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Wang L, Liu H, Ma T, Wu X, Zhang L. Reconstruction of Soft Tissue Defects in the Hand with a Free Anterolateral Thigh Deep Fascia Flap. Orthop Surg 2021; 13:758-767. [PMID: 33666370 PMCID: PMC8126942 DOI: 10.1111/os.12948] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 12/27/2020] [Accepted: 01/16/2021] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To report our experience in the reconstruction of soft tissue defects in the hand with a free anterolateral thigh deep fascia flap and describe the clinical outcomes. METHODS This study was a retrospective trial. From November 2016 to January 2020, six patients (four men and two women) with soft tissue defects in the hand were included in this study. The average age of the patients was 33.7 ± 12.7 years (range, 20 to 50 years). All patients underwent reconstructions with free anterolateral thigh deep fascia flaps. Relevant clinical characteristics were recorded prior to surgery. The size and thickness of the deep fascia flap and the thickness of the skin were measured intraoperatively. The survival of the flaps and skin grafts and the occurrence of infection were recorded after the operation. At follow-up, donor site complications and postoperative effects were evaluated according to the outcome satisfaction scale. The pain in the injured hand was assessed using the visual analog scale. RESULTS The average body mass index (BMI) was 26.6 ± 1.7 kg/m2 (range, 23.9 to 28.7 kg/m2 ). The defect sizes ranged from 5 cm × 5 cm to 13 cm × 8 cm (average, 53.1 ± 27.9 cm2 ). The six anterolateral thigh deep fascia flaps ranged from 7 cm × 6 cm to 14 cm × 9 cm in size (average, 71.8 ± 29.1 cm2 ). The thicknesses of skin ranged from 25 mm to 40 mm (average, 32.5 ± 4.8 mm), and the thicknesses of the deep fascia flaps ranged from 2 mm to 3 mm (average, 2.5 ± 0.5 mm). After the operation, the blood supply of the deep fascia flap was normal in all cases. The second-stage skin grafts of most patients survived completely. The skin graft in one case was partially necrotic and healed after a dressing change. No infection occurred. At follow-up (average, 16.3 ± 6.9 months), there was only a linear scar and no loss of sensation at the donor site of each patient. According to the outcome satisfaction scale, the outcome satisfaction score ranged from 6 to 8 (average, 7.2 ± 0.9), all of which were satisfactory. Apart from one patient who reported mild pain, all the other patients reported no pain. Three typical cases are presented in this article. CONCLUSIONS The free anterolateral thigh deep fascia flap, which is suitable for reconstruction of soft tissue defects in the hand, can provide very good outcomes both functionally and aesthetically.
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Affiliation(s)
- Li Wang
- Department of Orthopedic Surgery, Hebei Medical University, Shijiazhuang, China.,Department of Hand Surgery, The Second Hospital of Tangshan, Tangshan, China
| | - Huiren Liu
- Department of Hand Surgery, The Second Hospital of Tangshan, Tangshan, China
| | - Tiepeng Ma
- Department of Hand Surgery, The Second Hospital of Tangshan, Tangshan, China
| | - Xueqiang Wu
- Department of Hand Surgery, The Second Hospital of Tangshan, Tangshan, China
| | - Liu Zhang
- Department of Orthopedic Surgery, Hebei Medical University, Shijiazhuang, China.,Department of Orthopedic Surgery, Emergency General Hospital, Beijing, China
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Stone MA, Carre A, Trasolini N, Minneti M, Omid R. Vascularized dermal autograft for the treatment of irreparable rotator cuff tears. J Shoulder Elbow Surg 2018; 27:1664-1671. [PMID: 29752152 DOI: 10.1016/j.jse.2018.02.069] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 02/27/2018] [Accepted: 02/28/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Irreparable rotator cuff tears (IRCTs) are a challenging problem with diverse treatment modalities. We propose a technique for the treatment of IRCTs in which a vascularized dermal autograft is transferred to the posterosuperior region of the rotator cuff using the supraclavicular artery (SCA) island flap. MATERIALS AND METHODS Dissection of 11 fresh cadavers (19 shoulders) was performed, and the SCA island flap was harvested in all specimens. A full-thickness posterosuperior rotator cuff defect was created, and the flap was tunneled under the acromion and secured into position over the defect using multiple suture anchors. Simulated flap perfusion was then assessed, and flap measurements were recorded. RESULTS There were 4 male and 7 female cadavers (19 shoulders). Flap perfusion was assessed in 10 shoulders. On average, the flap thickness was 4.7 mm (range, 3.5-7.1 mm); width, 32.6 mm (range, 25.5-38.0 mm); and length, 169.2 mm (range, 132.0-235.0 mm). The average distance from the flap tip to the Neviaser portal was 76.2 mm (range, 48.0-99.6 mm), and that from the flap tip to the anterolateral acromial edge was 54.1 mm (range, 29.5-75.1 mm). The pedicle-to-footprint distance was 113.7 mm (range, 88.5-147.0 mm). The average flap length exceeded the pedicle-to-footprint distance by 55.5 mm (range, 43.5-88.0 mm), indicating adequate excursion of the flap. All flaps demonstrated adequate simulated perfusion after fixation. CONCLUSION The SCA island flap may be an option for a vascularized dermal autograft for IRCTs, as shown in this cadaveric study. This illustrates a possible technique with vascular viability.
