1
|
Türker T, Hines E, Haddad D. Hemodynamics in Distally Based Sural Flaps for Lower Leg Reconstruction: A Literature Review. J Hand Microsurg 2023; 15:253-257. [PMID: 37701313 PMCID: PMC10495205 DOI: 10.1055/s-0042-1749445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Coverage of posttraumatic and chronic wounds at the distal leg is a difficult problem due to limited soft tissue available for local flaps. The sural flap is a versatile and effective method for reconstruction in this area since it does not need a significant amount of time or assistance to complete. Improving the survival of these flaps is critically dependent on understanding the basics of flap circulation and why recent modifications were introduced. This review will serve as a much-needed comprehensive analysis of these topics for surgeons looking to increase the reliability of their sural flaps.
Collapse
Affiliation(s)
- Tolga Türker
- Department of Orthopaedic Surgery, The University of Arizona-Banner University Medical Center Tucson, Tucson, Arizona, United States
| | - Eric Hines
- Department of Plastic and Aesthetic Surgery, University of California-Irvine School of Medicine, Irvine, California, United States
| | - David Haddad
- The University of Arizona College of Medicine-Tucson, Tucson, Arizona, United States
| |
Collapse
|
2
|
Yoshimatsu H, Karakawa R, Fuse Y, Yano T, Muro S, Akita K. The Use of the Deep Brachial Artery as the Recipient Artery for Free Perforator Flap Transfer: An Anatomic Study and Clinical Applications. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1087. [PMID: 37374291 DOI: 10.3390/medicina59061087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 05/30/2023] [Accepted: 06/02/2023] [Indexed: 06/29/2023]
Abstract
Background and Objectives: Soft tissue reconstruction after sarcoma ablation in the posterior aspect of the upper arm has been commonly addressed using the pedicled latissimus dorsi musculo-cutaneous flap. The use of a free flap for coverage of this region has not been reported in detail. The goal of this study was to characterize the anatomical configuration of the deep brachial artery in the posterior upper arm and assess its clinical utility as a recipient artery for free-flap transfers. Materials and Methods: In total, 18 upper arms from 9 cadavers were used for anatomical study to identify the deep brachial artery's origin and point of crossing the x-axis, which was set from the acromion to the medial epicondyle of the humerus. Measurements of the diameter were taken at each point. The anatomic findings of the deep brachial artery were employed clinically in the reconstruction of the posterior upper arm after sarcoma resection using free flaps in 6 patients. Results: The deep brachial artery was found in all specimens between the long head and the lateral head of the triceps brachii muscle, and it crossed the x-axis at an average distance of 13.2 ± 2.9 cm from the acromion, with an average diameter of 1.9 ± 0.49 mm. In all 6 clinical cases, the superficial circumflex iliac perforator flap was transferred to cover the defect. The average size of the recipient artery, the deep brachial artery, was 1.8 mm (range, from 1.2 to 2.0 mm). The average diameter of the pedicle artery, the superficial circumflex iliac artery, was 1.5 mm (range, from 1.2 to 1.8 mm). All flaps survived completely with no postoperative complications. Conclusions: The deep brachial artery can be a reliable recipient artery in free-flap transfers for posterior upper arm reconstruction, given its anatomical consistency and sufficient diameter.
Collapse
Affiliation(s)
- Hidehiko Yoshimatsu
- Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Department of Plastic and Reconstructive Surgery, 3-8-31 Ariake, Koto-ku, Tokyo 135-8550, Japan
- Department of Clinical Anatomy, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
| | - Ryo Karakawa
- Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Department of Plastic and Reconstructive Surgery, 3-8-31 Ariake, Koto-ku, Tokyo 135-8550, Japan
- Department of Clinical Anatomy, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
| | - Yuma Fuse
- Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Department of Plastic and Reconstructive Surgery, 3-8-31 Ariake, Koto-ku, Tokyo 135-8550, Japan
| | - Tomoyuki Yano
- Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Department of Plastic and Reconstructive Surgery, 3-8-31 Ariake, Koto-ku, Tokyo 135-8550, Japan
- Department of Clinical Anatomy, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
| | - Satoru Muro
- Department of Clinical Anatomy, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
| | - Keiichi Akita
- Department of Clinical Anatomy, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
| |
Collapse
|
3
|
Giunta G, Kapila A, Brussaard C, Nistor A, De Baerdemaeker R, Zeltzer A, Hamdi M. Redefining the vascular anatomy of the medial gastrocnemius muscle: A computed tomography angiography study. J Plast Reconstr Aesthet Surg 2023; 83:165-171. [PMID: 37276735 DOI: 10.1016/j.bjps.2023.04.074] [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: 12/27/2022] [Revised: 04/11/2023] [Accepted: 04/19/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND The medial gastrocnemius (GN) muscle flap is a historical reconstructive option in lower limb reconstruction. The flap is proximally based on the medial sural artery, and it is assumed not possible to harvest a distally based flap because of the absence of other minor pedicles. The aim of this study is to investigate the presence and the anatomy of a distal secondary pedicle given off by the posterior tibial artery (PTA). METHODS A retrospective CTA study was performed of 120 limbs between April 2018 and June 2020. 3D reconstruction was performed to delineate the anatomy of the distal secondary pedicle, if present. The distance of the pedicle, if found, from the intermalleolar line to the patella was noted. The number of pedicles, if multiple, was documented, as well as branches to the soleus muscle and the skin. RESULTS A distal pedicle to the gastrocnemius muscle was found in 64% of limbs. The average location from the intermalleolar line is 168 mm. The branching pattern from the PTA showed an isolated vessel going to the distal medial gastrocnemius (32.8%), two branches to the medial gastrocnemius and skin (39.3%), two branches to the medial gastrocnemius and soleus (24.6%), and three branches to the medial gastrocnemius, soleus, and the skin (3.3%). CONCLUSIONS This study confirms the presence of the secondary axial distal pedicle of the GN muscle. Furthermore, this study confirms that there is a likely association between the distal medial gastrocnemius pedicle and the PTA skin perforators.
Collapse
Affiliation(s)
- Gabriele Giunta
- Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospital (UZ) Brussels, Laarbeeklaan 101, 1090 Brussels, Belgium.
| | - Ayush Kapila
- Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospital (UZ) Brussels, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Carola Brussaard
- Department of Radiology, University Hospital (UZ) Brussels, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Alexandru Nistor
- Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospital (UZ) Brussels, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Randy De Baerdemaeker
- Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospital (UZ) Brussels, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Assaf Zeltzer
- Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospital (UZ) Brussels, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Moustapha Hamdi
- Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospital (UZ) Brussels, Laarbeeklaan 101, 1090 Brussels, Belgium
| |
Collapse
|
4
|
Shi Y, Xu Y, Fan X, Wang T, Su Y, Fang X, Yang X, Fu Q, Luo T, He X. Three-Dimensional Digitalized Virtual Planning of Free Anterior Tibial Artery Perforator Flap for Repairing Soft Tissue Defects in Extremities. World J Surg 2023; 47:1821-1827. [PMID: 37027024 DOI: 10.1007/s00268-023-06970-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND Traditional research methods have limited the application of anterior tibial artery perforator flap due to incomplete knowledge of the perforator. This study aimed to investigate the feasibility of three-dimensional digitalized virtual planning of free anterior tibial artery perforator flap for repairing soft tissue defects in extremities. METHODS A total of 11 patients with soft tissue defects in extremities were included. The patient underwent computed tomography angiography (CTA) of bilateral lower limbs, and then the three-dimensional models of bones, arteries, and skin were constructed. Septocutaneous perforators with appropriate length and diameter were selected to design anterior tibial artery perforator flaps in software, and the virtual flaps were superimposed onto the patient's donor site in a translucent state. During the operation, the flaps were dissected and anastomosed to the proximal blood vessel of the defects as designed. RESULTS Three-dimensional modeling showed clear anatomical relationships between bones, arteries, and skin. The origin, course, location, diameter, and length of the perforator obtained during the operation were consistent with those observed preoperatively. Eleven anterior tibial artery perforator flaps were successfully dissected and transplanted. Postoperative venous crisis occurred in one flap, partial epidermis necrosis occurred in another flap, while the remaining flaps completely survived. One flap was treated with debulking operation. The remaining flaps maintained aesthetic appearance, which did not affect the function of the affected limbs. CONCLUSIONS Three-dimensional digitalized technology can provide comprehensive information on anterior tibial artery perforators, thus assisting in planning and dissecting patient-specific flaps for repairing soft tissue defects in extremities.
Collapse
Affiliation(s)
- Yan Shi
- Department of Orthopedic Surgery, 920th Hospital of Joint Logistics Support Force of People's Liberation Army of China, 212 Daguan Road, Xishan District, Kunming, 650032, Yunnan, China
| | - Yongqing Xu
- Department of Orthopedic Surgery, 920th Hospital of Joint Logistics Support Force of People's Liberation Army of China, 212 Daguan Road, Xishan District, Kunming, 650032, Yunnan, China
| | - Xinyu Fan
- Department of Orthopedic Surgery, 920th Hospital of Joint Logistics Support Force of People's Liberation Army of China, 212 Daguan Road, Xishan District, Kunming, 650032, Yunnan, China
| | - Teng Wang
- Department of Orthopedic Surgery, 920th Hospital of Joint Logistics Support Force of People's Liberation Army of China, 212 Daguan Road, Xishan District, Kunming, 650032, Yunnan, China
| | - Yanting Su
- Department of Orthopedic Surgery, 920th Hospital of Joint Logistics Support Force of People's Liberation Army of China, 212 Daguan Road, Xishan District, Kunming, 650032, Yunnan, China
| | - Xiang Fang
- Department of Orthopedic Surgery, 920th Hospital of Joint Logistics Support Force of People's Liberation Army of China, 212 Daguan Road, Xishan District, Kunming, 650032, Yunnan, China
- Department of Clinical Medical College, Dali University, Dali, 671000, China
| | - Xi Yang
- Department of Orthopedic Surgery, 920th Hospital of Joint Logistics Support Force of People's Liberation Army of China, 212 Daguan Road, Xishan District, Kunming, 650032, Yunnan, China
| | - Qichen Fu
- Department of Orthopedic Surgery, 920th Hospital of Joint Logistics Support Force of People's Liberation Army of China, 212 Daguan Road, Xishan District, Kunming, 650032, Yunnan, China
| | - Tianxian Luo
- Department of Orthopedic Surgery, 920th Hospital of Joint Logistics Support Force of People's Liberation Army of China, 212 Daguan Road, Xishan District, Kunming, 650032, Yunnan, China
| | - Xiaoqing He
- Department of Orthopedic Surgery, 920th Hospital of Joint Logistics Support Force of People's Liberation Army of China, 212 Daguan Road, Xishan District, Kunming, 650032, Yunnan, China.
