Septocutaneous perforators of the peroneal artery relative to the fibula: anatomical basis of the use of pedicled fasciocutaneous flap

Reconstruction of soft tissue defects around the Achilles region with distally based extended peroneal artery perforator flap

INTRODUCTION

Achilles tendon rupture and soft tissue infections with wound dehiscence and tendon exposure following the tendon repair are not infrequent. Various procedures have been described for the reconstruction of soft tissue defects at the Achilles tendon region, yet there is lack of consensus on the ideal method. In this article we report our experience using the distally based peroneal artery perforator flap in reconstruction of combined defects of the Achilles tendon and overlying soft tissue.

METHODS

7 patients with Achilles tendon injury and full-thickness soft tissue defects over the Achilles region underwent tendon repair and soft tissue reconstruction with the distally based peroneal artery perforator flap. Perforator vessels were identified at the septum between the peroneus longus and soleus muscles. After choosing the perforator with the largest diameter, meticulous deep dissection of the perforator was performed and completed 6 cm proximal to the lateral malleolus. The peroneal artery was transected and ligated and transposition of the flap to the defect was performed through a subcutaneous tunnel.

RESULTS

The size of the soft tissue defects and flaps ranged between 2×3 cm to 4×10 cm and 4×5 cm to 5×12 cm, respectively. Six out of 7 flaps survived completely without any complications. Post-operative venous congestion was observed in one patient which resulted in partial tip necrosis of the flap. The resulting wound healed with conservative treatment. Donor sites healed uneventfully in all patients. All flaps had excellent contour and provided stable soft tissue coverage.

CONCLUSION

Distally based peroneal artery perforator flap can be considered as a reliable alternative for the reconstruction of soft tissue defects around the Achilles tendon region. Advantages include (1) extended reach of the flap for the defects around the plantar and dorsal aspects of the foot, provided by the perforator dissection, (2) convenience with footwear and walking, provided by the skin texture similarity with the target region, (3) creating a protective surface to allow tendon gliding and prevent tissue adhesions after the tendon repair, provided by the crural fascia included in the flap, (4) obviating the need for microsurgical anastomosis and associated length of the operation.

Flow-Through Free Anterolateral Thigh Flap in Reconstruction of Severe Limb Injury

Supplemental digital content is available in the text.

This study aimed to present the use of flow-through free anterolateral thigh (ALT) flap for the reconstruction of severe limb injury.

Use of anterolateral thigh free flap for reconstruction and salvage of thoracic limb caused by an arteriovenous malformation

Vascular arteriovenous malformations originate during the early stages of embryonic development and generally grow progressively, especially during adolescence and pregnancy. Limb salvage using microsurgery is presented, in a patient with an arteriovenous malformation who was initially a candidate for limb amputation. En bloc resection of the arteriovenous malformation of all segments with extended brachial approach and the cutaneous component was performed, with an anterolateral thigh free flap for the lateral reconstruction of the hand.

Peroneal Artery Adipofascial Flaps for Coverage of Distal Leg and Rearfoot

Chronic wounds of the lower extremity can pose several obstacles for the treating physician as well as the patient. Peroneal artery adipofascial flaps have been shown to be a reliable and durable option for reconstruction of these defects for many reasons, including ease of dissection, minimized donor site mobility, reliability of take to underlying surfaces, and cosmetically more pleasing outcome. This article discusses the current literature regarding the use of peroneal artery adipofascial flaps and our surgical technique for harvest, transfer, and postoperative course for this versatile flap.

The suprafascial course of lower leg perforators: An anatomical study

BACKGROUND

Perforator mapping has been well described in the literature. Once the suprafascial plane is reached, the course of perforators is considered constant. However, the surgeon must be aware of whether an anastomosis exists between perforators superficially to the fascia, in order to choose the best vessel upon which to base the reconstruction. Our retrospective in vivo anatomical study of lower leg perforator flaps presents the first description of variations in the suprafascial path of perforators, which may influence preoperative flap design.

METHODS

An anatomical study of lower limb perforators was performed on 46 nonconsecutive patients who were referred to our department from June 2012 to October 2018. Reconstruction with perforator-based propeller flaps was planned for each of the patients. In total, 72 perforators were preoperatively identified and surgically isolated. The suprafascial course of each perforator was reported.

