healed satisfactorily after conventional dressing change. All patients achieved esthetic outcome and acceptable functionality without further revisions needed. Our present study reports a useful method that involves using free fascia flaps in combination with split-thickness skin graft to repair deep burn wounds around the ankle. This method provided reliable and durable soft-tissue coverage with good outcomes.
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Affiliation(s)
- Xuekang Yang
- Department of Burns and Cutaneous Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Zhuoqun Fang
- Department of Burns and Cutaneous Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Mengdong Liu
- Department of Burns and Cutaneous Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Yue Zhang
- Department of Burns and Cutaneous Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Qiaohua Chen
- Department of Burns and Cutaneous Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Ke Tao
- Department of Burns and Cutaneous Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Juntao Han
- Department of Burns and Cutaneous Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Dahai Hu
- Department of Burns and Cutaneous Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
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Cao ZM, Du W, Qing LM, Zhou ZB, Wu PF, Yu F, Pan D, Xiao YB, Pang XY, Liu R, Tang JY. Reconstructive surgery for foot and ankle defects in pediatric patients: Comparison between anterolateral thigh perforator flaps and deep inferior epigastric perforator flaps. Injury 2019; 50:1489-1494. [PMID: 31300162 DOI: 10.1016/j.injury.2019.06.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 06/21/2019] [Accepted: 06/24/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUNDS Due to the delicate tissue, small blood vessels and incomplete development of interarticular ligaments, skin and soft-tissue defects of the foot and ankle in pediatric patients remain a challenge for orthopedic and plastic surgeons. Anterolateral thigh perforator (ALTP) flap and deep inferior epigastric perforator (DIEP) flap are the most commonly used flaps for the repair of lower-extremity soft-tissue defects. The literature contains a shortage of evidence involving the differences between ALTP and DIEP flaps in the reconstruction of young patients with complex foot and ankle defects. This study was designed to determine which type of flap is better for foot and ankle repair in pediatric patients. METHODS From January 2004 to January 2018, 79 children younger than 14 years treated with DIEP flap (41 cases) or ALTP flap (38 cases) for composite defects of the feet and ankles were retrospectively investigated. The two groups were homogeneous in terms of age, the location of the defect, etiology, and flap area. Complications, scarring, cosmetic appearance, flap sensory recovery, and functional outcome were analyzed, and statistical analysis was performed. RESULTS The ALTP group had shorter operation time (155.0 ± 12.0 min vs 212.2 ± 23.9 min), flap harvested time (39.6 ± 5.1 min vs 57.2 ± 10.4 min), and operative blood loss (143.4 ± 23.7 ml vs 170.7 ± 44.7 ml) than the DIEP group (P < 0.05). In short-term follow-up, ALTP group showed a lower flap necrosis rate (5.3% vs 24.4%) and vascular insufficiency rate (2.6% vs 19.5%) than DIEP group (P < 0.05). In long-term follow-up, ALTP group showed a lower late complication rate and better cosmetic, functional, scar outcomes than DIEP group (P < 0.05). CONCLUSIONS The study showed that an ALTP flap may brings better results than a DIEP flap in terms of short- and long-term complications, scarring, and morpho-functional outcomes for pediatric patients undergoing reconstruction of foot and ankle defects.
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Affiliation(s)
- Zhe-Ming Cao
- Department of Hand and Microsurgery, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan Province, 410008, China
| | - Wei Du
- Department of Hand and Microsurgery, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan Province, 410008, China; Department of Rehabilitation Medicine, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan Province, 410008, China
| | - Li-Ming Qing
- Department of Hand and Microsurgery, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan Province, 410008, China
| | - Zheng-Bing Zhou
- Department of Hand and Microsurgery, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan Province, 410008, China
| | - Pan-Feng Wu
- Department of Hand and Microsurgery, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan Province, 410008, China
| | - Fang Yu
- Department of Hand and Microsurgery, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan Province, 410008, China
| | - Ding Pan
- Department of Hand and Microsurgery, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan Province, 410008, China
| | - Yong-Bing Xiao
- Department of Hand and Microsurgery, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan Province, 410008, China
| | - Xiao-Yang Pang
- Department of Hand and Microsurgery, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan Province, 410008, China
| | - Rui Liu
- Department of Hand and Microsurgery, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan Province, 410008, China
| | - Ju-Yu Tang
- Department of Hand and Microsurgery, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan Province, 410008, China.
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Reconstruction of Diabetic Foot Defects With the Proximal Lateral Leg Perforator Flap. Ann Plast Surg 2019; 82:546-551. [DOI: 10.1097/sap.0000000000001745] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Abstract
Free tissue transfer has become the standard in wound coverage and further refinements have given us newer flap donor sites or modifications of existing flaps to decrease morbidity; smaller vessels are being anastomosed, a direct spin-off following successful distal replantations. Younger children are presenting with traumatic defects similar to adults. Although there were apprehensions of free tissue transfer in children occasioned by smaller vessels, duration of procedure and concerns of growth following flap harvest, reports of small and large series have appeared in the literature with similar success. Pediatric-free tissue transfer is now an established entity. This article seeks to arrive at a consensus based on a review of the existing literature on free flaps for skin and soft-tissue coverage of lower limb trauma in children.
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Affiliation(s)
- R. Srikanth
- Department of Plastic and Reconstructive Surgery, Nizams Institute of Medical Sciences, Hyderabad, Telangana, India
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24
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Elgohary H, Nawar AM, Zidan A, Shoulah AA, Younes MT. Functional and Aesthetic Outcomes of Reconstruction of Soft-Tissue Defects of the Heel with Free Flap. JPRAS Open 2018; 19:35-44. [PMID: 32158850 PMCID: PMC7061545 DOI: 10.1016/j.jpra.2018.10.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 08/24/2018] [Accepted: 10/25/2018] [Indexed: 11/16/2022] Open
Abstract
Objective To evaluate functional and aesthetic outcomes of the reconstruction of soft-tissue defects of the heel with microsurgical techniques using a free radial forearm flap and an anterolateral thigh flap. Patients and methods The study included 25 patients, 15 males and 10 females, with a mean age of 34.3 ± 10.4 years, with soft-tissue defects of the heel. Of them, 11 patients whose defects were of size between 5 and 10 cm in their largest dimension were treated using a free radial forearm flap, and 14 patients whose defects were of size larger than 10 cm in their largest dimension were treated using a free anterolateral thigh flap.Post-operatively, avoidance of weight-bearing and walking was required for 8 to 10 weeks. At the end of the follow-up, all patients underwent functional, aesthetic and sensation evaluation in addition to assessment of patient satisfaction. Results The median follow-up period was 24 months. The causes of the defect were trauma (14 patients), neuropathic ulcer (8 patients) and neoplasia (3 patients). The size of the defect ranged from 5 × 6 cm to 14 × 24 cm. Four patients had calcaneal fracture. By the end of the follow-up period, 21 cases showed complete success, whereas 2 flaps failed, one in each flap type, and the remaining two flaps showed partial loss of the edges (anterolateral thigh flaps). Failure was due to venous congestion (one patient) and ischaemia (one patient). Eighteen patients were satisfied with their aesthetic appearance, functional outcome and flap sensation. Conclusion Reconstruction of large heel defects, using radial forearm and anterolateral thigh free flaps, provides acceptable functional and aesthetic outcomes.