| |
Collapse
|
5
|
Lee CR, Kim SH, Kwon HJ, Ahn MY, Nam YS, Moon SH. Proximal peroneal perforator flap, cadaveric study, and clinical applications for shallow defect reconstructions. Microsurgery 2023. [PMID: 36756700 DOI: 10.1002/micr.31018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 12/02/2022] [Accepted: 01/19/2023] [Indexed: 02/10/2023]
Abstract
PURPOSE Peroneal artery perforator offers a versatile range of microvascular tissue transfer methods from local flaps to vascularized osteocutaneous fibula flaps. It is one of the few flaps that can cover shallow defects that require thin and pliable skin paddles, such as in hands and feet (Han et al., 2018). The proximal region of the lower leg offers such flexible and thin flap compared to the middle and distal lower leg (Winters & de Jongh, 1999). However, the anatomy of the proximal peroneal artery perforator is relatively unknown in literature and its proximity to the common peroneal nerve (CPN) has not yet been studied. This study conducted a cadaveric study and put it in application into clinical settings. METHODS Twenty lower leg specimens were dissected according to the methods of clinical proximal peroneal artery perforator flap harvest. Perforators arising in the proximal lower leg area of between 20 and 40 percentile of fibular length were inspected. Perforator length, location from fibular head, course, and location of CPN were recorded. Clinical reconstruction cases using the proximal lateral lower leg were analyzed. Six patients between the ages of thirty and seventy were included. Five cases were due to trauma, and one from mass excision, but all required thin and pliable flaps for reconstructions in hands or feet. Flaps were designed concentrical oval shapes, and harvest was done similarly to cadaveric perforator dissection, but perforator dissection was done only up to the required pedicle length. Perforator length, flap size, thickness, and long-term complications were recorded. RESULTS Among 20 specimens, a total of 20 perforators were found in 18 cadavers (90%). Two specimens showed no perforators while two specimens showed multiple perforators. The perforators were located at an average of 101 mm from fibular head, with an average length of 55 mm ranging from 20 to 153 mm. The average size of perforator at origin was 2.0 mm, ranging from 1.0 to 3.6 mm. 45% showed septocutaneous course and 55% intramuscular course. Two out of 20 perforators were shown to arise from source vessels other than the peroneal artery. All clinical cases were successful without complications or debulking for contour shaping. Flap sizes ranged from 15 to 40 cm2 . Largest flap width was 5 cm, and all donor sites were primarily closed without complications. One year of follow-up showed no complications. CONCLUSION Proximal peroneal artery perforator flap provides a reliable pedicle for a versatile tissue transfer. This study shows that the perforators of the proximal lateral lower leg often arise from vessels other than the peroneal artery, such as the anterior tibial artery or popliteal artery, as had been previously reported (Winters & de Jongh, 1999). Although the source vessel varies, perforator anatomy is at a safe distance from CPN. This variation of source vessels suggests a change in nomenclature to "proximal peroneal perforator flap." The clinical applications of this flap showed that it can be effectively used for reconstructions of shallow defects, such as in the hands and feet without secondary procedures for debulking.
Collapse
Affiliation(s)
- Chae Rim Lee
- Department of Plastic and Reconstructive Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sang Hyun Kim
- Catholic Institute for Applied Anatomy, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyo Jeong Kwon
- Department of Plastic and Reconstructive Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - Min Young Ahn
- Catholic Institute for Applied Anatomy, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yong Seok Nam
- Department of Anatomy, College of Korean Medicine, Dongshin University, Chonnam, Republic of Korea
| | - Suk-Ho Moon
- Department of Plastic and Reconstructive Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| |
Collapse
|
6
|
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.
Collapse
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
| |
Collapse
|
7
|
Ring A, Beutel H, Kirchhoff P, Bushart SU, Dellmann NC, Farzaliyev F. [Reconstruction of posttraumatic soft tissue defects of the ankle using free fascial flaps from the anterolateral thigh]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2023; 126:136-144. [PMID: 34686888 PMCID: PMC8533668 DOI: 10.1007/s00113-021-01100-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 09/29/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Free fascial flaps from the anterolateral thigh (ALT) were used to reconstruct soft tissue defects after trauma to the ankle. This modification was compared to the conventional fasciocutaneous method. MATERIAL AND METHODS The defect size, the thickness of the subcutaneous fat layer on the thigh and the extent of the soft tissue covering the ankle were determined retrospectively. The evaluations were compared between fascial (Fo) and fasciocutaneous flaps (Fc). The foot and ankle outcome score (FAOS) was used. Esthetic outcome surveys were carried out. RESULTS A total of 18 isolated fractures of the ankle were evaluated. In 94% of the cases a closed soft tissue damage predominated. After fracture fixation using a plate, soft tissue defects with a mean area of 40.4 ± 13.1 cm2 (28-76 cm2) developed. The thickness of the soft tissue covering over the affected malleoli increased significantly in both groups as a result of the flap surgery (4.5 ± 0.7 vs. 21.1 ± 6.4 mm, p < 0.05). A significant difference was found when comparing the body mass index (BMI) between the groups (Fc 26.3 ± 3.4 kg/m2 vs. Fo 30.1 ± 4.2 kg/m2, p < 0.05). For both groups there was a positive correlation (r = 0.843) between the BMI and the thickness of the epifascial fat layer of the thigh. The FOAS survey revealed 75.9 ± 28.9 and 47.9 ± 32.4 points, respectively, for "function in daily life" and "foot and ankle-related quality of life". The esthetic reconstruction result was rated as "acceptable" by 55% and as "good" by 45%. DISCUSSION The modified method of a free fascial flap from the ALT can be useful in situations where a bulky flap makes it difficult to fit it into the defect.
Collapse
Affiliation(s)
- Andrej Ring
- Klinik für Plastische Chirurgie, St. Rochus Hospital, Glückaufstraße 10, 44575, Castrop-Rauxel, Deutschland.
- Ruhr-Universität Bochum, Bochum, Deutschland.
| | - Hendrik Beutel
- Klinik für Plastische Chirurgie, St. Rochus Hospital, Glückaufstraße 10, 44575, Castrop-Rauxel, Deutschland
- Ruhr-Universität Bochum, Bochum, Deutschland
| | - Pascal Kirchhoff
- Klinik für Plastische Chirurgie, St. Rochus Hospital, Glückaufstraße 10, 44575, Castrop-Rauxel, Deutschland
| | - Sebastian Ulrich Bushart
- Klinik für Plastische Chirurgie, St. Rochus Hospital, Glückaufstraße 10, 44575, Castrop-Rauxel, Deutschland
| | - Niklas-Chris Dellmann
- Klinik für Plastische Chirurgie, St. Rochus Hospital, Glückaufstraße 10, 44575, Castrop-Rauxel, Deutschland
| | - Farhad Farzaliyev
- Klinik für Allgemein‑, Viszeral und Transplantationschirurgie, Universitätsklinikum Essen, Essen, Deutschland
| |
Collapse
|
8
|
Yoshimatsu H, Karakawa R, Scaglioni MF, Fuse Y, Yano T. Use of intraoperative indocyanine green angiography for detection and prediction of congestion in pedicled island flaps. Microsurgery 2023. [PMID: 36649266 DOI: 10.1002/micr.31009] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 10/16/2022] [Accepted: 12/30/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Pedicled island flaps, including pedicled propeller flaps and pedicled transposition flaps, are widely used especially for coverage of soft tissue defects in the extremities and the trunk. However, due to its mobility limitations, the inset of the pedicled flaps can be challenging at times, especially when rotation or pressure is applied to the pedicle. The aim of this report is to evaluate the feasibility of intraoperative indocyanine green (ICG) angiography for detection and prediction of intraoperative and postoperative flap congestion in pedicled island flaps. PATIENTS AND METHODS From June 2018 to November 2021, 26 consecutive patients who underwent immediate reconstruction using the pedicled island flap after sarcoma resection were enrolled. ICG angiography was performed after elevation of the flap, after temporary flap fixation, and after final flap inset. Sensitivity and specificity of the last ICG angiography were calculated. RESULTS In 22 cases where the last ICG angiography highlighting showed a satisfactory flap, the flap survived completely. In four cases where the flap was not highlighted by the final ICG angiography but did not show other clinical signs of congestion, all flaps underwent total loss due to congestion. The sensitivity and specificity of the final ICG angiography for predicting postoperative flap congestion were both 100%. CONCLUSION ICG angiography can accurately predict postoperative congestion of the pedicled island flap, with extremely high sensitivity and specificity. When the flap is insufficiently highlighted after final flap inset, other measures should be considered.
Collapse
Affiliation(s)
- Hidehiko Yoshimatsu
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Ryo Karakawa
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Mario F Scaglioni
- Department of Plastic and Reconstructive Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Yuma Fuse
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tomoyuki Yano
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| |
Collapse
|
9
|
Kaleem A, Patel N, Schubert E, Stanbouly D, Shanti R, Tursun R. Comparison of propeller flaps versus skin grafts for coverage of osteocutaneous fibula free flap donor site defects. Head Neck 2023; 45:135-146. [PMID: 36256590 DOI: 10.1002/hed.27217] [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: 02/05/2022] [Revised: 09/18/2022] [Accepted: 09/30/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Authors compare use of propeller flaps versus skin grafts in defect coverage after fibula flap harvest. MATERIALS AND METHODS Retrospective review of patients who received either PFPF or STSG. Primary predictor variable was technique, and secondary predictor variables were comorbidities. Primary outcome variable was flap/graft healing, and secondary outcome variables were cosmesis, adverse events, effect on activities of daily living (ADLs), pain, additional procedures, and cost. Statistical analysis performed via independent sample t tests, ANOVA, and χ2 tests. Logistic regression analysis was performed. RESULTS Study sample was 50 patients. PFPFs showed higher rates of success, while STSG showed increased complications and adverse events. Pain and ADLs significantly affected in STSG group. Cosmesis was better in the PFPF group, and overall cost was significantly higher in STSG group. CONCLUSION PFPFs show greater success rates, fewer complications, improved cosmesis, less pain, reduced cost compared to STSG for wound coverage after fibula flap harvest.
Collapse
Affiliation(s)
- Arshad Kaleem
- Head and Neck Surgical Oncology & Microvascular Reconstructive Surgery, High Desert Oral and Facial Surgery, El Paso, Texas, USA
| | - Neel Patel
- Head and Neck Oncology & Reconstructive Surgery, HCA Florida, Miami, Florida, USA
| | - Enrique Schubert
- Head and Neck Surgical Oncology & Microvascular Reconstructive Surgery, High Desert Oral and Facial Surgery, El Paso, Texas, USA
| | - Dani Stanbouly
- College of Dental Medicine, Columbia University, New York, New York, USA
| | - Rabie Shanti
- Oral and Maxillofacial Surgery, Head and Neck Oncology & Microvascular Surgery, Rutgers University, New Brunswick, New Jersey, USA
| | - Ramzey Tursun
- Oral and Maxillofacial Surgery, Head and Neck Oncology & Microvascular Surgery, Security Forces Hospital, Riyadh, Saudi Arabia
| |
Collapse
|
10
|
House AE, Romano MF, Orczykowski ME, Zumwalt A, Devaiah AK. Multimodal Microvascular Mapping for Head and Neck, Skull Base Research and Education: An Anatomical Donor Study. Skull Base Surg 2022; 83:435-442. [DOI: 10.1055/s-0041-1725026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 01/13/2021] [Indexed: 10/22/2022]
Abstract
Abstract
Objective This study was aimed to develop a method combining computed tomography (CT) and fluorescence imaging, allowing identification of microvasculature in anatomical donors and facilitating translational research and education.