RESULTS

During suprafascial surgical exploration, branching patterns were observed in four perforators. These perforators had been classified as single vessels in the preoperative ultrasonographic analysis. However, after surgical dissection, distal converging branches were noted in two of them.

CONCLUSIONS

Our study is the first description in the literature of suprafascial converging perforators, which might constitute an obstacle to planned reconstruction procedures. Despite the accuracy of preoperative evaluations, anatomical variations were present. Knowledge of suprafascial perforator variations may help surgeons to choose the correct perforator upon which to base a planned flap.

Osteocutaneous free transfer of vascularized fibula in cervico-thoracic spinal reconstruction with filling of an esophageal fistula: A case report

The case under review is a 60-year-old patient with a vertebral plasmocytoma treated by cervico-thoracic fusion 2 years previously. He presented a thoracic spinal septic non-union complicated by esophagospinal fistula. We performed vascularized fibula transplant with cutaneous pad to fill the esophageal fistula. Control CT at day 5 confirmed vascular anastomosis permeability and bone transplant position. Osseointegration was achieved at 18 months postoperatively. The patient was alive 3 years after the last procedure (5 years after tumorectomy). A systematic review of the literature on spinal reconstruction by vascularized fibula transplant showed the diversity of surgical techniques available. In view of the multiplicity of possible organ and soft tissue defects involving the spine, reminders are provided of the different approaches and recipient vessels in this type of reconstruction depending on location.

[The fascio-cutaneous fibular island flap]

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

A Novel Application of Double-Paddle Peroneal Chimeric Flap as External Sentinel Monitor in Hypopharyngeal Reconstruction

OBJECTIVES

Monitoring the viability of buried free flaps in hypopharyngeal reconstruction is difficult. Various methods have been proposed to monitor these buried flaps, but limitations remain.

METHOD

We present a method of using double-paddle chimeric peroneal flaps that permanently externalizes a flap skin paddle as a monitoring paddle in hypopharyngeal reconstructions. This study was performed in a medical center in southern Taiwan; between 2013 and 2015, 10 patients underwent double-paddle chimeric peroneal flap reconstruction in advanced stages of hypopharyngeal cancer. We retrospectively reviewed the medical records from these surgeries, searching for either short-term postoperative complications or long-term follow-up morbidity and researched relevant articles for comparisons with other monitoring methods.

RESULTS

None of the 10 flaps underwent total loss. The rate of stenosis and that of fistula formation was 10%. The average postoperative hospital stay was 39 days. Six of 10 patients were able to resume at least a soft diet after reconstruction, and none of the patients experienced significant complications.

CONCLUSIONS

The peroneal flap is a useful flap because it is thin and pliable, has minimal donor site morbidity in patients without peripheral vascular disease, and has the potential of multiple skin paddles so that one skin paddle can be used for monitoring the buried flap. Using this method, direct clinical monitoring is feasible, and early detection of vascular complications is possible. Furthermore, the drawbacks of using a monitoring paddle produced by a deepithelialized bridge can be avoided.

Perforators of the fibular artery and suprafascial network

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

[Versatility of the microvascular fibular flap in limb reconstruction]

BACKGROUND

The structural characteristics of the fibula, strength, shape, length and limited donor site morbidity make it more suitable for reconstructing long bone defects larger than 6cm in the limbs.

MATERIAL AND METHODS

A descriptive study was conducted using a non-probabilistic sample of consecutive cases undergoing on limb reconstruction with free fibular flap in the period from January 2010 to January 2015 in the Mexican Institute of Social Security No. 21, Monterrey Nuevo Leon.

RESULTS

The mean age of the ten cases included was 25 years, with the most common diagnosis being trauma in 4 patients, osteosarcoma in 2, followed by one congenital pseudoarthrosis of the tibia, one non-union fracture, and one gunshot wounds, respectively. The most common location was tibia, followed by humerus, radius, ulna and femur.

CONCLUSIONS

This study has shown that the fibular free flap can be an excellent option for management of long bone defects, regardless of cause of the injury. One or more skin islands can be added for coverage in exposure of deep tissue and osteosynthesis material, thus preserving the septocutaneous perforators.

Anatomical study of anterior supramalleolar artery and its potential application to design a bi-foliate fasciocutaneous flap

Purpose:

A further understanding of the anterior supramalleolar artery (ASMA) and its potential applications in reconstructive surgery.