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Affiliation(s)
- Hussein Elgohary
- Professor of General Surgery, Faculty of Medicine, Benha University
| | - Ahmed M Nawar
- Lecturer of General Surgery, Faculty of Medicine, Benha University
| | - Ahmed Zidan
- Assistant Professor of General Surgery, Faculty of Medicine, Benha University
| | - Ahmed A Shoulah
- Lecturer of General Surgery, Faculty of Medicine, Benha University
| | - Mohamed T Younes
- Lecturer of General Surgery, Faculty of Medicine, Benha University
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Song L, Zhang Z, Wang Y, Liu Y, Liu Z, Chen L, Lu L. Reconstruction of a Complex Foot Injury With Free Remodeled Fibular Osteocutaneous Flap: A Case Report and Literature Review. J Foot Ankle Surg 2018; 57:610-614. [PMID: 29428686 DOI: 10.1053/j.jfas.2017.10.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Indexed: 02/03/2023]
Abstract
Management of complex foot injuries, which involve open fractures and severe trauma to soft tissues, represent a challenge to orthopedic clinicians. In the present case report, we treated a complex foot injury with a remodeled fibular osteocutaneous free flap to reconstruct the anterior and lateral areas of the foot. The flap survived completely. At the 9-month follow-up examination, bony union of the graft bone was identified by radiographic examination. The reconstructed foot could bear body weight, and the patient could maintain a bipedal gait without discomfort. The remodeled fibular osteocutaneous free flap provides an option for functional reconstruction of foot defects.
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Affiliation(s)
- Liangsong Song
- Attending Doctor, Department of Hand and Foot Surgery, The First Hospital of Jilin University, Changchun, China
| | - Zhixin Zhang
- Professor, Department of Hand and Foot Surgery, The First Hospital of Jilin University, Changchun, China
| | - Yang Wang
- Attending Doctor, Department of Hand and Foot Surgery, The First Hospital of Jilin University, Changchun, China
| | - Yang Liu
- Attending Doctor, Department of Hand and Foot Surgery, The First Hospital of Jilin University, Changchun, China
| | - Zhigang Liu
- Professor, Department of Hand and Foot Surgery, The First Hospital of Jilin University, Changchun, China
| | - Lei Chen
- Associate Professor, Department of Hand and Foot Surgery, The First Hospital of Jilin University, Changchun, China
| | - Laijin Lu
- Professor, Department of Hand and Foot Surgery, The First Hospital of Jilin University, Changchun, China.
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Lee YK, Lee M. Treatment of infected Achilles tendinitis and overlying soft tissue defect using an anterolateral thigh free flap in an elderly patient: A case report. Medicine (Baltimore) 2018; 97:e11995. [PMID: 30170404 PMCID: PMC6392569 DOI: 10.1097/md.0000000000011995] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Infected segmental loss of the Achilles tendon with overlying soft tissue and skin defect remains a more complex reconstructive challenge. Here, we present a functional reconstruction of infected Achilles tendinitis with combined soft tissue defects using a free composite anterolateral thigh (ALT) flap with vascularized fascia lata in an elderly patient. CASE PRESENTATION A 71-year-old male patient was transferred to our department due to soft tissue defect of the left lower leg and infected Achilles tendinitis. The patient underwent incision and drainage of both lower legs with necrotizing fasciitis in another hospital 2 months ago. Physical examination revealed a 12 × 5 cm wound with exposed Achilles tendon over the posteromedial aspect of lower one-third of the leg. His wound culture grew methicillin-resistant Staphylococcus aureus (MRSA). All infected necrotic Achilles tendon with proximal muscle tissue was excised. The patient underwent successful Achilles tendon reconstruction and soft tissue coverage procedure with a 14 × 7 cm ALT flap with the fascia lata. At the 12-month follow-up, the patient resumed full daily activities, was able to squat, showed a range of motion at the ankle in the 15° dorsiflexion and 45° plantar flexion, and the American Orthopaedic Foot and Ankle Society (AOFAS) score was 94. CONCLUSION A free ALT composite flap with the vascularized fascia lata, was successfully used for the treatment of infected Achilles tendinitis with overlying soft tissue defect even in an elderly patient. Furthermore, it provided satisfactory functional and cosmetic outcomes. Hence, the use of free ALT composite flap is highly recommended in such patients.
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Affiliation(s)
- Young-Keun Lee
- Department of Orthopedic Surgery, Research Institute of Clinical Medicine of Chonbuk National University, Biomedical Research Institute of Chonbuk National University Hospital
| | - Malrey Lee
- The Research Center for Advanced Image and Information Technology, School of Electronics and Information Engineering, Chonbuk National University, Jeonju, Chonbuk, Republic of Korea
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Liang JL, Liu XY, Qiu T, Fu ZQ, Wang HY, Kong X, Tao K. Microdissected thin anterolateral thigh perforator flaps with multiple perforators: A series of case reports. Medicine (Baltimore) 2018; 97:e9454. [PMID: 29369171 PMCID: PMC5794355 DOI: 10.1097/md.0000000000009454] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION The study aimed to explore the effect of microdissected thin anterolateral thigh (MTALT) perforator flap with multiple perforators on patients with complex defects on the hand, elbow, heel, or knee. METHODS From March 2012 to February 2013, 5 patients with complex defects on the hand, elbow, heel, or knee were included. During the flap preparation, 2 to 3 perforators penetrating the fascia of the anterolateral femoral area were initially detected, and the deep fascia was incised. The superficial fascia layer of the flap and the deep adipose were then dissected, and removed after verifying the distribution of the blood vessels using an operating microscope. The whole flap was then elevated, and transposed to the recipient areas for microsurgical reparation. RESULTS Two cases of post-burn scar contracture and 3 cases of traumatic tissue defects were successfully reconstructed with these multiple-perforator MTALT flaps. No complication was reported, and secondary operative procedure was not needed in any patient in the follow-up. CONCLUSION MTALT perforator flap with multiple perforators is safe and reliable for patients with complex defects on the hand, elbow, heel, or knee.