Methods We investigated homogeneity and radiopacity of 30 different mixtures including radiopaque substances povidone–iodine (Betadine), barium sulfate (BaSO4), and bismuth subsalicylate (Pepto-Bismol) varying in suspension and dilution with agar, latex, or gelatin. Three candidate mixtures were selected for testing the extent of perfusion in renal vasculature to establish methodology. From these candidate mixtures, two were selected for mixture with fluorescein and infusion into cadavers based on their ability to perfuse renal vasculature. The extent to which these two candidate mixtures combined with fluorescein were able to perfuse vasculature in a cadaver head was used to determine which mixture was superior.
Results BaSO4 and bismuth subsalicylate–based mixtures demonstrated superior opacity in vials. In terms of solidifying agents, gelatin-based mixtures demonstrated increased friability and lower melting points compared with the other agents, so only latex and agar-based mixtures were used moving forward past the vial stage. Combinations of BaSO4 and latex and BaSO4 and 3% agar were found to perfuse kidneys superiorly to the mixture containing bismuth subsalicylate. Finally, in cadaver heads, the mixture containing BaSO4, agar, and fluorescein was found to perfuse the smallest vasculature.
Conclusion A final combination of BaSO4, 3% agar, and fluorescein proves to be a powerful and novel combination enabling CT imaging, fluorescence imaging, and dissection of vasculature. This paves the way for future translational research and education.
Collapse
Affiliation(s)
- Adrian E. House
- Department of Otolaryngology—Head and Neck Surgery, University of California San Francisco, San Francisco, California, United States
- Department of Anatomy and Neurobiology, Boston University School of Medicine, Boston, Massachusetts, United States
| | - Michael F. Romano
- Department of Anatomy and Neurobiology, Boston University School of Medicine, Boston, Massachusetts, United States
| | - Mary E. Orczykowski
- Department of Anatomy and Neurobiology, Boston University School of Medicine, Boston, Massachusetts, United States
- Division of Anatomical Sciences, University of Michigan Medical School, Ann Arbor, Michigan, United States
| | - Ann Zumwalt
- Department of Anatomy and Neurobiology, Boston University School of Medicine, Boston, Massachusetts, United States
| | - Anand K. Devaiah
- Department of Otolaryngology, Neurological Surgery, and Ophthalmology, Boston University School of Medicine,, Boston, Massachusetts, United States
- Institute for Health System Innovation and Policy, Boston University, Boston, Massachusetts, United States
| |
Collapse
|
11
|
Mansour AM, Jacobs A, Raj MS, Lee FG, Terrasse W, Wallace SJ, Miller NF. Lower Extremity Soft Tissue Reconstruction Review Article. Orthop Clin North Am 2022; 53:287-296. [PMID: 35725037 DOI: 10.1016/j.ocl.2022.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Reconstruction plays a valuable role in the management of lower extremity wounds for limb salvage. The goals of reconstruction are to improve function and quality of life, return to work, and pain reduction while providing a long-lasting durable reconstruction. The plastics and reconstructive surgical approach in conjunction with the orthopedic or trauma team, referred often as the "orthoplastic" approach, can yield the best outcomes for patients. The following sections discuss reconstruction principles and techniques that can be applied broadly for lower extremity wounds secondary to trauma, infection, and tumor resection.
Collapse
Affiliation(s)
- Ahmed M Mansour
- Division of Plastic and Reconstructive Surgery, Lehigh Valley Health Network, 1250 South Cedar Crest Boulevard, Allentown, PA 18103, USA.
| | - Aaron Jacobs
- Division of Plastic and Reconstructive Surgery, Lehigh Valley Health Network, 1250 South Cedar Crest Boulevard, Allentown, PA 18103, USA
| | - Mamtha S Raj
- Division of Plastic and Reconstructive Surgery, Lehigh Valley Health Network, 1250 South Cedar Crest Boulevard, Allentown, PA 18103, USA
| | - Frank G Lee
- University of South Florida Morsani College of Medicine, 2049 Street Wood Street, Allentown, PA 18103, USA
| | - Weston Terrasse
- Division of Plastic and Reconstructive Surgery, Lehigh Valley Health Network, 1250 South Cedar Crest Boulevard, Allentown, PA 18103, USA
| | - Sean J Wallace
- Division of Plastic and Reconstructive Surgery, Lehigh Valley Health Network, 3701 Corriere Road, Suite 15, Easton, PA 18045, USA
| | - Nathan F Miller
- Division of Plastic and Reconstructive Surgery, Lehigh Valley Health Network, 1250 South Cedar Crest Boulevard, Allentown, PA 18103, USA
| |
Collapse
|
12
|
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.
Collapse
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
| |
Collapse
|
13
|
Gupta S, Gupta P, Khichar P, Mohammad A, Escandón JM, Kalra S. Perforator propeller flaps for lower extremity soft-tissue defect reconstruction: Shortening the learning curve. J Clin Orthop Trauma 2022; 27:101831. [PMID: 35296056 PMCID: PMC8919289 DOI: 10.1016/j.jcot.2022.101831] [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: 12/01/2021] [Revised: 03/05/2022] [Accepted: 03/08/2022] [Indexed: 11/24/2022] Open
Abstract
Background The perforator propeller flap is an advantageous option for soft tissue reconstruction in the lower limb as it ensures the preservation of the main artery and muscle, eliminates the need for microsurgical reconstruction as well as provides "like with like" resurfacing of the defects. Despite this, it remains a technically demanding reconstructive option for residents and surgeons with little experience in perforator dissection. We aimed to evaluate the clinical outcomes of our patients whose soft tissue defects were addressed with propeller flaps. Methods A retrospective study of all propeller flap based reconstruction done on patients with soft tissue defects involving the distal third of the leg was undertaken from August 2018 to December 2020. Results 28 patients were treated with propeller flaps for various lower extremity defects. The median defect size was 12 cm2. The posterior tibial artery (PTA) was used in eleven cases (39.3%) and the peroneal artery (PA) in seventeen of the cases (60.7%). The complication rate was 28.6% (n = 8). The complete flap necrosis rate was 10.7% (n = 3) and partial flap necrosis rate was 7.1% (n = 2), The rate of venous congestion was 7.1% (n = 2) and wound dehiscence occurred in 3.5% (n = 1). There was a significant negative correlation between the number of cases performed by a resident and the operative time. Conclusion Although propeller flaps are a reliable option to address lower extremity defects, they have a long learning curve and require a good amount of experience and perforator dissection skills to reduce the probability of flap failure. We are of the opinion that residents should be adequately trained in this procedure to ensure optimal outcome delivery.
Collapse
Affiliation(s)
- Samarth Gupta
- Department of Plastic, Reconstructive and Burns Surgery, SMS Hospital Jaipur, Rajasthan, India
| | - Pradeep Gupta
- Department of Plastic, Reconstructive and Burns Surgery, SMS Hospital Jaipur, Rajasthan, India
| | - Pemaram Khichar
- Department of Plastic, Reconstructive and Burns Surgery, SMS Hospital Jaipur, Rajasthan, India
| | - Arbab Mohammad
- Aarupadai Veedu Medical College and Hospital, Puducherry, India
| | - Joseph M Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Sushrut Kalra
- Department of Plastic, Reconstructive and Burns Surgery, SMS Hospital Jaipur, Rajasthan, India
| |
Collapse
|
14
|
Perforator-based Adipofascial Flaps and ADM: A Novel Combined Approach to Distal Lower Extremity Defects. Plast Reconstr Surg Glob Open 2022; 10:e4131. [PMID: 35198355 PMCID: PMC8856593 DOI: 10.1097/gox.0000000000004131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 12/14/2021] [Indexed: 11/25/2022]
Abstract
Due to the wide spectrum of lower extremity defect presentation, various reconstructive techniques are available. Classic adipofascial flaps are still a second choice. The authors described a new multistage reconstructive approach with perforator-based pedicled adipofascial flap.
Collapse
|
15
|
Yildirim T, Unsal SS, Armangil M. Propeller flap: Orthoplastic approach for coverage of distal leg and ankle defects. Foot Ankle Surg 2021; 27:874-878. [PMID: 33339714 DOI: 10.1016/j.fas.2020.11.009] [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: 09/08/2020] [Revised: 11/04/2020] [Accepted: 11/27/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Covering soft tissue defects of the distal one-third of the leg and the Achilles tendon region and is a challenging problem for an orthopedic surgeon. With recent advancements in the anatomical knowledge of perforating vessels, perforator-pedicled propeller flaps have become increasingly popular in recent decades. We aimed to evaluate the clinical outcomes of our patients whose soft tissue defects in the distal leg were reconstructed with propeller flaps and assessed association of complications with age, gender, flap size and arc of rotation. METHODS Patients that had a reconstruction with a propeller flap at the ankle from 2013 to 2019 were retrospectively reviewed. The main indications for the propeller flap were small- and medium-sized soft tissue defects of the distal lower limb. 20 propeller flaps were applied to 19 patients (14 male, 5 female) for various lower extremity defects. RESULTS The mean follow-up duration was 2 years (range, 6 months to 6 years). The average flap size was 82 cm2 (range, 48-125 cm2). The flap was rotated 180 degrees in nine patients The source of the perforator vessel was the tibialis posterior artery in 14 cases, the peroneal artery in 4 cases, both the tibialis posterior and peroneal arteries in 1 case. Four complications (20 %) occured postoperatively. Two patients developed partial necrosis at the tip of the flap, and two patients developed superficial epidermolysis. No correlations were found between complications and flap size and the arc of rotation. CONCLUSIONS The propeller flap is a reliable option for reconstruction of small to moderate defects in the lower extremity with good clinical results and minimal donor-site morbidity. It is applicable for orthopedic surgeons who do not have microsurgical experience or an available microscope in the operating room.
Collapse
Affiliation(s)
- Tugrul Yildirim
- Ankara University Faculty of Medicine, Department of Orthopaedics and Traumatology, Department of Hand Surgery, Talatpasa Blv No:82 Altindag, Ankara, Turkey.
| | - Seyyid Serif Unsal
- Ankara University Faculty of Medicine, Department of Orthopaedics and Traumatology, Department of Hand Surgery, Talatpasa Blv No:82 Altindag, Ankara, Turkey
| | - Mehmet Armangil
- Ankara University Faculty of Medicine, Department of Orthopaedics and Traumatology, Department of Hand Surgery, Talatpasa Blv No:82 Altindag, Ankara, Turkey
| |
Collapse
|
16
|
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.
