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Kim KB, Ryu J, Lee JY. Fibular free flap with proximal perforator skin paddle due to aberrant anatomy - a case report. Maxillofac Plast Reconstr Surg 2024; 46:5. [PMID: 38376599 PMCID: PMC10879059 DOI: 10.1186/s40902-024-00416-x] [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: 10/04/2023] [Accepted: 01/29/2024] [Indexed: 02/21/2024] Open
Abstract
BACKGROUND The fibular free flap is considered one of the most valuable options for mandible reconstruction. A perforator flap has gained widespread acceptance in oral and maxillofacial reconstruction. Typically, the fibula flap is obtained primarily with the distal perforator due to its reliable blood supply, with less attention given to the proximal perforators during the harvesting process. Normally, the distal perforator of the fibula exhibits stability and shows limited anatomical variations. However, there have been reported cases in which the distal perforator is absent. At times, these vascular abnormalities remain undetectable through Doppler examination or preoperative angiography evaluation. Therefore, this case details the experience of encountering the rare event of vascular abnormality in oral cancer surgery. CASE PRESENTATION This article reports the case of a patient who presented with a congenital absence of the distal perforator in the peroneal artery, attributed to a vascular abnormality. Additionally, we provide a review of the concept of utilizing the proximal perforator as an alternative approach in the flap harvesting process. CONCLUSIONS While the distal perforator of the peroneal artery is typically utilized for fibula free flap procedures, surgeons must remain cognizant of the potential for its absence due to aberrant anatomy. Recognizing an alternative approach in such cases can be pivotal for precise surgical planning and favorable outcomes in oral and maxillofacial reconstruction.
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Affiliation(s)
- Kyu-Bum Kim
- Department of Oral & Maxillofacial Surgery, School of Dentistry, Pusan National University, Yangsan, Korea
| | - Jihye Ryu
- Department of Oral & Maxillofacial Surgery, School of Dentistry, Pusan National University, Yangsan, Korea
| | - Jae-Yeol Lee
- Department of Oral & Maxillofacial Surgery, School of Dentistry, Pusan National University, Yangsan, Korea.
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Arterial Injury Portends Worse Soft Tissue Outcomes and Delayed Coverage in Open Tibial Fractures. J Orthop Trauma 2022; 36:535-543. [PMID: 35324550 DOI: 10.1097/bot.0000000000002372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 03/22/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To investigate if any injury to the three primary branches of the popliteal artery in open tibia fractures lead to increased soft-tissue complications, particularly in the area of the affected angiosome. DESIGN Retrospective cohort comparative study. SETTING Two academic level one trauma centers. PATIENTS/PARTICIPANTS Sixty-eight adult patients with open tibia fractures with a minimum one-year follow up. INTERVENTION N/A. MAIN OUTCOME MEASUREMENTS Soft-tissue outcomes as measured by wound healing (delayed healing, dehiscence, or skin breakdown) and fracture related infection (FRI) at time of final follow-up. RESULTS Eleven (15.1%) tibia fractures had confirmed arterial injuries via CTA (7), direct intraoperative visualization (3), intraoperative angiogram (3). Ten (91.0%) were treated with ligation and 1 (9.1%) was directly repaired by vascular surgery. Ultimately, 6 (54.5%) achieved radiographic union and 4 (36.4%) required amputation performed at a mean of 2.62 ± 2.04 months, with one patient going on to nonunion diagnosed at 10 months. Patients with arterial injury had significantly higher rates of wound healing complications, FRI, nonunion, amputation rates, return to the OR, and increased time to coverage or closure. After multivariate regression, arterial injury was associated with higher odds of wound complications, FRI, and nonunion. Ten (90.9%) patients with arterial injury had open wounds in the region of the compromised angiosome, with 7 (70%) experiencing wound complications, 6 (60%) FRIs, and 3 (30%) undergoing amputation. CONCLUSIONS Arterial injuries in open tibia fractures with or without repair, have significantly higher rates of wound healing complications, FRI, delayed time to final closure, and need for amputation. Arterial injuries appear to effect wound healing in the affected angiosome. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Agrawal NK, Bhattacharya V, Dubepuria R. Radiological Evaluation of Postsurgical Course of Perforators in Retrograde Posterior Tibial Fasciocutaneous Flaps for Distal Leg and Foot Defects. Indian J Plast Surg 2021; 54:272-277. [PMID: 34667510 PMCID: PMC8515343 DOI: 10.1055/s-0041-1734568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background
Mapping of vascular perforators by various methodologies have been described for planning of a variety of flaps in the lower limbs. We attempted to assess the changes in posterior tibial perforators after transfer of fasciocutaneous flaps for leg defects.