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Affiliation(s)
- Michael A Stone
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| | - Antoine Carre
- Department of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Nicholas Trasolini
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Michael Minneti
- Fresh Tissue Dissection Program, University of Southern California Surgical Skills Simulation & Education Center, Los Angeles, CA, USA
| | - Reza Omid
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Ioppolo L, Stagno d'Alcontres F, Colonna MR, Casoli V, Lupo F, Delia G. Anterolateral adipofascial turnover flap of the leg: Anatomical study. J Plast Reconstr Aesthet Surg 2015; 69:77-83. [PMID: 26559616 DOI: 10.1016/j.bjps.2015.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Accepted: 09/07/2015] [Indexed: 11/15/2022]
Abstract
AIM The aim of this study is to clearly define the vascularisation of the lateral paratibial septum of the leg, defining the basis for a vertical pedicled adipofascial flap harvested from the anterolateral aspect of the leg to cover pretibial soft tissue defects. MATERIALS AND METHODS Twelve cadaver legs (eight fixed with formalin and four fresh) were dissected. The vessels running into the lateral paratibial septum were identified. The number of vessels were noted and evaluated at the lateral border of the proximal, middle and distal thirds of the leg. In addition, an angiographic study was performed on two limbs to confirm the connection between tibialis anterior artery and the overlaying fascia through these septal vessels. RESULTS All the specimens had periosteo-septal vessels running in the lateral aspect of the tibia. The average number was 6.6. The distribution was constant in all the thirds of the leg. CONCLUSION These data are useful to propose the harvesting technique for adipofascial flap with vertical pedicle as a suitable reconstructive option to cover pretibial soft tissue defects.
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Affiliation(s)
- L Ioppolo
- Plastic Reconstructive and Aesthetic Surgery Unit, University of Messina, Policlinico 'G. Martino', Via Consolare Valeria 1, 98125 Messina, Italy
| | - F Stagno d'Alcontres
- Plastic Reconstructive and Aesthetic Surgery Unit, University of Messina, Policlinico 'G. Martino', Via Consolare Valeria 1, 98125 Messina, Italy
| | - M R Colonna
- Plastic Reconstructive and Aesthetic Surgery Unit, University of Messina, Policlinico 'G. Martino', Via Consolare Valeria 1, 98125 Messina, Italy
| | - V Casoli
- Plastic and Burn Unit Fx Michelet Centre, Bordeaux Segalen University, Bordeaux, France
| | - F Lupo
- Plastic Reconstructive and Aesthetic Surgery Unit, University of Messina, Policlinico 'G. Martino', Via Consolare Valeria 1, 98125 Messina, Italy
| | - G Delia
- Plastic Reconstructive and Aesthetic Surgery Unit, University of Messina, Policlinico 'G. Martino', Via Consolare Valeria 1, 98125 Messina, Italy.