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Cheng L, Yang X, Chen T, Li Z. Peroneal artery perforator flap for the treatment of chronic lower extremity wounds. J Orthop Surg Res 2017; 12:170. [PMID: 29126421 PMCID: PMC5681812 DOI: 10.1186/s13018-017-0675-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 11/02/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Reconstruction of chronic lower extremity wounds remains challenging. These wounds are mainly associated with diabetes mellitus, infections, and osteomyelitis. Although several reconstructive techniques are available, the peroneal artery perforator flap has unique advantages. METHODS In this study, we discuss our experiences with peroneal artery perforator flaps in 55 patients who had suffered from chronic lower limb wounds. The size of the defect, comorbidities, etiology, flap size, and complications were recorded and analyzed based on a retrospective chart review. RESULTS All 55 flaps survived. In two cases, small superficial necrosis occurred, one of which healed with conservative treatment and the other was reconstructed with split thickness skin grafts. Partial necrosis was observed in nine cases, seven of which were covered with split thickness skin grafts and the remaining two sutured directly after adequate debridement. Vascular compromise was observed in one patient, which was salvaged successfully by performing an exploratory procedure and releasing a few sutures. No complications were seen in the remaining 44 cases. CONCLUSION The peroneal artery perforator flap is a reliable option for reconstruction of chronic lower extremity wounds.
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Affiliation(s)
- Liang Cheng
- Department of Hand and Plastic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109 Xue Yuan Xi Road, Wenzhou, Zhejiang, China
| | - Xiaqing Yang
- Department of Hand and Plastic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109 Xue Yuan Xi Road, Wenzhou, Zhejiang, China
| | - Tingxiang Chen
- Department of Hand and Plastic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109 Xue Yuan Xi Road, Wenzhou, Zhejiang, China
| | - Zhijie Li
- Department of Hand and Plastic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109 Xue Yuan Xi Road, Wenzhou, Zhejiang, China.
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Chou CY, Chiao HY, Wang CY, Sun YS, Lin CT, Dai NT, Chen SG, Chang SC. Functional results of free tissue transfer for complex heel-calcaneal defects. Microsurgery 2017; 38:381-387. [DOI: 10.1002/micr.30253] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 08/20/2017] [Accepted: 09/18/2017] [Indexed: 11/12/2022]
Affiliation(s)
- Chang-Yi Chou
- Division of Plastic Surgery, Department of Surgery; Tri-Service General Hospital, National Defense Medical Center; Neihu District, Taipei City Taiwan
- Department of Surgery; Taoyuan Armed Forces General Hospital; Taoyuan City Taiwan
| | - Hao-Yu Chiao
- Division of Plastic Surgery, Department of Surgery; Tri-Service General Hospital, National Defense Medical Center; Neihu District, Taipei City Taiwan
| | - Chi-Yu Wang
- Division of Plastic Surgery, Department of Surgery; Tri-Service General Hospital, National Defense Medical Center; Neihu District, Taipei City Taiwan
| | - Yu-Shan Sun
- Department of Family and Community Health; Tri-Service General Hospital; Taipei City Taiwan
| | - Chin-Ta Lin
- Division of Plastic Surgery, Department of Surgery; Tri-Service General Hospital, National Defense Medical Center; Neihu District, Taipei City Taiwan
| | - Niann-Tzyy Dai
- Division of Plastic Surgery, Department of Surgery; Tri-Service General Hospital, National Defense Medical Center; Neihu District, Taipei City Taiwan
| | - Shyi-Gen Chen
- Division of Plastic Surgery, Department of Surgery; Tri-Service General Hospital, National Defense Medical Center; Neihu District, Taipei City Taiwan
| | - Shun-Cheng Chang
- Division of Plastic Surgery, Department of Surgery; Tri-Service General Hospital, National Defense Medical Center; Neihu District, Taipei City Taiwan
- Division of Plastic Surgery, Department of Surgery, Shuang-Ho Hospital, Department of Surgery, School of Medicine, College of Medicine; Taipei Medical University; Taipei City Taiwan
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Reverse-Flow Lateral Tarsal Island Flap for Covering the Great Toe Donor Site of Wraparound Flap. Ann Plast Surg 2017; 77:445-9. [PMID: 26418775 DOI: 10.1097/sap.0000000000000612] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Coverage of the great toe donor site of wraparound flap remains a challenge. This report presents the results of using an innervated pedicled reverse-flow lateral tarsal island flap for covering the great toe donor site of wraparound flap. PATIENTS AND METHODS Between 2005 and 2010, 11 reverse-flow lateral tarsal island flaps were used to cover the great toe donor site of wraparound flap in 11 patients. This pedicled flap designed on the lateral tarsal area of foot was based distally on the dorsalis pedis artery; the lateral dorsal pedal cutaneous nerve was incorporated into the reverse-flow lateral tarsal island flap and coapted with the first plantar digital nerve. The donor sites of reverse-flow lateral tarsal island flap were covered with inguinal full-thickness skin grafts. RESULTS All flaps achieved primary healing except for two that suffered from mild venous insufficiency which was managed by conservative intervention. All skin grafts covering the donor site of reverse-flow lateral tarsal island flap healed uneventfully. The mean follow-up was 24 months (range, 18-48 months). The mean hallux metatarsophalangeal-interphalangeal scale score was 92 points (range, 85-97 points) at 6 months postoperatively. The static 2-point discrimination of the reverse-flow lateral tarsal island flap ranged from 6 to 14 mm (mean 10 mm). None of the patients were restricted in standing or walking during follow-up. CONCLUSIONS The reverse-flow lateral tarsal island flap based distally on the dorsalis pedis artery has a constant pedicle that is sufficiently long. This innervated pedicle flap is a reliable option to cover the great toe donor site of wraparound flap with satisfactory functional and cosmetic results and acceptable donor site morbidity.
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Balan JR. Medial sural artery perforator free flap for the reconstruction of leg, foot and ankle defect: an excellent option. ANZ J Surg 2017; 88:E132-E136. [PMID: 28512866 DOI: 10.1111/ans.14050] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 03/08/2017] [Accepted: 03/15/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND The defects over the leg, foot and ankle are best covered with a thin pliable flap. The use of muscle flap for the reconstruction of these defects leaves a grafted, aesthetically inferior result. The medial sural artery perforator (MSAP) free flap gives a thin pliable tissue for the reconstruction with better aesthesis. METHODS The study design was retrospective case analysis over a period of 2 years. All the patients who underwent flap for leg, foot and ankle defect reconstruction in the form of MSAP free flap were included in the study. The flap characteristics and aesthesis were assessed along with the patient satisfaction. The flap complication and donor site morbidity were also analysed. RESULTS A total of seven MSAP free flaps were done for leg, foot and ankle reconstruction. The mean flap size was 14.29 × 6.6 cm and mean pedicle length was 9.71 cm. One flap had venous congestion post-operatively resulting in marginal flap loss. All the flaps had acceptable aesthesis with good patient satisfaction. There was donor site morbidity in two patients, in the form of wound dehiscence. CONCLUSION MSAP free flap is a reliable choice for leg, foot and ankle defect reconstruction.