Collapse
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
| |
Collapse
|
17
|
Dimovska EOF, Yang C, Hung SY. Beware of the musculocutaneous peroneal artery perforator through peroneus longus in osteocutaneous free fibula flap harvests. Microsurgery 2021; 41:820-821. [PMID: 34622983 DOI: 10.1002/micr.30822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/14/2021] [Accepted: 09/17/2021] [Indexed: 11/12/2022]
Affiliation(s)
- Eleonora O F Dimovska
- Department of Plastic & Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden.,Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital & Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Cristhiam Yang
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital & Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Shao-Yu Hung
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital & Chang Gung University College of Medicine, Taoyuan, Taiwan
| |
Collapse
|
18
|
Athanaselis ED, Fyllos A, Zibis AH, Karachalios T, Hantes M, Dailiana Z, Malizos K, Varitimidis S. A Single-Center Surgical Experience With the Reverse Sural Artery Flap as a Reliable Solution for Lower Leg Soft Tissue Defects, With Minimum Two-Year Follow-Up. Cureus 2021; 13:e16574. [PMID: 34434674 PMCID: PMC8380273 DOI: 10.7759/cureus.16574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2021] [Indexed: 11/05/2022] Open
Abstract
AIM Small soft tissue defects of the distal tibia and hindfoot resulting from traumatic, operative, or neoplastic conditions and chronic ulcers can be successfully dealt with the use of the reverse sural artery flap (RSAF). This study aims to describe a single center's results and familiarity with this technique over a 15-year period of time. MATERIAL AND METHODS We retrospectively reviewed the clinical files of patients who were consecutively treated with RSAF and regularly followed up between January 1, 2004 and December 31, 2018, with a minimum postoperative follow-up period of two years. Patient demographics and comorbidities, location of the defect, performing surgeon, mean operation time, flap pedicle width, mean size of the defect, days of hospitalization following the operation, healing flap rate, and complications were recorded. RESULTS The sample consisted of 30 adult patients (25 men, 5 women), with a mean age of 51.07 years (16-80 years, SD 18.61). The mean operation time was 99.03 min (range 83-131, SD 10.57), and the mean size of the defect was 11.11 cm2 (range 6.1-19.4, SD 3.22). Successful flap rate (complete healing and coverage of the defect, with or without additional minor intervention) was 83.3% (25/30). Among successfully healed flaps, six patients with partial necrosis of the dermis were treated by an additional split-thickness skin graft. Five flaps failed to heal. Deep infection was present in two patients, leading to flap failure and reoperation. Serious venous congestion resulting in flap ischemia occurred in three cases. Circumferential keloid formation (not affecting successful outcome) was present in seven cases. Flap thickness approximated to normal within six months. All donor sites healed well (either by a split-thickness cutaneous flap or by immediate wound closure). Light paresthesia on the lateral border of the leg and foot disappeared within six months. CONCLUSIONS A single-center experience with the RSAF has yielded satisfactory clinical outcomes, and the long-term tackle with the difficult reconstruction conditions around the ankle, has led to valuable advice on surgical technique and postoperative protocol, based on an anatomical basis.
Collapse
Affiliation(s)
| | - Apostolos Fyllos
- Orthopaedics and Musculoskeletal Trauma, University Hospital of Larissa, Larissa, GRC
| | - Aristeidis H Zibis
- Anatomy, School of Health Sciences, University of Thessaly, Larissa, GRC
| | - Theofilos Karachalios
- Orthopaedics and Musculoskeletal Trauma, University Hospital of Larissa, Larissa, GRC
| | - Michael Hantes
- Orthopaedics and Musculoskeletal Trauma, University Hospital of Larissa, Larissa, GRC
| | - Zoe Dailiana
- Orthopaedics and Musculoskeletal Trauma, University Hospital of Larissa, Larissa, GRC
| | - Konstantinos Malizos
- Orthopedics and Musculoskeletal Trauma, University Hospital of Larissa, Larissa, GRC
| | - Sokratis Varitimidis
- Orthopaedics and Musculoskeletal Trauma, University Hospital of Larissa, Larissa, GRC
| |
Collapse
|
19
|
Reconstruction of soft tissue defects around the Achilles region with distally based extended peroneal artery perforator flap. Injury 2021; 52:1985-1992. [PMID: 33910686 DOI: 10.1016/j.injury.2021.04.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Revised: 03/18/2021] [Accepted: 04/05/2021] [Indexed: 02/02/2023]
Abstract
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.
Collapse
|
20
|
Zang M, Zhu S, Chen B, Li S, Han T, Liu Y. Perforator Propeller Flap "Relay" for Distal Lower Extremity Soft Tissue Reconstruction. J Foot Ankle Surg 2021; 59:1128-1132. [PMID: 32703651 DOI: 10.1053/j.jfas.2020.05.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/15/2020] [Accepted: 05/16/2020] [Indexed: 02/03/2023]
Abstract
The peroneal artery perforator propeller flap is commonly used for distal lower extremity reconstruction; however, closure of the donor site defect can limit the utility of this flap. To overcome this limitation, we introduced a perforator propeller flap relay technique to reconstruct the donor-site defect. Between July 2015 and February 2019, the propeller flap relay technique was applied in 9 patients. In each case, a peroneal artery perforator propeller flap was transferred to repair a defect in the distal lower leg or the foot. In addition, a neighboring perforator propeller flap was transferred to close the donor-site defect. The peroneal artery perforator propeller flaps ranged from 14 × 4 to 29 × 8 cm2 in size. Donor-site closure was accomplished using the relaying propeller flaps based on perforators from the peroneal, medial sural, and lateral sural arteries. Normal contour of the lower leg was preserved with acceptable scars. Additional time for the second flap procedure was less than 1 hour in each case. One peroneal artery perforator flap presented with partial flap necrosis. Other flaps survived completely without complication. Coverage of the donor-site defects of the peroneal artery perforator flaps can be achieved using various perforator propeller flaps. The perforator propeller flap relay technique allows surgeons to harvest a large peroneal artery perforator flap without being limited by significant donor-site morbidity. This technique can reconstruct defects at distal lower extremity with low morbidity and improved overall reconstructive results.
Collapse
Affiliation(s)
- Mengqing Zang
- Associate Professor, 11th Department, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Shan Zhu
- Associate Professor, 11th Department, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Bo Chen
- Attending Surgeon, 11th Department, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Shanshan Li
- Attending Surgeon, 11th Department, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Tinglu Han
- Resident, 11th Department, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yuanbo Liu
- Professor, 11th Department, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Beijing, China.
| |
Collapse
|
21
|
Abstract
Propeller flaps represent an outstanding alternative to conventional pedicled and free flap options in lower extremity reconstruction, offering significant advantages over the latter. An understanding of the perforasome concept, hot and cold perforator locations, and basic flap design enable the surgeon to readily harvest flaps based on any clinically relevant perforator in freestyle fashion. The purpose of this article is to review fundamentals of propeller flap design and harvest in the lower extremity and discuss reconstructive strategies by level of injury.
Collapse
Affiliation(s)
- Jordan T Blough
- Division of Plastic Surgery, Baylor Scott & White Health, Scott & White Memorial Hospital, 2401 South 31st Street, Temple, TX 76508, USA
| | - Michel H Saint-Cyr
- Division of Plastic Surgery, Baylor Scott & White Health, 2401 South 31st Street, Temple, TX 76508, USA.
| |
Collapse
|
22
|
Distally Based Sural Adipofascial Turnover Flap for Coverage of Complicated Wound in the Foot and Ankle Region. Ann Plast Surg 2021; 84:580-587. [PMID: 31663937 DOI: 10.1097/sap.0000000000002069] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUNDS Distally based perforator propeller flap from the lower leg region is a versatile local reconstructive technique for the foot and ankle defects. However, flap venous congestion remains a tough nut to crack. We hypothesize that raising an adipofascial flap with turnover mode of transposition can improve venous drainage and enhance flap safety. METHODS Based on the 2 rows of septocutaneous perforators in the posterior distal third of the lower leg, distally based adipofascial flap was raised from medial sural region nourished by 1 perforator bundle from the posterior tibial artery or from the lateral sural region from the peroneal artery. The superficial dissection was performed in subdermal plane and deep in to the subfascial space. The flap was nourished by perforator-plus-adipofascial pedicle and turned over 180 degrees upside down to reach the distal wounds. One week later, a split-skin graft was used to cover the exposed fascial flap. Postoperatively, flap survival, complications, and patient functional recovery were evaluated. RESULTS Distally based sural turnover adipofascial flaps were used in 12 cases with complicated wounds of the distal third lower leg, foot, and ankle region. All wounds were caused by trauma and experienced fracture implants fixation and 5 with osteomyelitis. The comorbidities include diabetes in 9 cases and smoking in 7. There were 8 medial ural flaps and 4 lateral sural flaps. The adipofiscial flaps measured from 6.0 cm × 5.0 cm to 17.0 cm × 6.0 cm (mean, 61.3 cm). Postoperatively, all flaps survived uneventfully without any complication such as flap ischemia and/or necrosis. Two minor donor site complications were encountered, one was postoperative hematoma, and another was hyperproliferative scar. After a mean of 14.6 months of follow-up, the adipofascial flap plus skin graft showed a durable esthetic coverage, with normal shoe wearing and walking. CONCLUSIONS Distally based sural adipofascial turnover flap is a simple and reliable wound coverage technique. It avoids venous congestion as usually seen in distally based fasciocutaneous flaps.
Collapse
|
23
|
Abstract
SUMMARY Wounds have been one of the most prominent pathologies since the beginning of humanity. For the last 5 decades, a drastic improvement of healing has been observed, thanks to new medical devices based on fluid aspiration capacities and the development of negative pressure wound therapy. Negative-pressure wound therapy was initially designed for a double action, fluid aspiration and mechanical stimulation of wound edges by a foam. Successive technical evolutions of negative pressure wound therapy were declined since 1997 when Argenta and Morykwas first presented their solution. The adjunct of instillation in 2009 was considered as the first interactive dressing, allowing topical wound solutions to sequentially reach the wound, in alternance with negative pressure. Other devices based on the same principle were designed to prevent postoperative infections when placed over a suture after surgery. This long evolution could enhance the armamentarium of possible solutions, considerably reducing the wound healing time.
Collapse
|
24
|
Shih YJ, Wang YC, Lin CT, Chang SC, Tzeng YS, Dai NT, Chen TM, Wang CH, Chen SG. Clinical Application of the Peroneal Artery Perforator Flap for Reconstruction of Lateral Malleolus Defects. INT J LOW EXTR WOUND 2021; 22:378-384. [PMID: 33949231 DOI: 10.1177/15347346211015828] [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] [Indexed: 11/15/2022]
Abstract
The reconstruction of defects of the lateral malleolus involving the exposed fibular bone or tendon is challenging. This study aimed to evaluate the clinical application of the peroneal artery perforator flap with or without split-thickness skin grafting for soft tissue reconstruction of the bony defect of the lateral malleolus of the ankle joints. Reconstruction using a peroneal artery perforator flap with or without split-thickness skin grafting was performed for 15 patients (10 men, 5 women) between January 2007 and December 2018. The mean age was 53.7 years, and the mean size of the flaps was 40 cm2. The flaps were elevated in the form of a perforator flap, and split-thickness skin grafting was performed over the flaps and adjoining raw areas. The flaps survived in all cases; however, partial necrosis was observed in 3 cases. In cases of small-sized defects of the lateral malleolus of the ankle joints where a flap is required for the exposed bone or tendon, reconstruction using the peroneal artery perforator flap is advantageous, since the morbidity rate of the donor site is low and soft tissue is reconstructed.
