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Stevanović G, Momčilović S. Anatomic study of septocutaneous system of the human fetuses' lower leg: peroneal artery. J Plast Surg Hand Surg 2023; 57:383-387. [PMID: 36369708 DOI: 10.1080/2000656x.2022.2142598] [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: 11/15/2022]
Abstract
The septocutaneous system of the lower leg perforating blood vessels consists of a vascular basis of fasciocutaneous flaps. This system is of particular importance when designing distally based fasciocutaneous flaps that are the 'workhorse' in reconstructing the distal third of the lower leg and foot. The aim of this study was to provide a comprehensive, clear and conclusive overview of the lower-leg septocutaneous system of skin blood supply in fetal age. Dissection was conducted on 20 fetuses of both sexes and gestational age from 20 to 28 weeks. The focus was on the vascular anatomy of peroneal artery and its septocutaneous (fasciocutaneous) perforating arterial vessels. Cluster analysis was applied to the obtained data. A total of 212 perforating arterial vessels were identified for peroneal artery. The average number of perforating arterial vessels was 5.32 (ranging from 4 to 7). Based on cluster analysis, perforating blood vessels were more likely to be found at certain lower-leg levels ('safe levels of finding perforators'). The presence of septocutaneous system of perforating blood vessels and reliability of their localization even in the fetal period allows for the application of these findings in the lower leg reconstructions in children of early age.
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Affiliation(s)
- Goran Stevanović
- Plastic and Reconstructive Surgery Clinic, University Clinical Center Niš, Niš, Serbia.,Department of Plastic and Reconstructive Surgery, Faculty of Medicine, University of Niš, Niš, Serbia
| | - Stefan Momčilović
- Plastic and Reconstructive Surgery Clinic, University Clinical Center Niš, Niš, Serbia.,Department of Plastic and Reconstructive Surgery, Faculty of Medicine, University of Niš, Niš, Serbia
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Radhakrishnan GS, Anand S, Salim S, Boopathi K. Caveats of Local Fasciocutaneous Flaps for Distal Leg Defects-Anatomical Study and Clinical Application. J Foot Ankle Surg 2022; 61:497-502. [PMID: 34702680 DOI: 10.1053/j.jfas.2021.09.025] [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: 10/15/2020] [Revised: 09/19/2021] [Accepted: 09/21/2021] [Indexed: 02/03/2023]
Abstract
The present trend for the management of distal leg defects is to opt for a free flap with local flaps being relegated to the backseat. We studied the perforator anatomy of the distal leg in the Indian population to see if there were any ethnic differences and then correlated it with a clinical study of local flaps used for the coverage of distal leg defects. A prospective observational study was carried out in 2 phases-anatomical study and clinical study from December 2018 to March 2020. In the anatomical study, 8 fresh cadavers, i.e., 16 lower limbs were dissected and the perforator anatomy in the distal leg was identified. In the clinical study, all patients undergoing local, pedicled fasciocutaneous flap cover for defects involving distal third leg were included with ages between 15 and 60 years. In the anatomical study, posterior tibial artery perforators in the distal-most part were found as a group of up to 3 perforators. In the clinical study, a total of 47 patients were included with a mean age of 38.0 ± 10.9 (range 17-55) years and female:male ratio being 1:2.6. The largest defect size was 120 cm2 (mean 28.2 ± 23.8 [range 6-120] cm2) and the most commonly used flap was the reverse sural artery flap in 20 (42.6%) cases. Overall, complications were seen in 7 (14.9%) cases and there was no case of flap failure. Thus, local flaps are an excellent option for coverage of distal leg defects and offer results comparable to free flaps.