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Affiliation(s)
- Jyoshid R Balan
- Department of Plastic Surgery, Sushrutha Institute of Plastic Reconstructive and Aesthetic Surgery, Elite Mission Hospital, Thrissur, India
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Myung Y, Yim S, Kim BK. A comparison of axial circumference between superficial circumflex iliac artery perforator flap and other workhorse flaps in dorsal foot reconstruction. J Plast Surg Hand Surg 2017; 51:381-386. [PMID: 28152328 DOI: 10.1080/2000656x.2017.1279621] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Management and reconstruction of dorsal foot defects present various difficulties and challenges. The main purpose of this article is to discuss experiences of using superficial circumflex iliac perforator (SCIP) flap in various defects of the dorsal foot region. METHODS From August 2012 to February 2015, a total of 13 patients - nine males and four females - received a reconstruction operation for dorsal foot defects using SCIP flaps (the SCIP group). The defects were caused by trauma (n = 9), diabetes (n = 3), and malignancy (n = 1). The mean age was 43.07 years, which ranged between 19-70 years. Additionally, 19 other patients, who underwent reconstruction operation of the foot dorsum using ALT and TDAP flaps during the same study period, were recruited for comparison. The axial circumference of the operated foot and unoperated contralateral foot was measured, and the difference were compared between all patients, as well as between the two groups. RESULTS All of the flaps survived after the operation, but secondary procedures were performed in two cases due to partial skin necrosis. The mean follow-up period was 13 months. The mean axial circumference discrepancy of the SCIP group (12.08 ± 2.96 mm) was significantly lower compared with ALT (25.21 ± 3.16 mm) and TDAP (29.88 ± 1.55 mm) groups (p < 0.01). CONCLUSIONS The authors experienced good results with using the SCIP flap in dorsal foot reconstruction. Reconstruction with the SCIP flap can be a good surgical option, with better postoperative symmetry and minimal donor sequelae, compared to conventional workhorse flaps.
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Affiliation(s)
- Yujin Myung
- a Department of Plastic and Reconstructive Surgery , Seoul National University Bundang Hospital, Seoul National University College of Medicine , Seoul , South Korea
| | - Sangjun Yim
- a Department of Plastic and Reconstructive Surgery , Seoul National University Bundang Hospital, Seoul National University College of Medicine , Seoul , South Korea
| | - Baek-Kyu Kim
- a Department of Plastic and Reconstructive Surgery , Seoul National University Bundang Hospital, Seoul National University College of Medicine , Seoul , South Korea
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Distal lower extremity coverage by distally based sural flaps: Methods to increase their vascular reliability. ANN CHIR PLAST ESTH 2017; 62:45-54. [DOI: 10.1016/j.anplas.2015.11.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Accepted: 11/19/2015] [Indexed: 11/18/2022]
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Li X, Cui J, Maharjan S, Lu L, Gong X. Reconstruction of the Foot and Ankle Using Pedicled or Free Flaps: Perioperative Flap Survival Analysis. PLoS One 2016; 11:e0167827. [PMID: 27930679 PMCID: PMC5145187 DOI: 10.1371/journal.pone.0167827] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 11/21/2016] [Indexed: 11/25/2022] Open
Abstract
Objective The purpose of this study is to determine the correlation between non-technical risk factors and the perioperative flap survival rate and to evaluate the choice of skin flap for the reconstruction of foot and ankle. Methods This was a clinical retrospective study. Nine variables were identified. The Kaplan-Meier method coupled with a log-rank test and a Cox regression model was used to predict the risk factors that influence the perioperative flap survival rate. The relationship between postoperative wound infection and risk factors was also analyzed using a logistic regression model. Results The overall flap survival rate was 85.42%. The necrosis rates of free flaps and pedicled flaps were 5.26% and 20.69%, respectively. According to the Cox regression model, flap type (hazard ratio [HR] = 2.592; 95% confidence interval [CI] (1.606, 4.184); P < 0.001) and postoperative wound infection (HR = 0.266; 95% CI (0.134, 0.529); P < 0.001) were found to be statistically significant risk factors associated with flap necrosis. Based on the logistic regression model, preoperative wound bed inflammation (odds ratio [OR] = 11.371,95% CI (3.117, 41.478), P < 0.001) was a statistically significant risk factor for postoperative wound infection. Conclusion Flap type and postoperative wound infection were both independent risk factors influencing the flap survival rate in the foot and ankle. However, postoperative wound infection was a risk factor for the pedicled flap but not for the free flap. Microvascular anastomosis is a major cause of free flap necrosis. To reconstruct complex or wide soft tissue defects of the foot or ankle, free flaps are safer and more reliable than pedicled flaps and should thus be the primary choice.
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Affiliation(s)
- Xiucun Li
- Department of Hand and Foot Surgery, The First Hospital of Jilin University, Changchun, Jilin Province, P.R. China
| | - Jianli Cui
- Department of Hand and Foot Surgery, The First Hospital of Jilin University, Changchun, Jilin Province, P.R. China
| | - Suraj Maharjan
- Department of Hand and Foot Surgery, The First Hospital of Jilin University, Changchun, Jilin Province, P.R. China
| | - Laijin Lu
- Department of Hand and Foot Surgery, The First Hospital of Jilin University, Changchun, Jilin Province, P.R. China
| | - Xu Gong
- Department of Hand and Foot Surgery, The First Hospital of Jilin University, Changchun, Jilin Province, P.R. China
- * E-mail:
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Jandali Z, Lam MC, Aganloo K, Merwart B, Buissink J, Müller K, Jiga LP. The free medial sural artery perforator flap: Versatile option for soft tissue reconstruction in small-to-moderate size defects of the foot and ankle. Microsurgery 2016; 38:34-45. [PMID: 27704609 DOI: 10.1002/micr.30100] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 07/15/2016] [Accepted: 08/04/2016] [Indexed: 11/10/2022]
Abstract
BACKGROUND The medial sural artery perforator (MSAP) flap shows advantages for reconstruction in the foot and ankle, where bulk is a liability. We evaluated the versatility of this flap and provide further evidence on its use for covering small-to-moderate size defects by comparing the outcome depending on the region of reconstruction. METHODS Twenty-two patients with variable defects of 4 × 4 to 18 × 7 cm underwent MSAP flap reconstruction. Final outcomes of all patients were evaluated 12-months postoperatively using the AOFAS ankle-hindfoot, midfoot and hallux scale for clinical-functional evaluation, and the SF-36 health survey for quality-of-life measurement. The scores were compared in three groups according to the anatomic region of MSAP flap reconstruction. RESULTS The flap size ranged between 6 × 4 and 21 × 9 cm. One venous congestion was salvaged by venous thrombectomy and reanastomosis, and one marginal flap necrosis healed by secondary intention. All flaps survived, and all patients returned to ambulation. Patients with reconstruction of the ankle-hindfoot or hallux showed significantly lower AOFAS ankle-hindfoot (P = 0.021) or hallux scores (P = 0.034), whereas reconstruction of the midfoot led to equal AOFAS midfoot scores (P = 0.265) as compared with patients without reconstruction in the respective region. Comparison of SF-36 physical (P = 0.936) and mental (P = 0.855) scores of all three regions remained insignificant. CONCLUSION The MSAP flap provides thin soft tissue coverage, enabling good functional recovery after defect reconstruction all around the foot and ankle, with evident advantages in the midfoot. However, the functional outcomes after reconstruction of the ankle-hindfoot or hallux region depend on the preexistent functional impairment.