Collapse
Affiliation(s)
- Yu-Jen Shih
- Division of Plastic Surgery, Department of Surgery, 63452Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan (R.O.C.)
| | - Yen-Chun Wang
- Division of Plastic Surgery, Department of Surgery, 63452Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan (R.O.C.)
| | - Chin-Ta Lin
- Division of Plastic Surgery, Department of Surgery, 63452Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan (R.O.C.)
| | - Shun-Cheng Chang
- Division of Plastic Surgery, Department of Surgery, 63452Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan (R.O.C.)
| | - Yuan-Sheng Tzeng
- Division of Plastic Surgery, Department of Surgery, 63452Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan (R.O.C.)
| | - Niann-Tzyy Dai
- Division of Plastic Surgery, Department of Surgery, 63452Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan (R.O.C.)
| | - Tim-Mo Chen
- Division of Plastic Surgery, Department of Surgery, 63452Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan (R.O.C.)
| | - Chih-Hsin Wang
- Division of Plastic Surgery, Department of Surgery, 63452Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan (R.O.C.)
| | - Shyi-Gen Chen
- Division of Plastic Surgery, Department of Surgery, 63452Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan (R.O.C.)
| |
Collapse
|
25
|
Abdelmegeed AG, Abulezz TA, Abo-Saeda MAA, Allam KA. Perforator-Based Pedicled Cross-Leg Flaps in Pediatric Patients: A New Idea to Increase Flap Reach. Ann Plast Surg 2021; 86:568-572. [PMID: 32826434 DOI: 10.1097/sap.0000000000002523] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Distal lower limb reconstruction is one of the most difficult and challenging tasks in plastic surgery. Despite the continuous advances in microsurgical techniques, pedicled cross-leg flaps still have a major role particularly in pediatric patients. Many techniques have been described to maximize the potential of the cross-leg flaps. The introduction of fasciocutaneous flaps has provided more potentials and made lower leg reconstruction easier and more successful. The description of perforator system in the leg has also made a revolution in the regional reconstruction. In this report, we present a new modification that increases the reach and facilitates the inset of the flaps. METHODS The flap is taken from the posteromedial skin of the middle third of the leg. The design is determined by the location, size, and shape of the defect. The base of the flap should contain at least 2 perforators located by Doppler device. After elevation of the fasciocutaneous flap, 2 back cuts are performed in the upper and lower edge of the flap base preserving the 2 previously located perforators. RESULTS Fifty patients, 32 males and 18 females, were reviewed and presented. Age of the patients ranged from 4 to 13 years and the defect size ranged from 20 to 130 cm. All flaps survived with 3 flaps had mild marginal ischemia, 2 flaps had mild infection, and 1 flap had partial dehiscence. CONCLUSIONS Back cuts made at the edges of the base of a cross-leg flap, preserving the feeding perforators, can increase the flap reach without jeopardizing its viability. It is also an easy to do technique and does not require any extra equipment or time.
Collapse
|
26
|
Comparative analysis of propeller flaps vs. modified perforator-based flaps in foot and ankle reconstruction. EUROPEAN JOURNAL OF PLASTIC SURGERY 2021. [DOI: 10.1007/s00238-020-01722-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
27
|
Zhou LL, Wei JW, Peng P, Liu LH, Yin CD, Luo ZB, Tao SB, Dong ZG. 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. J Reconstr Microsurg 2021; 37:580-588. [PMID: 33592636 DOI: 10.1055/s-0041-1723817] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND This study is to describe the distribution of natural true anastomoses associated with the distally based perforator-plus sural neurocutaneous flap (sural flap), summarize our experience in the flap with high pivot point, and compare the outcomes between the flaps with high and low pivot points. METHODS Five amputated lower limbs were perfused, and the integuments were radiographed. We retrospectively analyzed 378 flaps, which were divided into two groups: pivot points located ≤8.0 cm (low pivot point group) and >8.0 cm (high pivot point group) proximal to the tip of the lateral malleolus. Partial necrosis rates were compared between two groups. RESULTS The arterial chain surrounding the sural nerve was linked by true anastomoses from the intermalleolar line to popliteal crease. True anastomoses existed among peroneal perforators and between these perforators and the arterial chain. There were 93 flaps with high pivot point and 285 flaps with low pivot point. Partial necrosis rates were 16 and 9.1% in the high and low pivot point group (p = 0.059), respectively. CONCLUSION True anastomosis connections among peroneal perforators and the whole arterial chain around sural nerve enable the sural flap to survive with a greater length. The sural flap with high pivot point is a good option for reconstructing soft-tissue defects in the middle and distal leg, ankle, and foot, particularly when the lowest peroneal perforator presents damage, greater distance to the defects, discontinuity with the donor site, or anatomical variation.
Collapse
Affiliation(s)
- Ling-Li Zhou
- Department of Orthopedics, the Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Jian-Wei Wei
- Department of Orthopedics, the Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Ping Peng
- Department of Orthopedics, the Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Li-Hong Liu
- Department of Orthopedics, the Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Chao-Dong Yin
- Department of Orthopedics, the Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Zhao-Biao Luo
- Department of Orthopedics, the Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Shi-Bin Tao
- Department of Orthopedics, the Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Zhong-Gen Dong
- Department of Orthopedics, the Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| |
Collapse
|
28
|
Lin J, Zhou F, Sun YD, Gao YS, Li HZ, Zheng HP, Zhang YF, Li QF, Ward PJ, Yang YL, Liu CY. Modified Anterior Tibial Artery Perforator-Pedicled Propeller Flap for Soft-Tissue Coverage of the Ankle and Heel. World J Surg 2021; 44:2237-2242. [PMID: 32123981 DOI: 10.1007/s00268-020-05452-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND The ankle and heel are challenging regions to reconstruct functionally. Here, we explored the feasibility and clinical outcomes of a modified anterior tibial artery perforator-pedicled propeller flap for the repair of soft-tissue defects of the ankle and heel. PATIENTS AND METHODS Between January 2013 and December 2015, 12 patients with soft-tissue defects of the ankle and/or heel underwent reconstructive surgery that included our flap technique. The flaps measured 20 × 8 cm to 7 × 4 cm. A hand-held Doppler was used to identify a proper constant perforator in the distal ankle. In each case, the base of the flap was well preserved. The flap was transposed (180° rotation) to reach and cover the defect. RESULTS The average follow-up time was 13 months (10-28 months). We observed good texture matches and contour in all of the flaps. All patients could walk and wear normal footwear. All but one flap survived completely without complications. Partial loss was observed in one patient, and the necrotic region was healed with secondary intention. CONCLUSION Our modified anterior tibial artery free-style perforator-pedicled propeller flap provides a novel option for functional ankle and heel reconstruction. LEVEL OF EVIDENCE Level IV.
Collapse
Affiliation(s)
- Jian Lin
- Department of Orthopedics, Xinhua Hospital (Chongming) Affiliated to Medical College, Shanghai Jiao Tong University, Shanghai, 202150, China. .,Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, China.
| | - Feng Zhou
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, China
| | - Yi-Dan Sun
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, China
| | - Ya-Shan Gao
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, China
| | - Hai-Zhou Li
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, China
| | - He-Ping Zheng
- Anatomical Institution, Department of Orthopedics, General Hospital of People's Liberation Army Nanjing District, Fuzhou, China
| | - Ying-Fan Zhang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, China
| | - Qing-Feng Li
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, China
| | - Patricia J Ward
- Department of Cell Biology, Emory University School of Medicine, Atlanta, GA, USA
| | - Ya-Li Yang
- Department of Dermatology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, China.
| | - Cai-Yue Liu
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, China. .,Department of Plastic and Reconstructive Surgery, Changzheng Hospital, Navy Medical University, Shanghai, 200003, China.
| |
Collapse
|
29
|
Advancements in Reconstructive Surgery Broaden Opportunities for Salvage of the Injured Lower Extremity. Ann Plast Surg 2021; 84:238-245. [PMID: 31513085 DOI: 10.1097/sap.0000000000001977] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Advancements in microsurgery have made lower extremity reconstruction possible even after major soft tissue loss or tibial nerve disruption. There is an ongoing paradigm shift in the indications for amputation versus salvage and in flap selection protocols for different areas of the lower extremity. Initial evaluation, patient selection, triage, and timing of reconstruction are essential factors that can influence functional and aesthetic outcomes. The emergence of perforator flaps and the application of new concepts such as free-style flaps, propeller perforator flaps, thinning of free flaps, and supermicrosurgery have provided reconstructive surgeons with many techniques to decrease donor-site morbidity and improve outcomes. This includes options for reconstruction on extremities with single or no adequate runoff vessels. We present a review of the major advancements in reconstructive surgery for salvage of the traumatic lower extremity.
Collapse
|
30
|
Liu K, Zhang W, Wang Y, Xiang DW, Shi HB, Liu QL. Fibula osteal flap with proximal peroneal perforator skin paddle for composite oromandibular reconstruction: A case report. Medicine (Baltimore) 2020; 99:e23590. [PMID: 33327322 PMCID: PMC7738134 DOI: 10.1097/md.0000000000023590] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Cutaneous perforators of peroneal vessels are divided into proximal and distal perforators on the basis of perforator distributions and musculocutaneous or septocutaneous properties. The traditional fibular osteocutaneous free flap is raised over the distal two-thirds of the fibula with a skin paddle based on distal perforators, which is affixed to the posterior crural septum. However, the skin pedicle may not be available due to anatomic variations or intraoperative injuries. Herein, because of the absence of distal perforators, we reserved and expropriated proximal perforators originating from the musculocutaneous branch of the superior part of the peroneal artery before it divided into nutrient and arcuate arteries and successfully harvested a separate osteal fibula and proximal perforator skin paddle with a single vascular pedicle-peroneal vessel. PATIENT CONCERNS A 62-year-old man with a 6-month history of mandibular swelling and soft tissue invasion was referred to us. DIAGNOSIS Panoramic radiography and computed tomography showed an irregular radiolucent lesion of the mandibular body, and histopathological analysis confirmed a follicular-pattern ameloblastoma. INTERVENTIONS The diseased mandible and soft tissue were resected and reconstructed with a vascularized fibular osteal flap with the proximal perforator skin paddle. OUTCOMES The mandibular contour was successfully restored; the skin paddle in the mouth was in good condition after 8 months of follow-up. LESSONS The proximal perforator is reliable and practical for supplying a skin paddle and has significant potential for future applications. We recommend reserving the proximal perforator skin paddle as a backup flap when planning to raise a fibula flap, since unavailability or injury of the traditional fibular skin island based on distal perforators occurs frequently. This approach can avoid the exploration for a second donor site, save surgical time, and reduce surgical complexity. Moreover, we anticipate more frequent use of the proximal perforator flap in the future because of its flexibility and large volume, and since it can be combined with the osteal fibula or fibular osteocutaneous flap. However, an understanding of the traits of the proximal perforator and determination of its peroneal origin by computed tomography angiography is crucial for predesigning fibular osteal flaps with a proximal perforator skin paddle.