Materials and Methods:

A total of 24 fresh lower limbs from fresh cadavers were injected with red latex for dissection. The type of origin, course, diameter of the pedicle, and the distance between the origin of the ASMA from the anterior tibial artery to the extensor retinaculum (O-R) were recorded. Bi-foliate fasciocutaneous flaps were harvested using the branches of the ASMA.

Results:

We found four types of origin of the ASMA, and we have accordingly classified them into four types. 10 of them were type A, 7 were type B, 6 were type C and 1 was type D. The mean O-R (origin of ASMA to retinaculum) distance was 2.0 ± 0.8 cm. The diameter of the medial branch (D1), the diameter of the lateral branch (D2), and the diameter of artery stem (D3) (only in type A) were 1.0 ± 0.2 mm, 0.8 ± 0.3 mm, 1.1 ± 0.2 mm, respectively. The mean pedicle length of the lateral flap (L1) and medial flap (L2) were 5.1 ± 1.0 cm and 3.7 ± 0.6 cm, respectively.

Conclusions:

The ASMA exists constantly with four different types of origin. Its sizable diameter and lengthy pedicle make it suitable for bi-foliate fasciocutaneous flap transfer.

Use of a distal ulnar artery perforator-based bilobed free flap for repairing complex digital defects

PURPOSE

To retrospectively evaluate the effectiveness and safety of using a distal ulnar artery perforator (DUAP)-based bilobed free flap (BFF) for the repair of complex digital defects in the hand.

METHODS

We retrospectively studied 15 patients who sustained traumatic digital defects with complicating tendon and phalanx exposure and were hospitalized for repair using a DUAP-based BFF. Main outcome measures included patients' self-assessed physical appearance, total active motion, and 2-point discrimination.

RESULTS

The flaps survived and the wounds healed with primary intention in all patients except one who experienced partial flap necrosis of the distal margin and required treatment with a second skin graft. Patients were observed for a mean of 13 months. The physical appearance and texture of the repaired fingers were assessed as good with minimal scarring. Total active motion and 2-point discrimination were 113° to 255° (contralateral, 255° to 275°) and 6 to 11 mm (contralateral, 5 to 8 mm), respectively.

CONCLUSIONS

Use of the DUAP-based BFF is a feasible, effective, and safe treatment alternative for repairing complex digital defects with favorable aesthetic and sensorimotor outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Perforator plus fasciocutaneous flaps in the reconstruction of post-burn flexion contractures of the knee joint

BACKGROUND

A post-burn flexion contracture of the knee joint is a disabling condition which interferes with an upright posture and a bipedal locomotion. Islanded perforator flaps have been used to resurface the tissue defect which is produced as a result of the contracture release. Despite their various advantages, they are limited by an increased tendency to undergo venous congestion. Perforator-plus flaps can be used to overcome this limitation, while retaining the merits of the islanded perforator flaps.

METHODS

Ninteen patients with post flame burn flexion contractures of the knee joints underwent surgical releases and coverages by various local fasciocutaneous perforator-plus flaps. The patients were followed up for 6 months and the various aspects of the functional and the aesthetic rehabilitations were assessed.

RESULTS

All the local fasciocutaneous perforator-plus flaps resurfaced the tissue defect over popliteal fossa with good colour and texture match and maintenance of the contour. None of the flaps had any significant early or delayed complications (which included venous congestions) which necessitated reoperations. All the patients were satisfied with the functional and aesthetic outcomes.

CONCLUSION

Local fasciocutaneous perforator-plus flaps can be considered as one of the primary treatment modalities for the surgical release and reconstruction of post burn flexion contractures of the knee.

Reverse peroneal artery flap for large defects of ankle and foot: A reliable reconstructive technique

Background:

Large soft tissue defects around the lower third of the leg, ankle and foot always have been challenging to reconstruct. Reverse sural flaps have been used for this problem with variable success. Free tissue transfer has revolutionised management of these problem wounds in selected cases.

Materials and Methods:

Twenty-two patients with large defects around the lower third of the leg, ankle and foot underwent reconstruction with reverse peroneal artery flap (RPAF) over a period of 7 years. The mean age of these patients was 41.2 years.

Results:

Of the 22 flaps, 21 showed complete survival without even marginal necrosis. One flap failed, where atherosclerotic occlusion of peroneal artery was evident on the table. Few patients had minor donor site problems that settled with conservative management.

Conclusions:

RPAF is a very reliable flap for the coverage of large soft tissue defects of the heel, sole and dorsum of foot. This flap adds versatility in planning and execution of this extended reverse sural flap.