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Affiliation(s)
- Zaher Jandali
- Department of Plastic, Aesthetic, Reconstructive and Hand Surgery, Evangelisches Krankenhaus Oldenburg, Medical Campus University of Oldenburg, Oldenburg, Germany
| | - Martin C Lam
- Department of Plastic, Aesthetic, Reconstructive and Hand Surgery, Evangelisches Krankenhaus Oldenburg, Medical Campus University of Oldenburg, Oldenburg, Germany
| | - Kiomars Aganloo
- Department of Plastic, Aesthetic, Reconstructive and Hand Surgery, Evangelisches Krankenhaus Oldenburg, Medical Campus University of Oldenburg, Oldenburg, Germany
| | - Benedikt Merwart
- Department of Plastic, Aesthetic, Reconstructive and Hand Surgery, Evangelisches Krankenhaus Oldenburg, Medical Campus University of Oldenburg, Oldenburg, Germany
| | - Jouke Buissink
- Department of Plastic, Aesthetic, Reconstructive and Hand Surgery, Evangelisches Krankenhaus Oldenburg, Medical Campus University of Oldenburg, Oldenburg, Germany
| | - Klaus Müller
- Department of Plastic, Aesthetic and Reconstructive Surgery, Asklepios Klinik Barmbek, Asklepios Medical School, Hamburg, Germany
| | - Lucian P Jiga
- Department of Plastic, Aesthetic, Reconstructive and Hand Surgery, Evangelisches Krankenhaus Oldenburg, Medical Campus University of Oldenburg, Oldenburg, Germany
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Kim YH, Kim KH, Sung KY, Kim JT, Kim SW. Toe resurfacing with a thin thoracodorsal artery perforator flap. Microsurgery 2015; 37:312-318. [PMID: 26612346 DOI: 10.1002/micr.30007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 08/19/2015] [Accepted: 10/29/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND In toe reconstruction, amputation procedures are much more common than salvage procedures. However, toe resurfacing, rather than amputation, provides superior functional and aesthetic results. In this study, we report the clinical outcomes of toe resurfacing using a thin thoracodorsal artery perforator flap. PATIENTS AND METHODS Between January 2004 and June 2013, a total of 15 patients underwent toe resurfacing using thoracodorsal artery perforator flaps. Thin flaps were harvested by discarding the deep adipose layer. Twelve cases involved a great toe defect, three, a second toe defect, three, a third toe defect, and one, a fourth toe defect. Patient ages ranged from 19 to 82 years (mean, 42.9 years). The mechanism of injury varied, including crushing injury, degloving injury, and diabetic foot infection. RESULTS The size of thoracodorsal artery perforator flap ranged from 4 × 3 to 20 × 8 cm2 and the thickness of the flap ranged from 4 to 9 mm (mean, 6.5 mm). All flap survived completely without complications. The mean follow-up period was 18.8 months (range, 12-60 months). Only one patient with rheumatoid arthritis had mild gait disturbance. All patients were satisfied with the aesthetic and functional results. CONCLUSION Toe resurfacing with thin thoracodorsal artery perforator flaps appears to be a safer and more reliable option than amputation for preserving their function. © 2015 Wiley Periodicals, Inc. Microsurgery 37:312-318, 2017.
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Affiliation(s)
- Youn Hwan Kim
- Department of Plastic and Reconstructive Surgery, College of Medicine, Hanyang University, Seoul, Korea
| | - Ki Ho Kim
- Department of Plastic and Reconstructive Surgery, College of Medicine, Hanyang University, Seoul, Korea
| | - Kun-Yong Sung
- Department of Plastic and Reconstructive Surgery, Kangwon National University Hospital, Republic of Korea
| | - Jeong Tae Kim
- Department of Plastic and Reconstructive Surgery, College of Medicine, Hanyang University, Seoul, Korea
| | - Sang Wha Kim
- Department of Plastic and Reconstructive Surgery, College of Medicine, Seoul National University, Seoul National University Hospital, Seoul, Korea
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Hu R, Ren YJ, Yan L, Xiao ZH, Ding F, Li F, Han Q, Cheng WJ, Kan WS. A free anterolateral thigh flap and iliotibial band for reconstruction of soft tissue defects at children's feet and ankles. Injury 2015. [PMID: 26206164 DOI: 10.1016/j.injury.2015.06.046] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND PURPOSE High-energy injury to children caused by a traffic accident is usually characterised by extensive soft tissue defects with exposure or loss of tendons and bone at the foot. Segmental loss of the Achilles tendon along with soft tissue defects is a great challenge for microsurgical reconstruction. Free anterolateral thigh (ALT) flap is indicated for reconstruction of such defects because limited local tissues are available. Additionally, iliotibial band in the donor area can be used to reconstruct the damaged tendon. MATERIALS AND METHODS Here we described our successful management of 25 paediatric patients with such high-energy injury at feet and ankles in one-stage transplantation of a free ALT flap and an iliotibial band from January 2008 to January 2013. The tendon defect, ranging from 3 to 16cm in length, was reconstructed with an iliotibial band. The flaps ranged from 5 to 12cm in width and 8 to 18cm in length. RESULTS All the flaps survived completely and no donor site complications were observed. In two flaps there was a small area of distal necrosis which was healed by dressing changes. The mean follow-up time was 14.2 months (from 6 to 24 months). Limb function was assessed using the Maryland Foot Score. The excellent and good rate was 92%. CONCLUSIONS We believe a free ALT flap is ideal for reconstruction of massive soft tissue defects at the foot and ankle in children and an iliotibial band from the same donor site can be used for reconstruction of a damaged tendon.
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Affiliation(s)
- Rui Hu
- Department of Reparative and Reconstructive Surgery, Puai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430033, China
| | - Yi-Jun Ren
- Department of Reparative and Reconstructive Surgery, Puai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430033, China.
| | - Li Yan
- Department of Reparative and Reconstructive Surgery, Puai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430033, China
| | - Zhi-Hong Xiao
- Department of Reparative and Reconstructive Surgery, Puai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430033, China
| | - Fan Ding
- Department of Reparative and Reconstructive Surgery, Puai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430033, China
| | - Fan Li
- Department of Reparative and Reconstructive Surgery, Puai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430033, China
| | - Qiong Han
- Department of Reparative and Reconstructive Surgery, Puai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430033, China
| | - Wen-Jun Cheng
- Department of Reparative and Reconstructive Surgery, Puai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430033, China
| | - Wu-Sheng Kan
- Department of Reparative and Reconstructive Surgery, Puai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430033, China
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Abstract
Plantar area reconstruction represents the most challenging part of the lower limb. The anterolateral thigh (ALT) flap proved to be a versatile flap for this special area. Herein, we present the application of bilateral ALT free flaps for foot salvage after frostbite injury and long-term follow-up. Single perforator bilateral ALT flaps (304 and 320 cm(2)) were harvested and anastomosed to posterior tibial vessels. The lateral femoral cutaneous nerve was anastomosed to the calcaneal branches of the posterior tibial nerve. The two-point discrimination test showed values from 16 to 28 mm in different flap areas 5 years later. The patient is able to walk with crutches. This is the first case report of bilateral ALT for foot salvage.