Collapse
Affiliation(s)
- Kang Liu
- Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, Jilin University, Changchun
| | - Wei Zhang
- Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, Jilin University, Changchun
| | - Yue Wang
- Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, Jilin University, Changchun
- Department of Oral and Maxillofacial Surgery, Yantai Affiliated Hospital of Binzhou Medical University, Yantai, PR China
| | - Dan-Wei Xiang
- Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, Jilin University, Changchun
| | - Hai-Bo Shi
- Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, Jilin University, Changchun
| | - Qi-Lin Liu
- Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, Jilin University, Changchun
| |
Collapse
|
31
|
Demiri E, Tsimponis A, Pavlidis L, Spyropoulou GA, Foroglou P, Dionyssiou D. Reverse neurocutaneous vs propeller perforator flaps in diabetic foot reconstruction. Injury 2020; 51 Suppl 4:S16-S21. [PMID: 32184012 DOI: 10.1016/j.injury.2020.03.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 02/23/2020] [Accepted: 03/07/2020] [Indexed: 02/02/2023]
Abstract
Introduction Reverse neurocutaneous and propeller perforator flaps are both used to reconstruct diabetic distal lower limb defects. Our study aims to compare outcomes between these two groups of flaps with an emphasis on indications and complication rates. Method A retrospective analysis was conducted, reviewing data from 54 diabetic patients who underwent reconstruction of acute or chronic wounds of the foot and ankle between 2005-2018. Thirty-four patients (Group A) had a reverse neurocutaneous flap (NCF): nineteen sural and fifteen lateral supramalleolar flaps. Twenty patients (Group B) had a propeller flap (PF) based on peroneal (n = 13) or posterior tibial artery perforators (n = 7). All patients had a preoperative Doppler examination to identify the nutrient artery of the flap. In both groups, we recorded patients' demographics, characteristics of the defect, postoperative complications and time to heal. Follow-up ranged from 6 to 59 months. Student's t-test and chi-squared test were used for statistical analysis. Results Mean patients' age was 59.1 and 50.8 years for Group A and B, respectively. Defects were located at the Achilles zone (n = 16), posterior heel (n = 14), foot dorsum (n = 9), lateral and medial malleolar areas (n = 8), anterior ankle (n = 5) and lateral foot (n = 2). Mean size of the defect was 42.8 cm2 in Group A and 23 cm2 in Group B. Uneventful healing was recorded in 20/34 neurocutaneous flaps and in 12/20 propeller flaps; complications included two complete flap losses (one NCF, one PF), seventeen distal flap necroses (10 NCFs, 7 PFs), fifteen delayed wound healing events over the donor or recipient site (12 NCFs, 3 PFs). Secondary surgeries were required in 15 NCF and 8 PF patients. Mean healing time was 48.1 and 40.7 days for Group A and B, respectively. All patients, except one NCF case, which resulted in leg amputation, returned to previous levels of ambulation. Conclusion Reverse neurocutaneous and propeller flaps may provide stable reconstruction of diabetic lower limb defects; neurocutaneous flaps are specially indicated for larger and more distally located defects, although they might be associated with longer healing time and additional revision surgeries. Propeller flaps were more frequently used in younger patients for smaller and more proximally located defects.
Collapse
Affiliation(s)
- Efterpi Demiri
- Department of Plastic Surgery, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece, Papageorgiou Hospital, Thessaloniki, Greece.
| | - Antonios Tsimponis
- Department of Plastic Surgery, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece, Papageorgiou Hospital, Thessaloniki, Greece
| | - Leonidas Pavlidis
- Department of Plastic Surgery, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece, Papageorgiou Hospital, Thessaloniki, Greece
| | - Georgia-Alexandra Spyropoulou
- Department of Plastic Surgery, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece, Papageorgiou Hospital, Thessaloniki, Greece
| | - Periclis Foroglou
- Department of Plastic Surgery, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece, Papageorgiou Hospital, Thessaloniki, Greece
| | - Dimitrios Dionyssiou
- Department of Plastic Surgery, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece, Papageorgiou Hospital, Thessaloniki, Greece
| |
Collapse
|
32
|
Zubler C, Haberthür D, Hlushchuk R, Djonov V, Constantinescu MA, Olariu R. The anatomical reliability of the superficial circumflex iliac artery perforator (SCIP) flap. Ann Anat 2020; 234:151624. [PMID: 33129977 DOI: 10.1016/j.aanat.2020.151624] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 08/23/2020] [Accepted: 10/12/2020] [Indexed: 12/31/2022]
Abstract
INTRODUCTION In order to achieve a satisfactory functional and aesthetic result a thin skin flap is often required in surgical reconstruction of various body regions. Perforator flaps based on either the superficial or deep branch of the superficial circumflex iliac artery (SCIA) have been used for this purpose mainly in the Asian population. Recently the superficial plane has been established as a new way of elevating the flap. Anatomical studies and details of this new flap are lacking. MATERIAL AND METHODS Wide areas were harvested subfascially from the groin of Thiel-fixated cadavers. Both deep and superficial branches of the superficial circumflex iliac artery were carefully dissected and individually injected with μAngiofil. After CT-imaging the flaps were raised on the superficial plane, perforators were marked and the flaps subsequently rescanned. High-resolution images of regions of interest were taken using micro-CT. RESULTS A total of 21 flaps were harvested and analyzed. Both the deep and superficial branch provided more than three perforators per branch, however, the deep branch based flap was significantly larger (202 vs. 112 cm2, p < 0.01) and had a longer pedicle (9.1 vs. 6.6 cm, p < 0.01). Raising the flap in the superficial plane reliably reduces bulk and increases homogeneity. CONCLUSIONS The SCIP flap appears to have a reliable vascular blood supply. The SCIA and its main branches and perforators have a consistent vascular pattern. The deep branch of the SCIA has the anatomic potential to be the preferred pedicle in case larger flaps with longer pedicles are necessary.
Collapse
Affiliation(s)
- Cédric Zubler
- Institute of Anatomy, University of Bern, Baltzerstrasse 2, 3012 Bern, Switzerland; Department of Plastic and Hand Surgery, Inselspital University Hospital Bern, Freiburgstrasse, 3010 Bern, Switzerland
| | - David Haberthür
- Institute of Anatomy, University of Bern, Baltzerstrasse 2, 3012 Bern, Switzerland
| | - Ruslan Hlushchuk
- Institute of Anatomy, University of Bern, Baltzerstrasse 2, 3012 Bern, Switzerland
| | - Valentin Djonov
- Institute of Anatomy, University of Bern, Baltzerstrasse 2, 3012 Bern, Switzerland
| | - Mihai A Constantinescu
- Department of Plastic and Hand Surgery, Inselspital University Hospital Bern, Freiburgstrasse, 3010 Bern, Switzerland
| | - Radu Olariu
- Department of Plastic and Hand Surgery, Inselspital University Hospital Bern, Freiburgstrasse, 3010 Bern, Switzerland.
| |
Collapse
|
33
|
Distally Based Posterior Tibial Artery Perforator Flaps for Reconstruction of the Defects in Achilles Region. Ann Plast Surg 2020; 83:452-454. [PMID: 31524741 DOI: 10.1097/sap.0000000000001909] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Patients with Achilles region defects remain a challenge for clinicians. The purpose of this article is to evaluate the surgical procedure to reconstruct the defects in Achilles region using distally based posterior tibial artery perforator flaps. METHODS Between May 2015 and May 2017, 10 patients (aged from 35 to 68 years. 4 females and 6 males) with soft-tissue defects (sizes from 3 × 2 cm to 8 × 4 cm) in Achilles region received surgical therapy of posterior tibial artery perforator flap transplantation in the Affiliated Hospital of Xuzhou Medical University. RESULTS The length of hospital stay ranged from 10 to 15 days (mean, 12 days). Local small superficial necrosis (5% of the area) was observed in only 1 case; however, it healed well after dressing was changed. All the others survived and healed well. At follow-up ranging from 12 to 24 months, all patients were satisfied with the aesthetic and functional aspects. CONCLUSIONS Using the posterior tibial artery perforator flaps to cover the Achilles region defects is a promising, feasible, first-line, safe option and should be extensively applied in clinical therapy.
Collapse
|
34
|
Johnson L, Liette MD, Green C, Rodriguez P, Masadeh S. The Reverse Sural Artery Flap: A Reliable and Versatile Flap for Wound Coverage of the Distal Lower Extremity and Hindfoot. Clin Podiatr Med Surg 2020; 37:699-726. [PMID: 32919599 DOI: 10.1016/j.cpm.2020.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The reverse sural artery flap is a distally based fasciocutaneous or adipofascial flap used for wound coverage of the distal one-third of the lower extremity, ankle, and posterior heel. The flap harvest can be performed without sacrificing major arteries of the lower extremity. It can be elevated and mobilized with relative ease and a short operative time. It provides a good alternative to free tissue transfer in complex lower-extremity wounds with exposed bone, tendon, or hardware. The surgeon must be familiar with the management of venous congestion to improve the success of the flap.
Collapse
Affiliation(s)
- Lance Johnson
- University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0513, Cincinnati, OH 45276, USA
| | - Michael D Liette
- University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0513, Cincinnati, OH 45276, USA
| | - Chris Green
- American College of Foot and Ankle Surgeons, Integris Limb Salvage Center, Oklahoma City, OK, USA
| | - Pedro Rodriguez
- Plastic and Reconstructive Surgery, OSF Saint Anthony Medical Center, University of Illinois, 698 Featherstone Road, Rockford, IL 61107, USA
| | - Suhail Masadeh
- University of Cincinnati Medical Center, Cincinnati Veteran Affairs Medical Center, 231 Albert Sabin Way, ML 0513, Cincinnati, OH 45276, USA.
| |
Collapse
|
35
|
Oexeman S, Ward KL. Understanding the Arterial Anatomy and Dermal Perfusion of the Lower Extremity with Clinical Application. Clin Podiatr Med Surg 2020; 37:743-749. [PMID: 32919601 DOI: 10.1016/j.cpm.2020.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Respecting vascular territories is crucial for flap design and viability. There are 6 angiosomes in the foot and ankle originating from the posterior tibial, anterior tibial, and peroneal arteries. Reliable perforators from the 3 major source vessels of the lower extremity are found in 5-cm intervals within intermuscular septa. Computed tomography angiography, Doppler, and infrared cameras can be used preoperatively to help identify the perforators of the lower extremity.
Collapse
Affiliation(s)
- Stephanie Oexeman
- Complex Deformity Correction & Microsurgical Limb Reconstruction Fellowship, AMITA Health- St. Joseph Hospital, Attn: Podiatric Fellowship Office, 2900 North Lake Shore Drive, Chicago, IL 60657, USA
| | - Kaitlyn L Ward
- Complex Deformity Correction & Microsurgical Limb Reconstruction Fellowship, AMITA Health- St. Joseph Hospital, Attn: Podiatric Fellowship Office, 2900 North Lake Shore Drive, Chicago, IL 60657, USA.
| |
Collapse
|
36
|
Abstract
Wounds of the lower extremity involving the distal third of the leg remain a significant challenge due to anatomic location and often poor host physiology. Perforator-based propeller flaps may provide rapid coverage of these wounds with a relatively low rate of major complications and often readily managed minor complications. A thorough vascular evaluation must be performed prior to the procedure to ensure adequate flap design and selection of the correct perforator is performed. They have the added advantage over their soft tissue free flap counterparts in that they have significantly less host morbidity with similar rates of total necrosis.
Collapse
|
37
|
Perry WC, Masadeh S, Thione A. The Distally Based Posterior Tibial Artery Flap. Clin Podiatr Med Surg 2020; 37:671-680. [PMID: 32919597 DOI: 10.1016/j.cpm.2020.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Soft tissue defects to the distal leg and hindfoot are challenging with only the smallest defects closed primarily without tissue transposition. These defects to the distal leg and hindfoot can lead to tendon desiccation, damaged neurovascular structures, and exposed joint surfaces. These wounds can be the result of postoperative dehiscence and exposed orthopedic hardware, with high susceptibility to infection. Pedicled fasciocutaneous flaps of the medial leg provide an excellent solution with good outcomes that do not require microanastomosis and have similar outcomes as compared with free flap reconstruction in the lower extremity.
