Distally Based Perforator-Plus Sural Neurocutaneous Flap with High or Low Pivot Point: Anatomical Considerations and a Retrospective Study of a Clinical Series of 378 Flaps

Modified medial gastrocnemius myocutaneous flap with extended anterior, inferior and/or posterior boundaries: Anatomical observation and report of a clinical series of 33 flaps

INTRODUCTION

Reports on medial gastrocnemius myocutaneous (MGM) flaps with extended inferior and posterior boundaries are rare, and information about the MGM flaps with extended anterior boundaries is unavailable. Thus, this study aimed to investigate the vascular anatomical basis and clinical reliability of the modified MGM flap with extended anterior, inferior and/or posterior boundaries.

METHODS

Five fresh lower limb specimens from patients with recurrent tumours in the thigh were immediately irrigated and perfused. The stripped integuments were radiographed. The pretibial skin was equally divided into nine zones. The reconstruction outcomes of the modified MGM flaps were documented in 33 patients.

RESULTS

True anastomotic connections existed among the branches of the saphenous artery, the perforator from the inferior medial genicular artery and 3-5 (mean, 4.5) perforators from the posterior tibial artery in the upper two-thirds of the leg. A total of 33 modified MGM flaps were applied. The anterior margins of 26 modified flaps with extended anterior boundaries exceeded the medial edge of the tibia by 1.0-4.5 cm (mean, 2.1 cm). Fourteen modified MGM flaps were used to repair the defects involving the lower third leg, whose distal edges were located in the seventh (n = 8) or eighth (n = 6) zone. A 1-169-month (median, 9 months) follow-up was conducted for 33 patients. Of the 33 flaps, 29 (87.9 %) survived completely, partial necrosis occurred in four flaps with extended anterior (n = 2) or inferior (n = 2) boundaries.

CONCLUSIONS

Multiple source vessels are the vascular anatomical basis of the modified MGM flap with extended anterior, posterior and/or inferior boundaries. The modification of the MGM flap is feasible and reliable, broadening the applicable scope of the flap. The modified MGM flap can be applied to repair more distal, wider and larger-area defects with a simpler design and procedure.

More potential uses of specific perforator flaps in the calf - A cadaveric study on the subdermal vascular structure of the lower leg

BACKGROUND

The perforator flap has garnered significant interest since its inception due to its advantage of not needing a vascular network at the deep fascial level. Perforator flaps are commonly utilized in different flap transplant surgeries, and the thigh flap is presently the most widely used perforator flap. Is it possible for the calf to replace the thigh as a more suitable site for harvesting materials? Currently, there is a lack of relevant anatomical research. This study aims to address this question from an anatomical and imaging perspective.

METHODS

This study used cadavers to observe the branches and courses of perforators on the calf and the distribution of skin branches using microdissection techniques, digital X-ray photography, and micro-computed tomography techniques.

RESULTS

The perforators had three main branches: the vertical cutaneous branch, the oblique cutaneous branch, and the superficial fascial branch. The superficial fascial branch traveled in the superficial fascia and connected with the nearby perforators. The vertical and oblique cutaneous branches entered the subdermal layer and connected with each other to create the subdermal vascular network.

CONCLUSIONS

We observed an intact calf cutaneous branch chain between the cutaneous nerve and the perforator of the infrapopliteal main artery at the superficial vein site. Utilizing this anatomical structure, the calfskin branch has the potential to serve as a substitute for thigh skin flap transplantation and may be applied to perforator flap transplantation in more locations.

Modified lateral gastrocnemius myocutaneous flap with extended anterior and/or inferior boundary

There is little information regarding the boundaries of the lateral gastrocnemius myocutaneous (LGM) flap. The aim of this study was to introduce the modified technique of the LGM flap with extended anterior and/or inferior boundaries and its anatomical basis. Five fresh lower limb specimens were perfused and radiographed. Between December 2003 and August 2018, 27 modified LGM flaps with extended anterior and/or inferior boundaries were raised in 27 patients to reconstruct the soft tissue defects over the middle and upper leg, knee, and lower thigh. Both the lateral popliteal cutaneous artery and musculocutaneous perforators from the lateral sural artery had rich linked arteries communicating with the chain-linked arterial network around both the posterolateral intermuscular septum and the sural nerve, and they also had rich transverse communicating arteries connecting with the perifascial arterial network overlying the anterior compartment in the upper and middle calf. Continuous fascial arterial networks were extended up to the level at the intermalleolar line. Twenty-three flaps survived uneventfully, 2 flaps displayed distal de-epithelialization, and 2 flaps (7.41%) developed partial necrosis. Osteomyelitis was cured successfully in all patients, and no relapse of infection was encountered during the follow-up period. Multiple feeder arteries are the arterial anatomic basis of the modified LGM flap. The modified LGM flap with extended anterior and/or inferior boundaries is feasible, and the modified flap with extended anterior boundaries is safe and reliable.