Methods
20 patients with distal leg and foot defects were studied by computed tomography angiography (CTA) and preoperative audio Doppler to ascertain perforators of posterior tibial artery. Fasciocutaneous flaps were raised, based on these perforators, depending on the site and size of soft-tissue defects. The number of perforators and their distance from the medial malleolus were also studied. Postoperative CTA was performed on the 7th to 10th day, with emphasis on postoperative changes of the perforators on which the flaps were based.
Results
One to four posterior tibial perforators were found between 5 cm and 8 cm proximal to the medial malleolus. After flap transfer, the perforators could be traced to variable distance through the total length of the flap. The perforators formed small vascular loop in 12 patients, following retrograde posterior tibial flap transfer. The height of the loop, the number of such loops, the dilatation and tortuosity of the perforators, and their longitudinal orientation were studied in detail. Most of the findings can be explained by mechanical realignment of perforators as well as by the delay phenomenon associated with retrograde fasciocutaneous flaps.
Conclusion
It was concluded that the morphological changes associated with the perforators explained the vascular rationality and success of these flaps.
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Affiliation(s)
- Neeraj Kant Agrawal
- Department of Plastic Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Visweswar Bhattacharya
- Department of Plastic Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Rahul Dubepuria
- Department of General Surgery, Sri Aurobindo Institute of Medical Sciences, Indore, Madhya Pradesh, India
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Fritz C, Meroni M, Fritsche E, Rajan G, Scaglioni MF. Free double-paddle posterior tibial artery perforator flap for hypopharynx reconstruction: A case report and literature review. Microsurgery 2021; 41:660-665. [PMID: 34289177 DOI: 10.1002/micr.30790] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 06/30/2021] [Accepted: 07/09/2021] [Indexed: 01/09/2023]
Abstract
Microsurgical free tissue transfer is nowadays considered to be one of the main options for head and neck reconstruction. The free posterior tibial artery perforator (PTAP) flap is a well-known reconstructive technique for local defect coverage in the distal leg, and only recently has been employed for head and neck reconstructions. Being a very thin and pliable flap, with low donor site morbidity and constant anatomy, the PTA perforator-based flap could be a great alternative to the more commonly-employed radial forearm free flap (RFFF). The present case report shows a complex head and neck defect coverage by means of a free double-paddle PTA flap, with a concise literature review of previous PTA flap descriptions in this setting. A 59-year-old male patient presented with a hypopharynx leakage after radiotherapy due to hypopharynx carcinoma. Since the patient had an occluded ulnar artery on the left side and an arterial line in the radial artery on the right side, both a RFFF and an ulnar artery perforator (UAP) flap were contraindicated. Moreover, two different cutaneous flaps were needed to reconstruct a 6 × 8 cm2 defect, one for the reconstruction of the hypopharynx and one for the resurfacing of the neck, since previous surgeries and radiotherapy led to severe fibrosis of the neck. The patient had a BMI of 25.4 kg/m2, which led us to exclude the anterolateral thigh (ALT) flap because of its thickness. For the forementioned reasons, an unconventional double-paddle PTAP flap based on two perforator vessels was chosen. Based on two perforators, two skin islands were harvested, building a double-paddle PTA perforator-based flap. The proximal skin island was 6 × 7 cm2 and the distal one was 6 × 4 cm2 . The larger skin flap was set at the leakage of the hypopharynx. The smaller skin island was used to monitor the survival of the whole flap and for resurfacing the outer side of the neck. The postoperative course was uneventful and at 3 months follow up the reconstructive result was good with no functional drawback. In view of the obtained result, we can consider that the PTA flap might be a reliable alternative to the much widely used RFFF, with a minor donor site morbidity, for delicate head and neck reconstructions.