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Panagakos P, McDonald P, Norem N, Shapiro H, Boc SF, Mitra A. De-epithelialized fasciocutaneous turnover flap for recurrent calcaneal wound with osteomyelitis. J Foot Ankle Surg 2013; 53:83-7. [PMID: 23910737 DOI: 10.1053/j.jfas.2013.03.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2011] [Indexed: 02/03/2023]
Abstract
Recurrent ulcerations of the foot and ankle almost always present a challenge to lower extremity surgeons. Recalcitrant heel ulcerations with osteomyelitis are especially difficult to treat because of the lack of soft tissue coverage. The turnover flap is a simple, fast, and effective treatment method for lower extremity wounds. It is a de-epithelialized fasciocutaneous flap harvested from the adjacent area of the wound. We believe it is an underused technique for advanced wound closure in the lower extremity. It offers several advantages compared with traditional, more difficult to perform, flaps. We have seen an excellent result 18 months after using the turnover flap in a patient with recurrent posterior heel ulceration with calcaneal osteomyelitis.
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Affiliation(s)
| | - Patrick McDonald
- Associate, Mountain Valley Orthopedics, PC, East Stroudsburg, PA
| | - Nathan Norem
- Chief Resident, Podiatric Medicine and Surgery, Hahnemann University Hospital, Philadelphia, PA
| | - Howard Shapiro
- Assistant Director, Podiatric Medicine and Surgery Residency, Hahnemann University Hospital, Philadelphia, PA
| | - Steven F Boc
- Director, Podiatric Medicine and Surgery Residency, Hahnemann University Hospital; Assistant Professor of Surgery, Drexel College of Medicine, Philadelphia, PA
| | - Amit Mitra
- Chief, Plastic Surgery Department, Hahnemann University Hospital, Philadelphia, PA
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Cadaveric study and clinical application of turnover fascial flap for lower-limb defects. EUROPEAN JOURNAL OF PLASTIC SURGERY 2011. [DOI: 10.1007/s00238-010-0540-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Improving the Reliability of the Distally Based Posterior Tibial Artery Adipofascial Flap With the Great Saphenous Venoneural Network. Ann Plast Surg 2011; 67:288-93. [DOI: 10.1097/sap.0b013e3182198bff] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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The ankle extensor-tendon-sheath flap – a versatile fascial flap for coverage of the tibia and pretibial area: A preliminary report. J Plast Reconstr Aesthet Surg 2011; 64:663-70. [DOI: 10.1016/j.bjps.2010.08.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2010] [Revised: 08/26/2010] [Accepted: 08/31/2010] [Indexed: 11/20/2022]
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V–Y gastrocnemius muscle slide with turnover fascial flap for compound Achilles defects: A simple solution. J Plast Reconstr Aesthet Surg 2010; 63:e406-10. [DOI: 10.1016/j.bjps.2009.09.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2009] [Revised: 09/11/2009] [Accepted: 09/20/2009] [Indexed: 10/20/2022]
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Anatomical study and colour Doppler assessment of the skin perforators of the anterior tibial artery and possible clinical applications. J Plast Reconstr Aesthet Surg 2008; 62:1524-9. [PMID: 18703389 DOI: 10.1016/j.bjps.2008.06.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2007] [Revised: 03/05/2008] [Accepted: 03/04/2008] [Indexed: 11/21/2022]
Abstract
BACKGROUND Traumatic or trophic defects of the soft tissue of the lower leg are quite often very difficult to manage, especially in the distal third of the leg. Fasciocutaneous flaps are a relatively simple option for covering small- and medium-sized defects of the lower leg. The aim of this study is to investigate the distribution of septocutaneous perforators of the anterior tibial artery and their possible clinical applications. METHODS An anatomical study was performed on 50 fresh adult cadaveric lower extremities. Using coloured contrast materials, the location of septocutaneous perforators, originating from the anterior tibial artery, were mapped. These findings were then compared with colour Doppler imaging (CDI) data in 20 living volunteers. RESULTS The septocutaneous perforators of the anterior tibial artery follow a reproducible pattern all over the lower leg (septa I, II and III). In the distal segment, we found relatively few perforators. There was a marginal difference between cadaveric and CDI data for perforators with diameter >or=1mm. The average number of anterior tibial artery septocutaneous perforators in anatomical dissections was 6.6+/-2.4, while CDI revealed 8.2+/-3.2 perforators in living volunteers (P=0.053). In five areas of the lower leg, there is a >50% chance that a septocutaneous perforator with diameter >or=1mm is coming off the anterior tibial artery. Anatomical dissections for a cutaneous territory 5 cm above the lateral maleollus, and 10 cm in width, revealed 6.1+/-2.2 septocutaneous perforators (range 4 to 12). CONCLUSIONS CDI, paired with knowledge of anatomical details, is a reliable tool for preoperative identification of septocutaneous perforators of 1mm or larger outer diameter, thus providing critical information for planning and harvesting safe fasciocutaneous flaps of the lower leg. Additionally, according to our anatomical study, a new transverse fasciocutaneous flap (Type B according to the Nahai-Mathes classification), located over the distal anterolateral third of the lower leg and based on perforators of the anterior tibial artery, may be successfully used for covering selected defects of the distal third of the lower leg.