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39
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Chao WN, Wang PH, Chen BR, Chen SC. Chimeric groin free flaps: Design and clinical application. Microsurgery 2015; 36:206-15. [DOI: 10.1002/micr.22442] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Revised: 05/10/2015] [Accepted: 05/28/2015] [Indexed: 11/05/2022]
Affiliation(s)
- Wai-Nang Chao
- Institute of Medicine & School of Medicine; Chung Shan Medical University; Taichung Taiwan
- Division of Plastic Surgery, Department of Surgery; Changhua Christian Hospital; Changhua Taiwan
- Chienkuo Technology University; Changhua Taiwan
| | - Po-Hui Wang
- Institute of Medicine & School of Medicine; Chung Shan Medical University; Taichung Taiwan
| | - Bing-Ren Chen
- Division of Plastic Surgery, Department of Surgery; Liouying Chi-Mei Hospital; Tainan Taiwan
| | - Shiuan-Chih Chen
- Institute of Medicine & School of Medicine; Chung Shan Medical University; Taichung Taiwan
- Department of Family and Community Medicine; Chung Shan Medical University Hospital; Taichung Taiwan
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40
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Ayestaray B, Elbaz M, Lelievre H, Scharyki S, Foufa A. Reconstruction of post-traumatic drop foot deformity by the chimeric deep inferior epigastric artery perforator free flap associated with a composite quadriceps osteotendinous graft. Microsurgery 2015; 36:334-338. [DOI: 10.1002/micr.22438] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 05/26/2015] [Accepted: 06/03/2015] [Indexed: 11/06/2022]
Affiliation(s)
- Benoit Ayestaray
- Department of Plastic and Reconstructive Surgery; Sud Francilien Hospital University Paris Sud XI; 91000 Evry France
| | - Matthias Elbaz
- Department of Plastic and Reconstructive Surgery; Sud Francilien Hospital University Paris Sud XI; 91000 Evry France
| | - Henri Lelievre
- Department of Orthopedic Surgery; Sud Francilien Hospital University Paris Sud XI; 91000 Evry France
| | - Stéphane Scharyki
- Department of Orthopedic Surgery; Sud Francilien Hospital University Paris Sud XI; 91000 Evry France
| | - Adnan Foufa
- Department of Orthopedic Surgery; Sud Francilien Hospital University Paris Sud XI; 91000 Evry France
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41
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Rednam RS, Rinker BD. Reconstruction of posterior compartment of lower extremity using a functional latissimus dorsi free flap: A case report. Microsurgery 2015; 36:77-80. [DOI: 10.1002/micr.22443] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Revised: 06/02/2015] [Accepted: 06/03/2015] [Indexed: 11/08/2022]
Affiliation(s)
- Rukmini S. Rednam
- Division of Plastic & Reconstructive Surgery; Department of Surgery; University of Kentucky; Lexington KY
| | - Brian D. Rinker
- Division of Plastic & Reconstructive Surgery; Department of Surgery; University of Kentucky; Lexington KY
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42
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Cho YJ, Lee JH, Chung DW. Pedicled chimeric gastrocnemius-medial sural artery adipofascial flap for reconstruction of anterolateral defects of the knee. Microsurgery 2015; 37:206-211. [PMID: 26095849 DOI: 10.1002/micr.22436] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2014] [Revised: 05/19/2015] [Accepted: 05/26/2015] [Indexed: 11/09/2022]
Abstract
A medial gastrocnemius muscle flap is useful for soft tissue reconstruction of the knee and proximal tibia but insufficient to cover defects involving the lateral aspect of the knee. The purpose of this report is to present the results of the use of a pedicled chimeric gastrocnemius-medial sural artery adipofascial flap for reconstruction of defects of the knee and lateral aspect of the knee. Six patients underwent soft tissue reconstruction of the knee by means of the described procedure. Patients included one female and five males. The mean age of the patients was 48 years. The cause of soft tissue defects was open fractures in three cases and infection in three cases. The mean size of soft tissue defects was 9.3 × 7 cm (range: 6 × 3 to 18 × 14 cm), and the mean size of adipofascial components was 6.8 × 3.8 cm (range: 6 × 3 to 10 × 6 cm). Medial knee defects were covered by the medial gastrocnemius muscle component and lateral knee defects were covered by the medial sural artery adipofascial component. All flaps survived in the six cases. Soft tissue reconstruction and infection control were successful without any additional surgical procedures. A pedicled chimeric gastrocnemius-medial sural artery adipofascial flap may be considered effective for soft tissue reconstruction of the knee as it reduces scars at the donor site and reconstructs the lateral knee defects not covered by the medial gastrocnemius muscle flap. © 2015 Wiley Periodicals, Inc. Microsurgery 37:206-211, 2017.
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Affiliation(s)
- Young Joo Cho
- Department of Orthopedic Surgery, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Jae Hoon Lee
- Department of Orthopedic Surgery, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Duke Whan Chung
- Department of Orthopedic Surgery, Kyung Hee University Hospital at Gangdong, Seoul, Korea.,Kyung Hee Medical Center, School of Medicine, Kyung Hee University, Seoul, Korea
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43
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Hwang KT, Kim SW, Sung IH, Kim JT, Kim YH. Is delayed reconstruction using the latissimus dorsi free flap a worthy option in the management of open IIIB tibial fractures? Microsurgery 2015; 36:453-9. [PMID: 25976771 DOI: 10.1002/micr.22428] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 03/17/2015] [Accepted: 04/14/2015] [Indexed: 01/27/2023]
Abstract
Early reconstruction of severe open fractures, performed within 7 days of the injury, has a better outcome than closure after 7 days. However, the uncertain demarcation of damaged tissue often results in delayed reconstruction. In this article, we report our surgical outcomes of delayed reconstruction using latissimus dorsi free flap with internal fixation. Twenty-three patients with Gustilo type IIIB open tibial fractures Between March 2009 and May 2012 were included in this study. There were 16 cases of distal 1/3 fracture of the tibia, 4 of midshaft fracture, 1 of proximal 1/3 fracture, and 2 of segmental fracture. Serial debridement with application of negative pressure wound therapy (NPWT) was performed before the final operation. All patients underwent internal fixation of the bone and reconstruction of soft tissue defect using latissimus dorsi free flap. The number of serial debridements, excluding those performed during emergency and finial operation, ranged from 1 to 5 (mean 2.69) times. Mean time from injury to final operation was 10.65 (range, 7-22) days. All flaps survived without complications. Three cases (13%) were infected, and three cases required further bone graft surgery to facilitate bone union (13%). Bone union was achieved after a mean 6.3 (range, 3-12) months. Mean follow-up period was 16.34 (range, 12-26) months. During follow-up, all patients were able to ambulate without use of an aid. In cases of severe open fracture, treatment should emphasize soft tissue coverage rather than rushing to achieve definitive fixation in the setting of poor surrounding tissues. When delayed reconstruction is inevitable, radical debridement is performed first, then NPWT is used as bridging therapy, and free flap could be considered for definite soft tissues coverage. © 2015 Wiley Periodicals, Inc. Microsurgery 36:453-459, 2016.