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Affiliation(s)
- G S Radhakrishnan
- Associate Professor, Institute for Research and Rehabilitation of Hand & Department of Plastic Surgery, Government Stanley Medical College and Hospital, Chennai, Tamil Nadu, India
| | - Sunil Anand
- Senior Resident, Institute for Research and Rehabilitation of Hand & Department of Plastic Surgery, Government Stanley Medical College and Hospital, Chennai, Tamil Nadu, India.
| | - Shalini Salim
- Senior Resident, Institute for Research and Rehabilitation of Hand & Department of Plastic Surgery, Government Stanley Medical College and Hospital, Chennai, Tamil Nadu, India
| | - K Boopathi
- Professor and Head of Department, Institute for Research and Rehabilitation of Hand & Department of Plastic Surgery, Government Stanley Medical College and Hospital, Chennai, Tamil Nadu, India
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Agrawal NK, Bhattacharya V, Dubepuria R. Radiological Evaluation of Postsurgical Course of Perforators in Retrograde Posterior Tibial Fasciocutaneous Flaps for Distal Leg and Foot Defects. Indian J Plast Surg 2021; 54:272-277. [PMID: 34667510 PMCID: PMC8515343 DOI: 10.1055/s-0041-1734568] [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] [Indexed: 11/17/2022] Open
Abstract
Background
Mapping of vascular perforators by various methodologies have been described for planning of a variety of flaps in the lower limbs. We attempted to assess the changes in posterior tibial perforators after transfer of fasciocutaneous flaps for leg defects.
Methods
20 patients with distal leg and foot defects were studied by computed tomography angiography (CTA) and preoperative audio Doppler to ascertain perforators of posterior tibial artery. Fasciocutaneous flaps were raised, based on these perforators, depending on the site and size of soft-tissue defects. The number of perforators and their distance from the medial malleolus were also studied. Postoperative CTA was performed on the 7th to 10th day, with emphasis on postoperative changes of the perforators on which the flaps were based.
Results
One to four posterior tibial perforators were found between 5 cm and 8 cm proximal to the medial malleolus. After flap transfer, the perforators could be traced to variable distance through the total length of the flap. The perforators formed small vascular loop in 12 patients, following retrograde posterior tibial flap transfer. The height of the loop, the number of such loops, the dilatation and tortuosity of the perforators, and their longitudinal orientation were studied in detail. Most of the findings can be explained by mechanical realignment of perforators as well as by the delay phenomenon associated with retrograde fasciocutaneous flaps.
Conclusion
It was concluded that the morphological changes associated with the perforators explained the vascular rationality and success of these flaps.
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Affiliation(s)
- Neeraj Kant Agrawal
- Department of Plastic Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Visweswar Bhattacharya
- Department of Plastic Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Rahul Dubepuria
- Department of General Surgery, Sri Aurobindo Institute of Medical Sciences, Indore, Madhya Pradesh, India
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Risk factors related to the partial necrosis of the posterior tibial artery perforator-plus fasciocutaneous flap. Eur J Trauma Emerg Surg 2021; 48:1247-1253. [PMID: 33611624 DOI: 10.1007/s00068-021-01616-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 02/05/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE AND BACKGROUND The posterior tibial artery perforator-plus fasciocutaneous (PTAPF) flap is commonly used for defects over the distal lower extremity. However, the causes of partial necrosis of the PTAPF flap are unknown. This paper aimed to explore the factors related to the partial necrosis of the PTAPF flap. METHODS A retrospective study was conducted on 59 patients who received the PTAPF flap for soft-tissue defects between September 2007 and September 2017. The clinical outcomes of the flap were evaluated, and the patient and surgical factors related to flap survival were analyzed. RESULTS Of the 59 patients, 9 (15.25%) flaps exhibited partial necrosis. No significant differences were found between the survival and partial necrosis groups regarding gender, age, soft tissue defect site, length and width of the fascia pedicle, length of the skin island, length-width ratio (LWR), and pivot point (P > 0.05). However, the survival group showed significantly less width of the skin island and total length of the flap than the partial necrosis group (P < 0.05). Multiple logistic regression analysis revealed that the width of the skin island was an independent risk factor affecting partial flap necrosis (OR = 4.028; P = 0.041). CONCLUSIONS The PTAPF flap can be effectively used to repair small and medium wounds of the lower and middle leg, ankle and foot. As the width of the skin island exceeds 6 cm, the risk of partial flap necrosis significantly increases.