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Affiliation(s)
- Caroline Fritz
- Department of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Matteo Meroni
- Department of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Elmar Fritsche
- Department of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Gunesh Rajan
- Department of Otolaryngology, Head and Neck Surgery, Luzerner Kantonsspital, Lucerne, Switzerland.,Otolaryngology, Head and Neck Surgery, Medical School, University of Western Australia, Perth, Australia
| | - Mario F Scaglioni
- Department of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
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The suprafascial course of lower leg perforators: An anatomical study. Arch Plast Surg 2020; 47:165-170. [PMID: 32203994 PMCID: PMC7093275 DOI: 10.5999/aps.2019.00962] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 02/13/2020] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Perforator mapping has been well described in the literature. Once the suprafascial plane is reached, the course of perforators is considered constant. However, the surgeon must be aware of whether an anastomosis exists between perforators superficially to the fascia, in order to choose the best vessel upon which to base the reconstruction. Our retrospective in vivo anatomical study of lower leg perforator flaps presents the first description of variations in the suprafascial path of perforators, which may influence preoperative flap design. METHODS An anatomical study of lower limb perforators was performed on 46 nonconsecutive patients who were referred to our department from June 2012 to October 2018. Reconstruction with perforator-based propeller flaps was planned for each of the patients. In total, 72 perforators were preoperatively identified and surgically isolated. The suprafascial course of each perforator was reported. RESULTS During suprafascial surgical exploration, branching patterns were observed in four perforators. These perforators had been classified as single vessels in the preoperative ultrasonographic analysis. However, after surgical dissection, distal converging branches were noted in two of them. CONCLUSIONS Our study is the first description in the literature of suprafascial converging perforators, which might constitute an obstacle to planned reconstruction procedures. Despite the accuracy of preoperative evaluations, anatomical variations were present. Knowledge of suprafascial perforator variations may help surgeons to choose the correct perforator upon which to base a planned flap.
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Mashrah MA, Mai L, Wan Q, Huang Z, Wang J, Lin Z, Fan S, Pan C. Posterior Tibial Artery Flap with an Adipofascial Extension. Plast Reconstr Surg 2020; 145:142e-152e. [DOI: 10.1097/prs.0000000000006396] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kerfant N, Monnerie C, Henry AS, Ta P, Hu W, Letissier H, Le Nen D. Posterior tibial perforator-based flaps for leg and foot defects: Indications, limitations, and technical considerations. Orthop Traumatol Surg Res 2018; 104:1227-1230. [PMID: 30393069 DOI: 10.1016/j.otsr.2018.06.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 05/31/2018] [Accepted: 06/17/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Covering defects at the lower leg and foot is a common challenge in reconstructive surgery. A flap is often required, and free flaps are widely used. The posterior tibial perforator-based flap constitutes a valuable option in this situation. The objectives of this study were to evaluate the reliability of the posterior tibial perforator-based flap, report any complications, and describe the outcomes, with the goal of defining the indications of this flap in the treatment of lower limb defects. HYPOTHESIS The posterior tibial perforator-based flap is a useful and reliable option for soft-tissue defect reconstruction at the leg and foot. MATERIAL AND METHOD Patients managed using a posterior tibial perforator-based flap to cover soft-tissue defects of the leg and foot were reviewed retrospectively. A physical examination was performed and radiographs obtained at the last postoperative follow-up visit. RESULTS Thirteen patients with a mean age of 46.9 years (range: 25-73 years) were reviewed after a mean follow-up of 19.5 months (range: 16-63 months). The tissue defects were due to compound fractures in 10 patients and to postoperative complications in 3 patients. Mean flap size was 12.3cm by 6.2cm. The donor site was covered by a skin graft in 12 patients and closed primarily in 1 patient. The procedure was successful in 11 (85%) patients. DISCUSSION The posterior tibial perforator-based flap is a method of choice for covering soft-tissue defects at the leg and foot. Careful patient selection and flawless technique contribute to minimise the failure rate. LEVEL OF EVIDENCE IV, retrospective study.
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Affiliation(s)
- Nathalie Kerfant
- Service de chirurgie plastique, reconstructrice et esthétique, CHRU de Brest, boulevard Tanguy-Prigent, 29609 Brest cedex, France.