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Affiliation(s)
- Kyu Tae Hwang
- Department of Orthopedic Surgery, College of Medicine, Hanyang University, Seoul, Korea
| | - Sang Wha Kim
- Department of Plastic and Reconstructive Surgery, Seoul National University, College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Il Hoon Sung
- Department of Orthopedic Surgery, College of Medicine, Hanyang University, Seoul, Korea
| | - Jeong Tae Kim
- Department of Plastic and Reconstructive Surgery, College of Medicine, Hanyang University, Seoul, Korea
| | - Youn Hwan Kim
- Department of Plastic and Reconstructive Surgery, College of Medicine, Hanyang University, Seoul, Korea.
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44
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Lee G, Jeong E. Coverage of defect over toes after failure of microsurgical replantation with medial sural artery perforator flap: A case report. Microsurgery 2015; 36:161-4. [PMID: 25867277 DOI: 10.1002/micr.22415] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Revised: 03/18/2015] [Accepted: 03/25/2015] [Indexed: 11/11/2022]
Abstract
In this report, we present a case of toe reconstruction with a medial sural artery perforator free flap after failure of replantation. A 35-year-old male suffered a crush injury from a heavy object falling over the left 1st, 2nd, and 3rd toes and underwent microsurgical replantation of the toes at an outside facility. Over the next 2 weeks, ischemic necrosis of all the toes developed. This condition was very frustrating for the patient who had very high expectations of preserving the toes, and also for the surgeon to determine the optimal method to reconstruct the distal foot and toes. After debridement of non-viable tissues, the defect over the toes was resurfaced using a medial sural artery perforator free flap and full thickness skin graft. Subsequently, several minor operations, including interdigitation, excision of neuromas, and defatting procedure were performed to complete his reconstruction. Eighteen months later, the patient had very aesthetically pleasing and fully functional toes. A medial sural artery perforator free flap may be used to repair the soft tissue defect on the toes after failed replantation, and provides sufficient skin.
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Affiliation(s)
- Gordon Lee
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Palo Alto, CA
| | - Euicheol Jeong
- Department of Plastic Surgery, SMG-SNU Boramae Medical Center, Seoul, Korea
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45
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Song B, Chen J, Han Y, Hu Y, Su Y, Li Y, Zhang J, Guo S. The use of fabricated chimeric flap for reconstruction of extensive foot defects. Microsurgery 2015; 36:303-9. [PMID: 25752811 DOI: 10.1002/micr.22399] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Revised: 01/07/2015] [Accepted: 02/17/2015] [Indexed: 11/08/2022]
Abstract
Repair of extensive foot defects requires both adequate tissues for wound coverage and special tissues for functional reconstruction. To maximize its function reconstruction, fabricated chimeric flaps consisting of multiple separate flaps were designed to reconstruct such defects. Five patients suffered extensive foot defects with sizes ranging from 23 × 12 cm to 38 × 14 cm(2) in multiple regions including heel, forefoot, dorsum, ankle, anterior leg, and even toes. Causes included crushing injuries, avulsion injuries, and scar excision. Most areas of the defects except heel were first covered by latissimus dorsi muscle flap or anterolateral thigh flap and their pedicles were anastomosed with recipient vessels. Then free medial plantar flaps were transferred for heel reconstruction and their pedicles were further attached to either side branches of the main source vessel or to its distal continuation. All chimeric flaps survived uneventfully and all patients were able to walk in normal footwear during the 1.5- to 4-years follow-up. None of the flaps developed ulcer and flap breakdown. The assessment by Maryland Foot Score showed that four of the five patients gained a "good" recovery and one patient showed moderate improvement of foot functions. Appearances of reconstructed heels were near-normal. The results indicate that fabricated chimeric flap has good design flexibility and may provide an option for functional reconstruction of extensive foot defects. © 2015 Wiley Periodicals, Inc. Microsurgery 36:303-309, 2016.
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Affiliation(s)
- Baoqiang Song
- Department of Plastic Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Jianwu Chen
- Department of Plastic Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Yan Han
- Department of Plastic Surgery, 301 Military Hospital of China, Beijing, China
| | - Yalan Hu
- Department of Plastic Surgery, 260th Hospital of PLA, Shijiazhuang, China
| | - Yingjun Su
- Department of Plastic Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Yang Li
- Department of Plastic Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Juan Zhang
- Department of Plastic Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Shuzhong Guo
- Department of Plastic Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
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46
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Kim SW, Youn DH, Hwang KT, Sung IH, Kim JT, Kim YH. Reconstruction of the lateral malleolus and calcaneus region using free thoracodorsal artery perforator flaps. Microsurgery 2015; 36:198-205. [PMID: 25732603 DOI: 10.1002/micr.22389] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Revised: 01/19/2015] [Accepted: 01/22/2015] [Indexed: 11/06/2022]
Abstract
Reconstruction of the lateral malleolus or calcaneus region is challenging because of poor vascularity, minimal presence of soft tissue, and difficulties with flap positioning during and after the operation. In many cases, local flaps are limited in terms of size, durability, and vascularity. Free tissue transfer can be useful for complicated wounds. We report here on the results of the reconstruction in this region using free thoracodorsal artery perforator flaps. Between October 2010 and October 2013, 16 cases of lateral malleolus or calcaneus defects were reconstructed using free thoracodorsal artery perforator flaps. The defects varied from 2 × 5 cm(2) to 12 × 16 cm(2), and the flaps from 3 × 5 cm(2) to 10 × 15 cm(2). Two cases were reconstructed using chimeric-pattern flaps. Only the superficial adipose layers were harvested for all the flaps, without further thinning or debulking process. Five cases with complications occurred, including three cases of partial necrosis of the flap and two cases of venous congestion caused by thrombosis and compression of the venous pedicle, and one flap was totally lost. The mean follow-up duration was 11.8 months. All the patients were able to wear shoes. All but one were able to walk. The thoracodorsal artery perforator flap can be made super-thin, allowing patients to wear shoes, and it can be harvested in a chimeric-pattern for complex defects. Therefore, it may represent a viable alternative choice for the reconstruction of the lateral malleolus and calcaneus region.
