Endoscopically-assisted adipofascial flap harvest for soft tissue defects of the lower leg

The esthetic outcome of lower limb reconstruction

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.

A novel endoscopic-assisted harvesting of pedicled freestyle fasciocutaneous flaps

The endoscopy-assisted technique has been demonstrated in harvesting muscle flaps; however, for pedicled freestyle fasciocutaneous flaps, few studies have applied this technique. We present a surgical procedure utilizing endoscopic-assisted method to identify the perforators of pedicled freestyle fasciocutaneous flaps for the reconstruction of soft tissue defects. From August to December 2012, 9 consecutive patients underwent endoscopic-assisted harvesting of fasciocutaneous flaps for the reconstruction of soft tissue defects. All of the defects were caused by trauma with tendon or bone exposure. Postoperatively, all patients were requested to return for outpatient follow-up visits for at least 3 months. The age of the 9 patients (8 men and 1 woman) ranged from 20 to 79 years (median 59 years). The defects ranged in size from 2 × 2 to 6 × 8 cm2. Two patients received anterolateral thigh transmuscular perforator flaps, 5 patients received fibular septocutaneous perforator flaps, and 2 patients received medial gastrocnemius transmuscular perforator flaps. The median incision length was 10 cm, and the median operative time was 120 minutes. None of the patients had intraoperative complications, and intraoperative bleeding was minimal (<50 mL). At the end of the 3-month follow-up period, none of the patients had any complications on either recipient or donor site, including total or partial necrosis of the flaps, flap dehiscence, hematomas, seromas, wound infections, or any conditions that indicated additional unplanned operative procedures. All of the patients had surviving flaps. Our results demonstrated that the endoscopic-assisted method could be a valuable and reliable alternative in harvesting pedicled freestyle fasciocutaneous flaps.

Minimally invasive harvesting of adipofascial scapular flaps

INTRODUCTION

Scapular flaps are a reliable system for reconstruction. Disadvantages of reconstruction with these flaps include unsightly scars at the donor site due to wound healing under excessive tension and the use of skin grafts. Minimally invasive harvesting techniques may reduce potential donor-site morbidity. There has been no report on endoscopically assisted harvesting of the scapular adipofascial flap.

METHODS

Two patients with large defects are reviewed. Endoscopically assisted minimally invasive techniques for harvest of scapular adipofascial flaps were used in reconstruction of these soft-tissue defects.

RESULTS

Both defects were successfully reconstructed in the primary setting without any donor-site wound complications.

CONCLUSIONS

This is the first time that a scapular flap has been harvested successfully with a minimally invasive technique for reconstruction. This technique allows the use of a scapular flap as a pedicled flap or as a free flap. Minimally invasive harvest of the adipofascial scapular flap has the advantages of short incision and better cosmesis of the donor site, for scarring is minimized and the incision can be closed primarily without skin grafting therefore reducing donor-site morbidity compared with the traditional open technique.

Distally based adipofascial flaps for dorsal foot and ankle soft tissue defects

Soft tissue defects of the dorsal foot and ankle are difficult to reconstruct because the contour of the foot must be maintained for shoe fitting. The adipofascial flap, covered with a skin graft, is a suitable method of reconstruction that fulfills this important requirement. Twelve patients with soft tissue defects of the dorsal foot and at the ankle were treated in our unit with this method. Ten (83%) were children, 2 (17%) were adults. All defects were due to road traffic accidents. Three (25%) patients were women; 9 (75%) were men. The right foot was affected in 10 (83.4%) patients, with 2 (16.6%) patients having the left foot involved. The flaps used were the peroneal artery perforator flap (distally based lateral adipofascial flap) in 9 (75%) patients, the superficial sural artery flap in 2 patients (17%), and the posterior tibial artery perforator flap (distally based medial adipofascial flap) in 1 patient (8%). All flaps were successful, providing adequate contour of the foot for wearing ordinary shoes. There were 2 partial skin graft necroses, and, in 1 patient, the tips of the donor site skin flaps were necrosed. In conclusion, the distally based adipofascial flap, covered with skin graft, is a suitable method for reconstruction of soft tissue loss of the dorsal foot and ankle and provides optimum functional and aesthetic outcome with minimum donor site morbidity.