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Abstract
BACKGROUND "Adipofascial turnover flap" is a well-known procedure, but it is generally not used for the surgical treatment of pilonidal sinus disease. The "lumbar adipofascial turnover flap" has been used in this study for the reconstruction of uncomplicated pilonidal sinus disease. METHODS Ten cases (8 male and 2 female patients) were operated on by this technique. The reconstruction was performed with the lumbar adipofascial turnover flap. The flap sizes ranged from 4 x 7 cm to 5 x 9 cm (mean, 4.5 x 8 cm), and they were elevated with length-to-base ratio below 2:1. The follow-up period was 14 to 26 months. RESULTS Postoperative magnetic resonance imaging, computed tomography scan, and power Doppler ultrasound examinations revealed viability of the flaps in all patients. There was no distortion of anatomic landmarks in any of the cases. The esthetic results were satisfying for all patients as well. There was no recurrence in any cases. CONCLUSIONS The hospital stay and mean time off work were shorter compared with other methods of reconstruction and there was no recurrence. We advocate that the lumbar adipofascial turnover flap is an excellent choice for reconstruction of cases with uncomplicated pilonidal sinus disease.
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Affiliation(s)
- Aydin Turan
- Plastic and Reconstructive Surgery Clinic, SSK Vakif Gureba Hospital, Istanbul, Turkey.
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Mitra A, Spears J, Newsome E, McCampbell B, Kiran R, Mitra A. Expanding the Scope of the Turnover Flap. Plast Reconstr Surg 2006; 118:125-33. [PMID: 16816684 DOI: 10.1097/01.prs.0000221225.13063.a7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Turnover flaps are often utilized as alternatives to more traditional flaps, especially in situations where traditional flap viability is limited. Most turnover flaps are currently used in the lower extremities. METHODS This study examined the senior author's use of the turnover flap in 103 cases between 1987 and 2004. Postoperative follow-up ranged from 3 months to 10 years, with an average follow-up of 9 months. RESULTS The majority (n = 90) of the cases involved the lower extremities and carried high success rates; there were 72 successful operations (complete graft take), 10 partial flap losses (partial graft take that could be treated postoperatively without surgery), and eight complete flap losses (no graft take and the necessity of additional surgery). Three of the partial flap losses and two of the complete flap losses involved patients with end-stage vascular disease. End-stage vascular disease cases represented 20.0 percent of the lower extremity cases and carried a significantly higher percentage of partial or complete flap loss (27.8 percent). These circumstances were examined in detail; the authors found that the turnover flap provided improved outcome to such end-stage patients who otherwise would have undergone amputation. In 13 cases, turnover flaps were utilized in nontraditional regions, such as the chest wall, abdominal wall, head and neck region, and upper extremities, with a high degree of success (zero partial or complete flap losses). These approaches are discussed in detail. The surgical approach is examined with recommendations regarding preferred wound size and type and overall flap design. CONCLUSIONS This study indicates that turnover flaps are effective and useful as an alternative and, in some cases, primary procedure. In addition, the results serve to expand the present scope of the turnover flap by examining nontraditional regions in which the flap was highly successful. The authors believe the turnover flap should be given higher priority as a reconstructive option, but more research is needed to explain the sources of blood supply in these flaps.