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Roulet S, De Luca L, Bulla A, Casoli V, Delgove A. The medial adipofascial flap for infected tibia fractures reconstruction: 10 years of experience with 59 cases. ANN CHIR PLAST ESTH 2020; 66:234-241. [PMID: 32800463 DOI: 10.1016/j.anplas.2020.07.010] [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: 06/17/2020] [Revised: 07/12/2020] [Accepted: 07/24/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the results of the medial adipofascial flap (MAF) in infected tibia fractures reconstruction and to identify criteria for success or failure. PATIENTS AND METHODS Fifty-nine patients treated with a MAF were enrolled. Age, BMI, tobacco use and bone status were recorded. Early and late postoperative complications were assessed. Bone healing and flap success were systematically evaluated at 12 months. RESULTS Tibia fractures were initially open in 48 cases (81%) and closed in 11 cases (19%). Infection was acute (<30 days) in 9 cases (15%) and chronic in 50 (85%). Thirty-one patients (53%) experienced no early postoperative complications (<30 days). There were 10 (17%) cases of necrosis of the skin graft, 2 (3%) cases of necrosis and 4 (7%) haematomas in the harvesting area, 7 (12%) cases of partial flap necrosis at its tip and 4 (7%) flap failures. None of the criteria was statistically correlated with the occurrence of a complication. At 12 months, 53 flaps (90%) were successful. Immediate skin graft were significantly correlated with flap success (P=0.05). Forty-six patients (78%) had complete bone healing documented by CT scan. CONCLUSION The MAF provides a reliable alternative for lower leg reconstruction. Its major advantages are sparing of the major leg vessels, no donor site morbidity and relatively easy and rapid dissection.
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Affiliation(s)
- S Roulet
- Plastic Surgery and Burns Unit, Centre François-Xavier Michelet, Bordeaux University Hospital, 33076 Bordeaux, France; Department of Orthopaedic Surgery 1 and 2, Trousseau University Hospital, Medical University François-Rabelais, Tours, France.
| | - L De Luca
- Plastic Surgery and Burns Unit, Centre François-Xavier Michelet, Bordeaux University Hospital, 33076 Bordeaux, France
| | - A Bulla
- Plastic Surgery Unit, Department of Surgical, Microsurgical and Medical Sciences, University of Sassari, Italy
| | - V Casoli
- Plastic Surgery and Burns Unit, Centre François-Xavier Michelet, Bordeaux University Hospital, 33076 Bordeaux, France; School of Surgery, University of Bordeaux, 33076 Bordeaux, France
| | - A Delgove
- Plastic Surgery and Burns Unit, Centre François-Xavier Michelet, Bordeaux University Hospital, 33076 Bordeaux, France; School of Surgery, University of Bordeaux, 33076 Bordeaux, France
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Kerfant N, Monnerie C, Henry AS, Ta P, Hu W, Letissier H, Le Nen D. Posterior tibial perforator-based flaps for leg and foot defects: Indications, limitations, and technical considerations. Orthop Traumatol Surg Res 2018; 104:1227-1230. [PMID: 30393069 DOI: 10.1016/j.otsr.2018.06.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 05/31/2018] [Accepted: 06/17/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Covering defects at the lower leg and foot is a common challenge in reconstructive surgery. A flap is often required, and free flaps are widely used. The posterior tibial perforator-based flap constitutes a valuable option in this situation. The objectives of this study were to evaluate the reliability of the posterior tibial perforator-based flap, report any complications, and describe the outcomes, with the goal of defining the indications of this flap in the treatment of lower limb defects. HYPOTHESIS The posterior tibial perforator-based flap is a useful and reliable option for soft-tissue defect reconstruction at the leg and foot. MATERIAL AND METHOD Patients managed using a posterior tibial perforator-based flap to cover soft-tissue defects of the leg and foot were reviewed retrospectively. A physical examination was performed and radiographs obtained at the last postoperative follow-up visit. RESULTS Thirteen patients with a mean age of 46.9 years (range: 25-73 years) were reviewed after a mean follow-up of 19.5 months (range: 16-63 months). The tissue defects were due to compound fractures in 10 patients and to postoperative complications in 3 patients. Mean flap size was 12.3cm by 6.2cm. The donor site was covered by a skin graft in 12 patients and closed primarily in 1 patient. The procedure was successful in 11 (85%) patients. DISCUSSION The posterior tibial perforator-based flap is a method of choice for covering soft-tissue defects at the leg and foot. Careful patient selection and flawless technique contribute to minimise the failure rate. LEVEL OF EVIDENCE IV, retrospective study.