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Affiliation(s)
- Sang Wha Kim
- Department of Plastic and Reconstructive Surgery, The Catholic University of Korea, Seoul, Korea
| | - Dong Hyun Youn
- Department of Plastic and Reconstructive Surgery, College of Medicine, Hanyang University, Seoul, Korea
| | - Kyu Tae Hwang
- Department of Orthopedic Surgery, College of Medicine, Hanyang University, Seoul, Korea
| | - Il Hoon Sung
- Department of Orthopedic Surgery, College of Medicine, Hanyang University, Seoul, Korea
| | - Jeong Tae Kim
- Department of Plastic and Reconstructive Surgery, College of Medicine, Hanyang University, Seoul, Korea
| | - Youn Hwan Kim
- Department of Plastic and Reconstructive Surgery, College of Medicine, Hanyang University, Seoul, Korea.,Department of Plastic and Reconstructive Surgery, Seoul National University Hospital, Seoul, Korea
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47
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Vargas CR, Nguyen JT, Ashitate Y, Silvestre J, Venugopal V, Neacsu F, Kettenring F, Frangioni JV, Gioux S, Lee BT. Near-infrared imaging for the assessment of anastomotic patency, thrombosis, and reperfusion in microsurgery: a pilot study in a porcine model. Microsurgery 2015; 35:309-14. [PMID: 25571855 DOI: 10.1002/micr.22376] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 12/13/2014] [Accepted: 12/19/2014] [Indexed: 11/09/2022]
Abstract
BACKGROUND Advances in microsurgical techniques have increased the use of free tissue transfer. Methods of intraoperative flap perfusion assessment, however, still rely primarily on subjective evaluation of traditional clinical parameters. Anastomotic thrombosis, if not expeditiously identified and revised, can result in flap loss with significant associated morbidity. This study aims to evaluate the use of near-infrared (NIR) fluorescence imaging in the assessment of microsurgical anastomotic patency, thrombosis, and vascular revision. MATERIALS AND METHODS A model of pedicle thrombosis was created using bilateral abdominal flaps isolated on deep superior epigastric vascular pedicles in four Yorkshire pigs. Following flap elevation, microvascular arterial and venous anastomoses were performed unilaterally, preserving an intact contralateral control flap. Thrombosis was induced at the arterial anastomosis site using ferric chloride, and both flaps imaged using NIR fluorescence angiography. The thrombosed vascular segments were subsequently excised and new anastomoses performed to restore flow. Follow-up imaging of both flaps was then obtained to confirm patency using fluorescence imaging technology. RESULTS Pedicled abdominal flaps were created and successful anastomotic thrombosis was induced unilaterally in each pig. Fluorescence imaging technology identified large decreases in tissue perfusion of the thrombosed flap within 2 minutes. After successful revision anastomosis, NIR imaging demonstrated dramatic increase in flow to the reconstructed flap, but intensity did not return to pre-thrombosis levels. CONCLUSIONS Early identification of anastomotic thrombosis is important in successful free tissue transfer. Real-time, intraoperative evaluation of flap perfusion, anastomotic thrombosis, and successful revision can be performed using NIR fluorescence imaging.
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Affiliation(s)
- Christina R Vargas
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - John T Nguyen
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Yoshitomo Ashitate
- Division of Cancer Diagnostics and Therapeutics, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Jason Silvestre
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Vivek Venugopal
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Division of Hematology and Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Florin Neacsu
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Division of Hematology and Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Frank Kettenring
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Division of Hematology and Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - John V Frangioni
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Division of Hematology and Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Curadel, LLC, Worcester, MA
| | - Sylvain Gioux
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Division of Hematology and Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Bernard T Lee
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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48
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Scaglioni MF, Kuo YR, Chen YC. Reconstruction of distal hand and foot defects with the free proximal peroneal artery perforator flap. Microsurgery 2014; 36:183-90. [DOI: 10.1002/micr.22364] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2014] [Revised: 11/24/2014] [Accepted: 12/01/2014] [Indexed: 11/08/2022]
Affiliation(s)
- Mario F. Scaglioni
- Department of Plastic and Reconstructive Surgery; Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine; Kaohsiung Taiwan
| | - Yur-Ren Kuo
- Department of Plastic and Reconstructive Surgery; Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine; Kaohsiung Taiwan
| | - Yen-Chou Chen
- Department of Plastic and Reconstructive Surgery; Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine; Kaohsiung Taiwan
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49
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Busnardo FF, Coltro PS, Olivan MV, Faes JC, Lavor E, Ferreira MC, Rodrigues AJ, Gemperli R. Anatomical comparison among the anterolateral thigh, the parascapular, and the lateral arm flaps. Microsurgery 2014; 35:387-92. [DOI: 10.1002/micr.22357] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Revised: 11/05/2014] [Accepted: 11/10/2014] [Indexed: 11/11/2022]
Affiliation(s)
- Fábio F. Busnardo
- Division of Plastic Surgery and the Cancer Institute of São Paulo; University of São Paulo School of Medicine; São Paulo Brazil
| | - Pedro S. Coltro
- Division of Plastic Surgery and the Cancer Institute of São Paulo; University of São Paulo School of Medicine; São Paulo Brazil
| | - Marcelo V. Olivan
- Division of Plastic Surgery and the Cancer Institute of São Paulo; University of São Paulo School of Medicine; São Paulo Brazil
| | - Jose C. Faes
- Division of Plastic Surgery and the Cancer Institute of São Paulo; University of São Paulo School of Medicine; São Paulo Brazil
| | - Elizeu Lavor
- Division of Plastic Surgery and the Cancer Institute of São Paulo; University of São Paulo School of Medicine; São Paulo Brazil
| | - Marcus C. Ferreira
- Division of Plastic Surgery and the Cancer Institute of São Paulo; University of São Paulo School of Medicine; São Paulo Brazil
| | - Aldo J. Rodrigues
- Division of Plastic Surgery and the Cancer Institute of São Paulo; University of São Paulo School of Medicine; São Paulo Brazil
| | - Rolf Gemperli
- Division of Plastic Surgery and the Cancer Institute of São Paulo; University of São Paulo School of Medicine; São Paulo Brazil
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50
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Hayashida K, Hiroto S, Morooka S, Kuwabara K, Fujioka M. The vascularized sural nerve graft based on a peroneal artery perforator for reconstruction of the inferior alveolar nerve defect. Microsurgery 2014; 35:244-8. [PMID: 25346479 DOI: 10.1002/micr.22346] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2014] [Revised: 10/09/2014] [Accepted: 10/13/2014] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Kenji Hayashida
- Division of Plastic and Reconstructive Surgery, National Nagasaki Medical Center, Ohmura City, Japan
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