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Affiliation(s)
- Avir Mitra
- Department of Plastic and Reconstructive Surgery, Temple University School of Medicine, NJ, USA
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Tavares Filho JM, Cláudio-da-Silva CS, Souza FZD. Uso de expansores de tecidos nos membros inferiores. Rev Col Bras Cir 2005. [DOI: 10.1590/s0100-69912005000600002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJETIVO: A expansão tecidual é um fenômeno, que pode ser observado na gravidez e no crescimento de tumores. A expansão controlada, descrita pela primeira vez em 1957, foi aprimorada e desenvolvida em quase todas as regiões corpóreas, a partir da década de 80. A expansão tecidual, nos membros inferiores, tem se mostrado de difícil realização devido à pouca elasticidade da pele, principalmente no 1/3 inferior da perna e do pé. Ocorre ainda falta de anteparo rígido, circulação terminal, restrição das atividades físicas dos pacientes durante a fase de infiltração e maior índice de complicações, o que restringe suas indicações. O objetivo deste trabalho é descrever nossa experiência com a expansão tecidual nos membros inferiores. MÉTODO: Estudo de 24 procedimentos de expansão nos membros inferiores indicados no tratamento de hemangioma (4,2%), seqüela de poliomielite (8,3%), seqüela pósqueimadura (33,3%) e pós-trauma (54,2%). RESULTADOS: Das expansões realizadas, tivemos sucesso no resultado prévio planejado, em 19 casos (79,1%) e insucesso em quatro casos (16,7%), nos quais o resultado final foi parcial, e um caso (4,2%), com interrupção precoce da expansão, em que não se obteve qualquer resultado. CONCLUSÕES: A expansão nos membros inferiores é viável, com menor índice de complicações, desde que se faça uma seleção adequada dos pacientes e se adote uma sistematização para a colocação, período de infiltração e retirada do expansor.
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Igras E, Gahankari D, Yuen C, Fish M, Pegg S. Deep burn due to an unusual cause--boiling blood! Burns 2003; 29:287-90. [PMID: 12706625 DOI: 10.1016/s0305-4179(02)00308-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Emma Igras
- Royal Brisbane Hospital, Queensland, Brisbane, Australia
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Onishi K, Maruyama Y. Sacral adipofascial turn-over flap for the excisional defect of pilonidal sinus. Plast Reconstr Surg 2001; 108:2006-10. [PMID: 11743392 DOI: 10.1097/00006534-200112000-00026] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The aim of pilonidal sinus surgery includes complete resection of the lesion and filling of the resultant soft-tissue defect by some means; this has a major influence on whether a lesion will occur after surgical treatment. The creation of a sacral adipofascial turn-over flap for the excisional defect has been performed in seven cases of pilonidal sinus since November of 1992. During the postoperative follow-up period, which ranged from 10 months to 7 years 11 months (mean duration, 5 years 2 months), partial dehiscence of the wound as a result of fatlysis was observed and treated conservatively in one case; however, primary healing was obtained in the other cases. No recurrence was seen in any of the seven cases. This procedure is not indicated in patients in whom wide skin resection is required because of the excessive tension associated with skin closure in such cases. However, the method is convenient, less invasive, and reliable, and therefore considered to be useful in the treatment of pilonidal sinus.
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Affiliation(s)
- K Onishi
- Department of Plastic and Reconstructive Surgery, Toho University Hospital, Tokyo, Japan.
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McHenry TP, Early JS, Schacherer TG. Peroneus Brevis Rotation Flap: Anatomic Considerations and Clinical Experience. ACTA ACUST UNITED AC 2001; 50:922-6. [PMID: 11371853 DOI: 10.1097/00005373-200105000-00025] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Large soft tissue defects of the distal third of the leg are common occurrences at trauma centers. Massive defects often require vascularized free tissue transfer for coverage; however, smaller defects may frequently be closed by rotation of local tissue. The peroneus brevis muscle is ideally located to provide coverage of the exposed distal fibula. METHODS An anatomic dissection of the peroneus brevis muscle and its vascular pedicles was performed in 10 fresh cadaveric leg specimens. Patients who underwent this procedure at our institution were retrospectively reviewed. RESULTS Each dissected muscle had an average of 3.5 vascular pedicles (range, 2-6), which arose from the peroneal artery in all but two cases. The average distance of the distal pedicle from the tip of the lateral malleolus was 6.7 cm (range, 3.5-12.0 cm). The muscle belly ended an average of 6.0 mm proximal to the tip of the lateral malleolus. Half of the specimens had muscle bellies that extended to or past the tip of the lateral malleolus. This rotation flap has been successful in covering four wounds with exposed distal fibula in four patients. CONCLUSION The anatomic characteristics of the peroneus brevis muscle are ideal for soft tissue coverage of the distal fibula. Ease of elevation and reliability have made this rotational flap the procedure of choice for small soft tissue defects over the distal fibula at our institution.
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Affiliation(s)
- T P McHenry
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
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