Distally Based Lateral and Medial Leg Adipofascial Flaps: Need for Caution with Old, Diabetic Patients

BACKGROUND

Reconstruction of defects around the ankle region has always been challenging for plastic surgeons. Distally based lateral and medial leg adipofascial flaps are among the flaps of choice for coverage of this difficult region. Presented here is the authors' clinical experience with these flaps, particularly emphasizing the complicated attempts in diabetic patients.

METHODS

Seven skin defects around the ankle were reconstructed with lateral and medial leg adipofascial flaps. The lowermost perforators of the peroneal or posterior tibial artery were identified preoperatively, and a straight incision through skin only was made proximal to this perforator. With the skin flaps reflected, the adipofascial flap was than raised in the subfascial plane. The perforators to be retained in the base were located and the flap was then turned over to cover the defect, followed by application of a split-thickness skin graft over the flap. The donor site was closed primarily.

RESULTS

The ages of the patients ranged from 25 to 80 years, and the size of the flaps ranged from 3 x 5 cm to 7 x 10 cm. Four defects were reconstructed with lateral leg adipofascial flaps, and medial leg adipofascial flaps were used in three. Two flaps healed uneventfully. Partial or total graft loss and partial flap necrosis were observed in five patients, four of whom were diabetic.

CONCLUSIONS

Leg adipofascial flaps offer a valuable option for repair of defects around the ankle in many cases. However, adipofascial flaps should be used with caution in old, diabetic patients and, when performed, the probability of a second or third procedure should be considered.

Endoscopic harvest of the medial gastrocnemius muscle flap: a cadaveric study

The aim of our study was to prove that endoscopic-assisted harvest of the medial gastrocnemius muscle is as effective as the conventional technique. We performed endoscopic dissection on 10 fresh human cadavers, and found that the medial gastrocnemius muscle was easily harvested through a minor donor-site incision, because of its topography and constant dominant proximal vascular pedicle. The operative technique is described.

Endoscope-assisted management of varicose veins in the posterior thigh, popliteal fossa, and calf area

Varicose veins of the posterior thigh, popliteal fossa, and calf area were managed with the assistance of endoscopic surgery in 136 patients. Patients were divided into four types according to the normal veins involved in varicosities. With good illumination and magnified monitor viewing by means of a surgical endoscope, the main channel, tributaries of varicosities, incompetent perforating veins, and healthy veins could be clearly visualized and identified. Even though these varicosities had aberrant and tortuous courses, they could be completely dissected, divided, and then removed through one or more access incisions (2.5-3.0 cm in length). The incompetent perforating veins were also dissected and divided. The mean number of access incisions for each lower extremity was 2.2, 1.9, 1.3, and 1.0 for types I, II, III, and IV respectively. In all cases, the mean number of incisions was 1.6 in each lower limb. The most frequent morbidity was maceration of the access incision. Three wounds in 3 patients required debridement and resuturing, but the other wounds healed satisfactorily. Transient discoloration caused by bruising and numbness may present at the dissected area. There was no hematoma formation. Ischemic change with bleb formation of the dissected skin occurred in 1 patient. Subsequent secondary healing resulted in slight scarring in this area. With the assistance of endoscopic surgery, all the varicosities and the incompetent perforating veins could be completely dissected and removed. Accomplishment of removal of varicosities was double-checked between the preoperative skin marks of varicosities and the endoscopic findings. There is very little possibility for recurrence, because there were no residual varicosities or incompetent perforating veins after this operation. There was no recurrence in follow-up at least 2 months postoperatively. Patients were satisfied with the minimal surgical scarring and the complete absence of disfiguring varicosities.

Endoscopic excision of benign tumors in the forehead and brow

Twenty-five cases of benign tumor of the forehead and brow were excised successfully with endoscope-assisted surgery. The access incision was selected strategically behind the front hairline. For tumors in the middle of the forehead, the tumor was approached by subgaleal dissection. For those in the brow or temporal area, the dissection plane was just superficial to the deep temporal fascia. Patient age ranged from 3 to 59 years. The mass varied in size from 1.0 x 0.5 to 2.0 x 2.0 cm. There were 18 lipomas, 6 dermoid cysts, and 1 pilomatricoma. There was no residual mass or recurrence 1 to 24 months postoperatively. There was no paresthesia or numbness in the scalp. Patients and their families were greatly satisfied with this operation and the absence of visible scarring.