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Affiliation(s)
- Nathalie Kerfant
- Service de chirurgie plastique, reconstructrice et esthétique, CHRU de Brest, boulevard Tanguy-Prigent, 29609 Brest cedex, France.
| | - Charlotte Monnerie
- Service de chirurgie plastique, reconstructrice et esthétique, CHRU de Brest, boulevard Tanguy-Prigent, 29609 Brest cedex, France
| | - Anne-Sophie Henry
- Service de chirurgie plastique, reconstructrice et esthétique, CHRU de Brest, boulevard Tanguy-Prigent, 29609 Brest cedex, France
| | - Pierre Ta
- Service de chirurgie plastique, reconstructrice et esthétique, CHRU de Brest, boulevard Tanguy-Prigent, 29609 Brest cedex, France
| | - Weiguo Hu
- Service de chirurgie plastique, reconstructrice et esthétique, CHRU de Brest, boulevard Tanguy-Prigent, 29609 Brest cedex, France
| | - Hoel Letissier
- Service de chirurgie du membre supérieur, CHRU de Brest, boulevard Tanguy-Prigent, 29609 Brest cedex, France
| | - Dominique Le Nen
- Service de chirurgie du membre supérieur, CHRU de Brest, boulevard Tanguy-Prigent, 29609 Brest cedex, France
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Bulla A, Bolletta A, Fiorot L, Maffei M, Bandiera P, Casoli V, Montella A, Campus GV. Posterior tibial perforators relationship with superficial nerves and veins: A cadaver study. Microsurgery 2018; 39:241-246. [DOI: 10.1002/micr.30327] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 03/21/2018] [Accepted: 03/27/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Antonio Bulla
- Department of Medical, Surgical and Experimental Sciences, Plastic Surgery UnitUniversity of SassariSassari Italy
- Department of Biomedical Sciences ‐ Human AnatomyUniversity of SassariSassari Italy
| | - Alberto Bolletta
- Department of Medical, Surgical and Experimental Sciences, Plastic Surgery UnitUniversity of SassariSassari Italy
| | - Luca Fiorot
- Department of Medical, Surgical and Experimental Sciences, Plastic Surgery UnitUniversity of SassariSassari Italy
| | - Matteo Maffei
- Department of Medical, Surgical and Experimental Sciences, Plastic Surgery UnitUniversity of SassariSassari Italy
| | - Pasquale Bandiera
- Department of Biomedical Sciences ‐ Human AnatomyUniversity of SassariSassari Italy
| | - Vincent Casoli
- Department of Hand Surgery, Plastic Surgery, Burn SurgeryCHU University of Bordeaux, Centre François‐Xavier‐Michelet, Groupe Hospitalier Pellegrin, Place Amélie‐Raba‐LéonBordeaux, 33076 France
| | - Andrea Montella
- Department of Biomedical Sciences ‐ Human AnatomyUniversity of SassariSassari Italy
| | - Gian Vittorio Campus
- Department of Medical, Surgical and Experimental Sciences, Plastic Surgery UnitUniversity of SassariSassari Italy
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Hupkens P, Westland PB, Schijns W, van Abeelen MH, Kloeters O, Ulrich DJ. Medial lower leg perforators: An anatomical study of their distribution and characteristics. Microsurgery 2016; 37:319-326. [DOI: 10.1002/micr.30076] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 04/07/2016] [Accepted: 05/04/2016] [Indexed: 11/06/2022]
Affiliation(s)
- Pieter Hupkens
- Department of Plastic and Reconstructive Surgery; Radboud University Medical Center (Radboudumc); Geert Grooteplein-Zuid 10 Nijmegen GA 6525 the Netherlands
| | - Pèdrou B. Westland
- Department of Plastic and Reconstructive Surgery; Radboud University Medical Center (Radboudumc); Geert Grooteplein-Zuid 10 Nijmegen GA 6525 the Netherlands
| | - Wendy Schijns
- Department of Plastic and Reconstructive Surgery; Radboud University Medical Center (Radboudumc); Geert Grooteplein-Zuid 10 Nijmegen GA 6525 the Netherlands
| | - Marjolijn H.A. van Abeelen
- Department of Plastic and Reconstructive Surgery; Radboud University Medical Center (Radboudumc); Geert Grooteplein-Zuid 10 Nijmegen GA 6525 the Netherlands
| | - Oliver Kloeters