| | - Charlotte Monnerie
- Service de chirurgie plastique, reconstructrice et esthétique, CHRU de Brest, boulevard Tanguy-Prigent, 29609 Brest cedex, France
| | - Anne-Sophie Henry
- Service de chirurgie plastique, reconstructrice et esthétique, CHRU de Brest, boulevard Tanguy-Prigent, 29609 Brest cedex, France
| | - Pierre Ta
- Service de chirurgie plastique, reconstructrice et esthétique, CHRU de Brest, boulevard Tanguy-Prigent, 29609 Brest cedex, France
| | - Weiguo Hu
- Service de chirurgie plastique, reconstructrice et esthétique, CHRU de Brest, boulevard Tanguy-Prigent, 29609 Brest cedex, France
| | - Hoel Letissier
- Service de chirurgie du membre supérieur, CHRU de Brest, boulevard Tanguy-Prigent, 29609 Brest cedex, France
| | - Dominique Le Nen
- Service de chirurgie du membre supérieur, CHRU de Brest, boulevard Tanguy-Prigent, 29609 Brest cedex, France
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Bulla A, Bolletta A, Fiorot L, Maffei M, Bandiera P, Casoli V, Montella A, Campus GV. Posterior tibial perforators relationship with superficial nerves and veins: A cadaver study. Microsurgery 2018; 39:241-246. [DOI: 10.1002/micr.30327] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 03/21/2018] [Accepted: 03/27/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Antonio Bulla
- Department of Medical, Surgical and Experimental Sciences, Plastic Surgery UnitUniversity of SassariSassari Italy
- Department of Biomedical Sciences ‐ Human AnatomyUniversity of SassariSassari Italy
| | - Alberto Bolletta
- Department of Medical, Surgical and Experimental Sciences, Plastic Surgery UnitUniversity of SassariSassari Italy
| | - Luca Fiorot
- Department of Medical, Surgical and Experimental Sciences, Plastic Surgery UnitUniversity of SassariSassari Italy
| | - Matteo Maffei
- Department of Medical, Surgical and Experimental Sciences, Plastic Surgery UnitUniversity of SassariSassari Italy
| | - Pasquale Bandiera
- Department of Biomedical Sciences ‐ Human AnatomyUniversity of SassariSassari Italy
| | - Vincent Casoli
- Department of Hand Surgery, Plastic Surgery, Burn SurgeryCHU University of Bordeaux, Centre François‐Xavier‐Michelet, Groupe Hospitalier Pellegrin, Place Amélie‐Raba‐LéonBordeaux, 33076 France
| | - Andrea Montella
- Department of Biomedical Sciences ‐ Human AnatomyUniversity of SassariSassari Italy
| | - Gian Vittorio Campus
- Department of Medical, Surgical and Experimental Sciences, Plastic Surgery UnitUniversity of SassariSassari Italy
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Yu D, Hou Q, Liu A, Tang H, Fang G, Zhai X, Jiang H, Cao X. Delineation the anatomy of posterior tibial artery perforator flaps using human cadavers with a modified technique. Surg Radiol Anat 2016; 38:1075-1081. [PMID: 27083588 DOI: 10.1007/s00276-016-1671-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 03/21/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND To delineate the distribution and course layer of the perforator vessels using a modified technique. METHODS Twelve perforator flaps were obtained from the crura of six fresh adult cadavers. The flaps were randomized into three groups (n = 4 per group): the full-thickness flap group; the deep fascia-free flap group, and the subcutaneous adipose layer-free group. The flaps were smoothened on a silk screen on a batten frame and the isolated flaps were perfused at a perfusion pressure of 140 mmHg for 10 min via the trunk of the posterior tibial artery. Perforator flaps were photographed using a digital camera and radiographed using a mammography device. The imaging data were processed by digital software system. RESULTS The mean number of the posterior tibial artery perforator was 4.17 ± 0.94. The three relatively constant perforators varied in the projection points as well as the diameter and the length. The vascular branches and courses of the perforators were clearly visible on the mammograms. Elimination of all the deep fascia or the subcutaneous adipose tissues in the distal portion had no significant impact on the blood supply of posterior tibial artery perforator flaps while the vascular areas of the artery perforators were significantly reduced after the subcutaneous adipose tissue was eliminated in the proximal portion. CONCLUSIONS We developed an effective modified technique for delineating the vascular territory on perforator flaps of different thicknesses. Our results provide significant guidance for clinical surgeons by providing them with more detailed anatomical knowledge of perforator flaps.
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Affiliation(s)
- Dazhi Yu
- Department of Hand Surgery, Hospital 401 of the People's Liberation Army (PLA), Qingdao, Shandong, China.,Department of Orthopedic and Traumatic Surgery, General Hospital of Jinan Military Command, Jinan, Shandong, China.,Department of Plastic Surgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Qiang Hou
- Department of Plastic Surgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Antang Liu
- Department of Plastic Surgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Haiping Tang
- Department of Hand Surgery, Hospital 401 of the People's Liberation Army (PLA), Qingdao, Shandong, China
| | - Guangrong Fang
- Department of Hand Surgery, Hospital 401 of the People's Liberation Army (PLA), Qingdao, Shandong, China
| | - Xiaodong Zhai
- Department of Hand Surgery, Hospital 401 of the People's Liberation Army (PLA), Qingdao, Shandong, China
| | - Hua Jiang
- Department of Plastic Surgery, Changzheng Hospital, Second Military Medical University, Shanghai, China.
| | - Xuecheng Cao
- Department of Orthopedic and Traumatic Surgery, General Hospital of Jinan Military Command, Jinan, Shandong, China.
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