Collapse
Affiliation(s)
- William C Perry
- Cincinnati Veteran Affairs Medical Center, 3200 Vine Street, Cincinnati, OH 45220, USA.
| | - Suhail Masadeh
- Cincinnati Veteran Affairs Medical Center, 3200 Vine Street, Cincinnati, OH 45220, USA
| | - Alessandro Thione
- Department of Plastic Surgery and Burns, Hospital Universitari i Politecnic La Fe, 106 Avinguda de Fernando Abril Martorell, Valencia E-46026, Spain
| |
Collapse
|
38
|
Henry A, Ta P, Trimaille A, Monnerie C, Kerfant N, Hu W. Coverage of cutaneous substance loss in the leg: Techniques and indications. ANN CHIR PLAST ESTH 2020; 65:524-548. [PMID: 32891462 DOI: 10.1016/j.anplas.2020.07.005] [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: 07/05/2020] [Accepted: 07/09/2020] [Indexed: 11/17/2022]
Abstract
Cutaneous substance loss in the leg is frequent; more often than not, it is trauma-related. It calls for complex management and necessitates the application of all current reconstruction techniques, particularly microsurgery. As regards treatment, the available therapeutic arsenal is highly diversified, ranging from a simple free flap skin graft to local and locoregional flaps. During reconstruction, the surgeon is subjected to several constraints insofar as the objectives of the operation are esthetic as well as functional. Ideally, the fineness of the skin covering the anterior side of the leg will have been scrupulously respected. Reconstruction is aimed at producing a stable and reliable cutaneous envelope while limiting the morbidity of the donor site. The development of free perforator flaps corresponds to these two criteria by producing a fine flap adapted to the cutaneous thickness of the leg and limiting any functional and esthetic sequelae at the donor site.
Collapse
Affiliation(s)
- A Henry
- Service de chirurgie plastique, reconstructrice et esthétique (plastic, reconstructive and esthetic surgery unit), hôpital de la Cavale-Blanche, université de Bretagne Occidentale, CHRU de Brest, 29200 Brest, France.
| | - P Ta
- Service de chirurgie plastique, reconstructrice et esthétique (plastic, reconstructive and esthetic surgery unit), hôpital de la Cavale-Blanche, université de Bretagne Occidentale, CHRU de Brest, 29200 Brest, France
| | - A Trimaille
- Service de chirurgie plastique, reconstructrice et esthétique (plastic, reconstructive and esthetic surgery unit), hôpital de la Cavale-Blanche, université de Bretagne Occidentale, CHRU de Brest, 29200 Brest, France
| | - C Monnerie
- Service de chirurgie plastique, reconstructrice et esthétique (plastic, reconstructive and esthetic surgery unit), hôpital de la Cavale-Blanche, université de Bretagne Occidentale, CHRU de Brest, 29200 Brest, France
| | - N Kerfant
- Service de chirurgie plastique, reconstructrice et esthétique (plastic, reconstructive and esthetic surgery unit), hôpital de la Cavale-Blanche, université de Bretagne Occidentale, CHRU de Brest, 29200 Brest, France
| | - W Hu
- Service de chirurgie plastique, reconstructrice et esthétique (plastic, reconstructive and esthetic surgery unit), hôpital de la Cavale-Blanche, université de Bretagne Occidentale, CHRU de Brest, 29200 Brest, France
| |
Collapse
|
39
|
Liu P, Deng Z, Zhang T, Li X. Anatomical Characteristics of Cutaneous Branches Extending From the Second Dorsal Metacarpal Artery. Front Bioeng Biotechnol 2020; 8:995. [PMID: 32974317 PMCID: PMC7469484 DOI: 10.3389/fbioe.2020.00995] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 07/29/2020] [Indexed: 11/13/2022] Open
|
40
|
Ellabban MA, Awad AI, Hallock GG. Perforator-Pedicled Propeller Flaps for Lower Extremity Reconstruction. Semin Plast Surg 2020; 34:200-206. [PMID: 33041691 PMCID: PMC7542202 DOI: 10.1055/s-0040-1715154] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Reconstruction of the lower extremity is considered a major challenge due to frequent bone exposure and the absence of local tissue redundancy, as well as often due to the presence of vascular insufficiency. Many surgeons have preferred free flaps especially for reconstructing the more distal lower limb defects until the evolution of pedicled perforator flaps and propeller flaps in particular provided a like-with-like reconstruction of the lower extremity without affecting the main vessels of the limb or the underlying muscles, and without the risk of any microanastomosis especially in patients with multiple comorbidities. Perforator-pedicled propeller flaps as local flaps in the lower extremity are best suited for small- and medium-sized defects with minimal donor-site morbidity, regardless of the cause of the defect. Any of the three source vessels of the leg can provide reliable perforators for propeller flap coverage of the distal leg and foot. The three main risk factors that are relative contraindications may be advanced age, diabetes mellitus, and atherosclerotic peripheral vascular disease.
Collapse
Affiliation(s)
- Mohamed A. Ellabban
- Plastic and Reconstructive Surgery Unit, Suez Canal University Hospitals and Medical School, Ismailia, Egypt
| | - Ahmed I. Awad
- Plastic and Reconstructive Surgery Unit, Suez Canal University Hospitals and Medical School, Ismailia, Egypt
| | - Geoffrey G. Hallock
- Division of Plastic Surgery, St. Luke's Hospital – Sacred Heart Campus, Allentown, Pennsylvania
| |
Collapse
|
41
|
Adams S, Hudson DA. Local perforator flaps for soft tissue defects in lower limb trauma. EUROPEAN JOURNAL OF PLASTIC SURGERY 2020. [DOI: 10.1007/s00238-019-01605-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
42
|
Best Local Flaps for Lower Extremity Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2774. [PMID: 32440438 PMCID: PMC7209892 DOI: 10.1097/gox.0000000000002774] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 02/24/2020] [Indexed: 12/05/2022]
Abstract
Supplemental Digital Content is available in the text. The ideal reconstruction of lower limb defects should replace like with like and minimize morbidity to the donor site, achieving the best possible esthetic and functional outcome. The goal is to obtain stable healing and to resume daily life in an efficient manner. Although the classical local flaps such as gastrocnemius, soleus muscle flap, and the reverse sural flap have allowed to achieve those goals, perforator flaps are now added on to the armamentarium in lower extremity reconstruction using local flaps. A perforator-based local flap, such as a propeller or keystone flap, has made reconstruction efficient while further reducing donor-site morbidity. This article aims to provide a useful review of the best available local flaps for lower limb defects.
Collapse
|
43
|
Jakubietz RG, Schmidt K, Holzapfel BM, Meffert RH, Jakubietz MG. Pedicled perforator flaps for mid-tibial soft tissue reconstruction in medically compromised patients. JPRAS Open 2020; 24:47-55. [PMID: 32346592 PMCID: PMC7182687 DOI: 10.1016/j.jpra.2020.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 02/05/2020] [Indexed: 11/17/2022] Open
Abstract
Background The soft tissue of the central pretibial area is difficult to reconstruct often requiring free tissue transfer. Especially medically compromised patients are not ideal candidates for free tissue transfer and may benefit from expeditiously harvested local flaps with limited donor site morbidity. As muscle flaps are rare, pedicled flaps based on lateral perforators represent an alternative as the arc of rotation can often be limited to 90°. Material and Methods A retrospective analysis of patient data was conducted to identify patients over the age of 60 years with comorbidities that underwent pretibial soft tissue reconstruction with a single-pedicle perforator flap. Patient demographics, size and cause of the defect, flap dimension, arc of rotation and complications were recorded. Results Five patients with an average age of 71.4 years were included. The arc of rotation was 69°, all flaps healed. There were two recurrences of osteomyelitis. Conclusion Lateral perforators originating from the anterior tibial artery or peroneal artery are adequate source vessels for single pedicled perforator flaps even in medically compromised patients. A perforator located proximal to the defect allows limiting the arc of rotation to less than 90°, which increases the safety of the flap. Patients benefit from a simple procedure without a microvascular anastomosis and a donor site confined to one extremity.
Collapse
Affiliation(s)
- Rafael G. Jakubietz
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Wuerzburg, Oberduerrbacherstr. 6, DE-97080 Wuerzburg, Germany
- Corresponding author.