[Combined transplantation of a free skin island flap supplied by a septo-cutaneous perforator of the posterior tibial artery and the underlying fibula for the full reconstruction of the mandible and the mouth floor]

Microsurgical transplantation of the osteo-cutaneous fibula as a free flap to reconstruct the defect following radical resection of a mouth floor's tumor is a well-known and often applied procedure. Anatomy of the vessels supplying this flap is recognized but it may have some rare and unexpected variations. In this case report we discuss the reconstruction of the middle and lateral parts of the mandible which was resected due to a T4 gingival tumor. Interestingly, the aforementioned segment of the fibula and the overlying skin island were supplied by different pedicles, both emerging from the posterior tibial vessels. Both flaps were transplanted using autologous arterial and venous grafts of the peroneal artery and vein in case of the fibula. We believe this case is worth publishing due to its relative rarity in the literature and the applied surgical method.

The use of a combined bipedicled axial perforator based fasciocutaneous flap for the treatment of a traumatic diabetic foot wound: a case report

The axial and perforator vascularised fasciocutaneous flaps are reliable and effective treatment methods for covering lower limb post-traumatic, septic, Charcot, and diabetic foot wounds. The authors describe the unique utilisation of a hybrid flap as an axial-perforator flap combination for the treatment of a traumatic diabetic foot wound.

The extended peroneal artery perforator flap for lower extremity reconstruction

The peroneal artery perforator flap and its modifications have been widely used for coverage of soft tissue defects of ankle and foot in the past decade. In this article, we report on a series of upper knee, ankle, and foot reconstructions with a proximally or distally based extended peroneal artery perforator (EPAP) flap supplied by distinct perforating branches off the proximal or distal peroneal artery. Total pedicle length obtained ranged from 6 to 12 cm. Twelve patients with soft tissue defects of the lower extremity underwent reconstruction using the EPAP flap. The flaps were designed with the sizes from 10 x 6 cm to 25 x 15 cm. All 12 flaps survived completely without complications. Our experience demonstrates that the EPAP flap is reliable and versatile and can provide a large amount of soft tissue for coverage of defects in the leg anywhere from knee to forefoot obviating the need for free tissue transplantation.

The proximal radial artery perforator flap (PRAP-flap): an anatomical study for its use in elbow reconstruction

We investigated the anatomical vascular basis of the proximal radial artery perforator flap (PRAP-flap) and we report here the first clinical application in a case of reconstructive surgery as an alternative to traditional regional fasciocutaneous pedicled flaps or microsurgery solutions. In 16 unembalmed cadaveric forearms, the radial artery was slowly injected with acrylic resin through the brachial artery and the superficial flexor compartment was dissected. The flap was raised from the lateral and medial sides of the forearm toward the axis represented by the radial artery, and the characteristics (number, diameter, site and interval of origin, and course) of its collaterals were evaluated. In the proximal forearm, the vessels were less numerous (mean values 8.6 vs. 11.5, P < 0.05) but larger in diameter (mean values 0.7 vs. 0.4 mm, P < 0.05) than in the distal forearm. The first four proximal perforator arteries originated within a mean distance of 4.3 cm from the origin of the radial artery, with a 95% confidence interval of 3.8-4.8 cm. The perforator arteries followed the axis of the forearm and anastomosed in the fascial plane, forming longitudinal fan-shaped arterial chains, giving rise to an epifascial vascular network. This anatomical study allowed us to plan and perform a PRAP-flap in a 35-year-old woman who was suffering from comminuted fractures of the olecranon and distal epiphysis of the humerus and soft tissue loss from traumatic injury of the elbow. From the antebrachial surface, a proximally based radial forearm fasciocutaneous flap was raised, with a vascular pedicle of 16 x 5 cm, a cutaneous island of 4 x 5 cm, and a pivot point 5 cm from the interepicondylar line. The flap showed good immediate and long-term viability: it was completely incorporated with good pliability and the patient regained good functional quality of the elbow joint. The anatomical features and the demonstrative reconstructive result obtained in the here-reported surgical case support the clinical evidence that a reliable forearm skin paddle may be raised on a subcutaneous fascial axial pedicle supplied only by proximal perforators of the radial artery. The so-obtained PRAP-flap is useful for the coverage of elbow defects when other reconstructive options are no longer available.