- Department of Plastic and Reconstructive Surgery; Radboud University Medical Center (Radboudumc); Geert Grooteplein-Zuid 10 Nijmegen GA 6525 the Netherlands
| | - Dietmar J.O. Ulrich
- Department of Plastic and Reconstructive Surgery; Radboud University Medical Center (Radboudumc); Geert Grooteplein-Zuid 10 Nijmegen GA 6525 the Netherlands
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Yu D, Hou Q, Liu A, Tang H, Fang G, Zhai X, Jiang H, Cao X. Delineation the anatomy of posterior tibial artery perforator flaps using human cadavers with a modified technique. Surg Radiol Anat 2016; 38:1075-1081. [PMID: 27083588 DOI: 10.1007/s00276-016-1671-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 03/21/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND To delineate the distribution and course layer of the perforator vessels using a modified technique. METHODS Twelve perforator flaps were obtained from the crura of six fresh adult cadavers. The flaps were randomized into three groups (n = 4 per group): the full-thickness flap group; the deep fascia-free flap group, and the subcutaneous adipose layer-free group. The flaps were smoothened on a silk screen on a batten frame and the isolated flaps were perfused at a perfusion pressure of 140 mmHg for 10 min via the trunk of the posterior tibial artery. Perforator flaps were photographed using a digital camera and radiographed using a mammography device. The imaging data were processed by digital software system. RESULTS The mean number of the posterior tibial artery perforator was 4.17 ± 0.94. The three relatively constant perforators varied in the projection points as well as the diameter and the length. The vascular branches and courses of the perforators were clearly visible on the mammograms. Elimination of all the deep fascia or the subcutaneous adipose tissues in the distal portion had no significant impact on the blood supply of posterior tibial artery perforator flaps while the vascular areas of the artery perforators were significantly reduced after the subcutaneous adipose tissue was eliminated in the proximal portion. CONCLUSIONS We developed an effective modified technique for delineating the vascular territory on perforator flaps of different thicknesses. Our results provide significant guidance for clinical surgeons by providing them with more detailed anatomical knowledge of perforator flaps.
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Affiliation(s)
- Dazhi Yu
- Department of Hand Surgery, Hospital 401 of the People's Liberation Army (PLA), Qingdao, Shandong, China.,Department of Orthopedic and Traumatic Surgery, General Hospital of Jinan Military Command, Jinan, Shandong, China.,Department of Plastic Surgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Qiang Hou
- Department of Plastic Surgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Antang Liu
- Department of Plastic Surgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Haiping Tang
- Department of Hand Surgery, Hospital 401 of the People's Liberation Army (PLA), Qingdao, Shandong, China
| | - Guangrong Fang
- Department of Hand Surgery, Hospital 401 of the People's Liberation Army (PLA), Qingdao, Shandong, China
| | - Xiaodong Zhai
- Department of Hand Surgery, Hospital 401 of the People's Liberation Army (PLA), Qingdao, Shandong, China
| | - Hua Jiang
- Department of Plastic Surgery, Changzheng Hospital, Second Military Medical University, Shanghai, China.
| | - Xuecheng Cao
- Department of Orthopedic and Traumatic Surgery, General Hospital of Jinan Military Command, Jinan, Shandong, China.
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Distally based posterior tibial artery perforator flap for coverage of defects around the ankle, heel and lower third of leg. EUROPEAN JOURNAL OF PLASTIC SURGERY 2014. [DOI: 10.1007/s00238-014-0998-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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