| | - Karsten Schmidt
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Wuerzburg, Oberduerrbacherstr. 6, DE-97080 Wuerzburg, Germany
| | - Boris M. Holzapfel
- Department of Orthopaedic Surgery, KLH Julius Maximilian University Wuerzburg, Germany
| | - Rainer H. Meffert
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Wuerzburg, Oberduerrbacherstr. 6, DE-97080 Wuerzburg, Germany
| | - Michael G. Jakubietz
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Wuerzburg, Oberduerrbacherstr. 6, DE-97080 Wuerzburg, Germany
| |
Collapse
|
44
|
Brunetti B, Barone M, Tenna S, Salzillo R, Segreto F, Persichetti P. Pedicled perforator‐based flaps: Risk factor analysis, outcomes evaluation and decisional algorithm based on 130 consecutive reconstructions. Microsurgery 2020; 40:545-552. [DOI: 10.1002/micr.30590] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 01/29/2020] [Accepted: 03/27/2020] [Indexed: 11/06/2022]
Affiliation(s)
- Beniamino Brunetti
- Department of Plastic, Reconstructive and Aesthetic SurgeryCampus Bio‐Medico University of Rome Rome Italy
| | - Mauro Barone
- Department of Plastic, Reconstructive and Aesthetic SurgeryCampus Bio‐Medico University of Rome Rome Italy
| | - Stefania Tenna
- Department of Plastic, Reconstructive and Aesthetic SurgeryCampus Bio‐Medico University of Rome Rome Italy
| | - Rosa Salzillo
- Department of Plastic, Reconstructive and Aesthetic SurgeryCampus Bio‐Medico University of Rome Rome Italy
| | - Francesco Segreto
- Department of Plastic, Reconstructive and Aesthetic SurgeryCampus Bio‐Medico University of Rome Rome Italy
| | - Paolo Persichetti
- Department of Plastic, Reconstructive and Aesthetic SurgeryCampus Bio‐Medico University of Rome Rome Italy
| |
Collapse
|
45
|
Lese I, Grobbelaar AO, Sabau D, Georgescu AV, Constantinescu MA, Olariu R. The Propeller Flap for Traumatic Distal Lower-Limb Reconstruction: Risk Factors, Pitfalls, and Recommendations. J Bone Joint Surg Am 2020; 102:510-518. [PMID: 31804239 DOI: 10.2106/jbjs.19.00648] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Defects in the distal third of the leg are difficult to cover and often require free tissue transfer, even for defects of limited sizes. Propeller flaps have been designed specifically as an alternative to free tissue transfer but at times have been associated with unacceptably high complication rates. We therefore aimed to prospectively assess our own institutional experience with this technique and to define its role in lower-limb reconstruction. METHODS All patients who had been managed with reconstruction of the distal part of the leg with a propeller flap between 2014 and 2017 were included in the study. Demographic, clinical, and follow-up data on the patients and surgical procedures were recorded with special focus on the complication profile. RESULTS Twenty-six patients underwent propeller flap reconstruction of the distal part of the leg: 12 flaps were based on the posterior tibial artery, and 14 were based on the peroneal artery. Postoperative complications developed in association with 1 of the 12 flaps based on the posterior tibial artery, compared with 8 of the 14 flaps based on the peroneal artery (p = 0.015). Moreover, the presence of a higher Charlson comorbidity index (≥2) was strongly associated with the development of postoperative complications (p < 0.001). CONCLUSIONS Propeller flaps are a reliable option for traumatic reconstruction in carefully selected patients with lower-limb defects. In our experience, the rate of complications was higher for propeller flaps based on the peroneal artery and for patients with a Charlson comorbidity index of ≥2, whereas posterior tibial artery-based propeller flap reconstruction was a reliable surgical option for patients with a small defect in the distal third of the lower limb. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Ioana Lese
- Department of Plastic and Hand Surgery, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Adriaan O Grobbelaar
- Department of Plastic and Hand Surgery, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Dan Sabau
- Department III, Surgical Clinic, Lucian Blaga University of Sibiu, Sibiu, Romania
| | - Alexandru V Georgescu
- Department of Plastic Surgery and Reconstructive Microsurgery, and Clinic of Plastic Surgery and Reconstructive Microsurgery, Clinical Hospital of Recovery, University of Medicine Iuliu Hatieganu, Cluj Napoca, Romania
| | - Mihai A Constantinescu
- Department of Plastic and Hand Surgery, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Radu Olariu
- Department of Plastic and Hand Surgery, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| |
Collapse
|
46
|
Georgescu AV, Matei IR, Bumbasirevic M, Soucacos PN. Why, when and how propeller perforator flaps in reconstructive surgery. Injury 2019; 50 Suppl 5:S3-S7. [PMID: 31718794 DOI: 10.1016/j.injury.2019.10.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE The aim of this paper was to evaluate the outcomes of propeller perforator flaps used all over the body, and to appreciate their advantages and/or disadvantages over the free perforator flaps. METHOD Patients that required propeller perforator flaps used all over the body were eligible to participate in this study. A preoperative Doppler examination was performed for all the flaps in the trunk and thigh, but not regularly in the face, lower leg, foot, forearm and hand. We evaluated the most important technical aspects of harvesting the flaps, the main indications and advantages of using propeller perforator flaps, their disadvantages and complications. For post-excisional face and trunk defects after cancer or decubitus ulcers were performed approximately 25% of flaps. RESULTS We had very good results in approximately 70% of cases. In the remaining cases, excepting 3 cases in which the flaps were completely lost, we registered only minor complications due to venous congestion, which were solved spontaneously or by skin grafting. CONCLUSION The main advantages of propeller perforator flaps, i.e. no need of microvascular anastomoses, replacing like-with-like, faster functional rehabilitation, can reduce in well selected cases the indication for free flaps. The rate of complications is not higher than by using other methods. The single real disadvantage of propeller perforator flaps is the location of the perforator close to the defect, what can be an impediment in trauma cases.
Collapse
Affiliation(s)
- Alexandru Valentin Georgescu
- Department of Plastic Surgery and Reconstructive Microsurgery, University of Medicine Iuliu Hatieganu Cluj Napoca, Romania; Clinic of Plastic Surgery and Reconstructive Microsurgery, Clinical Hospital of Recovery, Cluj Napoca, Romania
| | - Ileana Rodica Matei
- Department of Plastic Surgery and Reconstructive Microsurgery, University of Medicine Iuliu Hatieganu Cluj Napoca, Romania; Clinic of Plastic Surgery and Reconstructive Microsurgery, Clinical Hospital of Recovery, Cluj Napoca, Romania.
| | - Marko Bumbasirevic
- Orthopedic and Traumatology University Clinic, Clinical Center of Serbia, Serbia; School of Medicine. University of Belgrade, Serbia
| | - Panayotis N Soucacos
- "Panayotis N. Soucacos" Orthopaedic Research & Education Center (OREC), National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital, Athens, Greece
| |
Collapse
|
47
|
Hifny MA, Tohamy AMA, Rabie O, Ali AAA. Propeller perforator flaps for coverage of soft tissue defects in the middle and distal lower extremities. ANN CHIR PLAST ESTH 2019; 65:54-60. [PMID: 31477322 DOI: 10.1016/j.anplas.2019.04.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 04/03/2019] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The middle and distal leg coverage is demanding procedure for reconstructive surgeon until evolution of local perforator flaps which becomes as valuable options in lower limb reconstruction. The goal of our study was to assess the results, reliability, safety, and possible complications of the local propeller perforator flaps in lower extremity reconstruction. PATIENTS AND METHODS We demonstrate a case series of 11 patients in whom we cover small-to-medium soft-tissue defects of the middle and distal leg by application of local propeller perforator flaps. RESULTS The site of soft tissue defects were in the distal third in 9 cases (81.8%) and 2 cases (18.1%) in the middle third. Flap dimensions ranged from 48 to 192cm2, with an average size of 88.9 cm2. The flap rotation was 180 degrees in (63.6%) of cases. The flaps were based on a single perforator of the posterior tibial artery in 8 (72.7%) cases and peroneal artery perforator in 3 (27.2%) cases. Complications were present in 18% of the perforator flaps which were based on peroneal artery perforator, one partial necrosis and one flap with a superfacial epidermolysis. The donor area is covered by split thickness skin graft in 63.6% of our cases and primary closure of in 36.3% of cases. CONCLUSION The perforator propeller flaps are safe, relatively simple procedure and consider as an ideal option in reconstructing small-medium defects of the middle and distal third of the leg which provide similar skin texture with low donor site morbidity.
Collapse
Affiliation(s)
- M A Hifny
- Plastic surgery Department, faculty of medicine, Qena university hospital, South Valley University, Qena, Egypt.
| | - A M A Tohamy
- Plastic surgery Department, faculty of medicine, Assiut university hospital, Assiut, Egypt.
| | - O Rabie
- Plastic surgery Department, faculty of medicine, Qena university hospital, South Valley University, Qena, Egypt.
| | - A A A Ali
- Plastic surgery Department, faculty of medicine, Qena university hospital, South Valley University, Qena, Egypt.
| |
Collapse
|
48
|
Severo AL, Coppi EFM, Cavalheiro HL, Bosco ALD, Filho DB, Lemos MB. Lower Limb Reconstruction - Fasciocutaneous Sural Flap. Rev Bras Ortop 2019; 54:128-133. [PMID: 31363257 PMCID: PMC6529321 DOI: 10.1016/j.rbo.2017.12.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 12/14/2017] [Indexed: 11/28/2022] Open
Abstract
Objective
The present study aims to evaluate the use of the reverse-flow sural fasciocutaneous flap to cover lesions in the distal third of the lower limb.
Methods
A total of 24 cases were analyzed, including 20 traumatic injuries, 3 sports injuries, and 1 case of tumor resection.
Results
Among the 24 evaluated medical records, 16 patients were male, and 8 were female. Their age ranged from 6 to 75 years old. Most of the patients evolved with total healing of the flap (
n=
21). There was only one case of total necrosis of the flap in an insulin-dependent diabetic, high blood pressure patient, evolving to subsequent limb amputation. In two cases, there was partial necrosis and subsequent healing by secondary intention; one of these patients was a heavy smoker. Complications were associated with comorbidities and, unlike other studies, no correlation was observed with the learning curve. There was also no correlation with the site or size of the lesion to be covered.
Conclusion
It is clinically relevant that the success rate of the reverse-flow sural fasciocutaneous flap technique was of 87.5%. This is a viable and effective alternative in the therapeutic arsenal for complex lower limb lesions.
Collapse
Affiliation(s)
- Antonio Lourenco Severo
- Hospital São Vicente de Paulo (HSVP-RS), Passo Fundo, RS, Brasil.,Instituto de Ortopedia e Traumatologia de Passo Fundo (IOT-RS), Passo Fundo, RS, Brasil
| | - Eduardo Felipe Mandarino Coppi
- Hospital São Vicente de Paulo (HSVP-RS), Passo Fundo, RS, Brasil.,Instituto de Ortopedia e Traumatologia de Passo Fundo (IOT-RS), Passo Fundo, RS, Brasil
| | - Haiana Lopes Cavalheiro
- Hospital São Vicente de Paulo (HSVP-RS), Passo Fundo, RS, Brasil.,Instituto de Ortopedia e Traumatologia de Passo Fundo (IOT-RS), Passo Fundo, RS, Brasil
| | - Alexandre Luiz Dal Bosco
- Hospital São Vicente de Paulo (HSVP-RS), Passo Fundo, RS, Brasil.,Instituto de Ortopedia e Traumatologia de Passo Fundo (IOT-RS), Passo Fundo, RS, Brasil
| | - Danilo Barreto Filho
- Hospital São Vicente de Paulo (HSVP-RS), Passo Fundo, RS, Brasil.,Instituto de Ortopedia e Traumatologia de Passo Fundo (IOT-RS), Passo Fundo, RS, Brasil
| | - Marcelo Barreto Lemos
- Hospital São Vicente de Paulo (HSVP-RS), Passo Fundo, RS, Brasil.,Instituto de Ortopedia e Traumatologia de Passo Fundo (IOT-RS), Passo Fundo, RS, Brasil
| |
Collapse
|
49
|
Carabelli G, De Cicco F, Barla J, Taype D, Sancineto C. Posterior Tibial Artery Perforator Flap Series of Cases. ACTA ACUST UNITED AC 2019. [DOI: 10.29337/ijops.39] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
50
|
Burusapat C. Perforator Flap Reconstruction for the Distal Third of Lower Extremity Defects: Clinical Application and Guideline Recommendation. INT J LOW EXTR WOUND 2019; 18:376-388. [DOI: 10.1177/1534734619861018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A distal third of lower extremity defect is challenging for plastic surgeons. The standard for treatment is microsurgery. Recently, perforator flap has been reported for small to medium defects. The objective was to analyze the outcomes of perforator flaps for distal third of lower extremity defects and to establish surgical guidelines. A retrospective review of patients with defects in distal third of lower extremities was conducted. Patients with multiple levels of lower extremity defects were excluded. A total of 8 patients with distal third of lower extremity defects were included. Seven patients were male. Overall mean age was 35.3 (18-60) years. Patients had 3 anterior, 3 lateral, and 2 medial defects. Lateral and anterior defects in 6 patients were closed using a peroneal-based propeller perforator flap with an angle of rotation of 90° to 160°. Medial defects in 2 patients were closed using a posterior tibial-based perforator advancement flap. Three patients (37.5%) developed venous congestion. No complications occurred for patients with medial defect closure using an advancement posterior tibial-based perforator flap. No total flap loss was observed. The perforator flap provides a similar texture to the skin at recipient area and a wide range of rotation. Perforator flaps should be the first choice for defects reconstruction in distal third lower extremities. Perforator flaps can be used for small to large defects, and can be moved by propeller or advancement depending on the perforator location. A guideline for perforator flaps reconstruction of the distal third of lower extremity defects was established.
Collapse
Affiliation(s)
- Chairat Burusapat
- Phramongkutklao Hospital and Phramongkutklao College of Medicine, Bangkok, Thailand
| |
Collapse
|