Distally based perforator propeller sural flap for foot and ankle reconstruction: a modified flap dissection technique. Ann Plast Surg. 2014;72:340-345. [PMID: 23277108 DOI: 10.1097/sap.0b013e31826108f1]

A new skin flap from the zygomaticotemporal region: Anatomical study and clinical application to eyelid reconstruction

BACKGROUND

Eyelid reconstruction is a demanding task faced by plastic surgeons. Island flaps from the zygomaticotemporal region, where the zygomatico-orbital artery predominates in vascularization, represent the recent local approaches to this problem. Questions exist as to where and on what element the flap should be based, and whether or not they should be adapted in relation to the behavior of the zygomatico-orbital artery.

METHODS AND MATERIALS

A total of 22 fresh-frozen adult cadaver heads were employed. The fasciocutaneous perforators of the zygomatico-orbital artery and their anastomoses with the surrounding arteries, especially those in the upper palpebra, were investigated. On this basis, a distally based perforator flap was created and executed for eyelid reconstruction in 7 patients.

RESULT

The zygomatico-orbital artery was interconnected through its perforators with the subdermal plexus over the zygomaticotemporal region and with the arteries in the surroundings. The transverse facial artery took the place of zygomatico-orbital artery where it was absent. Both the arteries anastomosed consistently with the superficial orbital arcade at a predictable site. All 7 flaps survived completely.

CONCLUSION

A new distally based perforator flap from the zygomaticotemporal region is described regarding its anatomical basis and clinical applications to eyelid reconstruction. With a vascular axis consistently present and a pivot adjacent to the defects, the flap is more reliable in vascularization, and less harm to its donor site than orbicularis oculi myocutaneous flaps, and poses no concern about whether the zygomatico-orbital artery is present or not.

Comparison of "complications" and functional outcome of anterolateral thigh flap and sural neurofasciocutaneus flap for foot and ankle reconstruction: A single center cohort study

BACKGROUND

Skin and soft-tissue defects around the foot and ankle remain a challenge for orthopedic and plastic surgeons. Anterolateral thigh (ALT) flap and sural neurofasciocutaneous (NFC) flap are both used to reconstruct lower-extremity soft-tissue defects. The purpose of this study was to compare outcomes of the two flaps and attempt to provide an optimal strategy.

METHODS

A retrospective study was conducted, reviewing data from 93 patients who underwent reconstruction of wounds around the foot and ankle with ALT flap (42 cases) or NFC flap (51 cases) from January 2014 to January 2020. Patients' demographics, characteristics of the defect, complications, cosmetic appearance, and functional outcome were analyzed, and statistical analysis was performed.

RESULT

There was no difference in gender and etiology; however, NFC flaps were more frequently used in elderly patients. Mean size of the flap in the ALT group was significantly larger in comparison with the NFC group. The ALT group had longer operation and hospitalization time than the NFC group (P < 0.05). The incidence of partial necrosis in ALT group was significantly lower than that in NFC group, while its general complications rate was higher. In long-term follow-up, esthetic appearance of the reconstructed site was comparable in both groups, the ALT group had a higher ratio of revision surgery. Moreover, the ALT group showed better overall esthetic outcomes in the donor site.

CONCLUSIONS

The study showed that anterolateral thigh flaps in wound coverage of foot and ankle achieved better outcomes than neurofasciocutaneous flaps in terms of recipient benefits and donor-site compromise with a special indication for larger and more distally located defects.

Calcaneogenesis: the use of tibial bone transport for treatment of massively infected hindfoot defects

Massive hindfoot defects which result after se- questrectomy of chronic osteomyelitis (COM) or Trauma or after tumors resection is a real challenge to the treating surgeons with either amputation or other reconstructive plastic procedures as the only available options, Calcaneal osteomyelitis is a major cause with classical surgical management to cure the infection has limited success in preservation of the hindfoot shape, function, and mechanical stability. The surgical procedure reported with the use of the Ilizarov apparatus for partial or total calcaneal OM is aimed to preserve the Hindfoot.

Materials and Methods

We retrospectively reviewed 10 patients which were treated by radical debridement of the infected area, Ilizarov frame application and arthrodesis with bone reconstruction by the Ilizarov apparatus using tibial transport for Hindfoot salvage. The mean age at presentation was 33.5 years (range; 24-57) and the mean follow-up was 5.1 years (range; 2-12).Patients clinical and radiographic data were assessed according to the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle- Hindfoot score.

Results

The mean preoperative American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score was 48.3(range; 38-86) while the mean postoperative (AOFAS) was 58.5 (range; 45-73) , p value < 0.01 . Clinically all patients had anatomically stable feet with deformity correction and no signs of infection recurrence.

Conclusion

The use of Ilizarov distal tibial bone transport to fill massive hindfoot defects proved to be a reliable method for elimination of infection and reconstruction of large defects without the need for bony or soft tissue plastic procedures. The technique also has the ability to produce a rigid limb fixation following debridement and to fill in massive hindfoot defects due to other etiologies as well.

Versatility of the Peroneal Perforator Propeller Sural Flap for Various Types of Injuries in the Ankle and Foot Regions

OBJECTIVES

The goals of soft tissue reconstruction in the distal lower extremities are to provide a functional limb and to help patients return to a normal life with the capability of wearing shoes or boots. A peroneal perforator propeller sural flap is a combination of a sural flap and a peroneal propeller perforator flap. This article presents the versatility of this flap in the foot and ankle regions.

PATIENTS AND METHODS

Eleven peroneal perforator propeller sural flaps were harvested to reconstruct the ankle and foot regions. There were 9 male and 2 female patients, with ages ranging from 9 to 64 years. The flaps were used for 7 different defect types including avulsion, gunshot, crush injury, diabetic foot, defect secondary to orthopedic surgery, tumor resection, and electrical burn. The flaps included 3 different insetting types and 2 different utilizations of the sural nerve.

RESULTS

Eight direct propeller flaps, 2 interpolation propeller flaps, and 1 passing-through-style propeller flap were harvested as flap insetting types. In 1 patient, sural nerve coaptation was used, and in 2 patients, an additional posterior tibial artery perforator flap was used. One patient underwent surgery at the time of the injury. Only 2 patients had complications related to the type of injury. There was no need for debulking surgery for patients to wear their own shoes or boots.

CONCLUSIONS

The peroneal perforator propeller sural flap can be harvested as a sensory flap with sural nerve coaptation, a passing-through- style, an interpolation style, an extended style, or as a component of double perforator flaps. This type of flap provides various options in the challenging field of reconstructive surgery.

Repair of Small-Size Wound With Achilles Tendon Exposure With Proximal Pedicled Cutaneous Neurovascular Flap

OBJECTIVE

To investigate the clinical outcomes associated with repairing of small-sized wounds of Achilles tendon exposure with proximal pedicled cutaneous neurovascular flap in the dorsolateral foot.

METHODS

After thorough debridement, 16 cases with small-sized wounds of Achilles tendon exposure were repaired by proximal pedicled cutaneous neurovascular flap of the dorsolateral foot, and their clinical outcomes were observed.

RESULTS

All the flaps in the 16 cases survived completely, excluding the marginal part necrosis in 1 case, and all the wounds were healed. The 2-point discrimination of the flaps was 14.53 ± 1.55 mm (range, 12-17 mm) in patients without sural nerve injury after 3 to 18 months follow-up. No discomfort was felt in wearing normal shoes by all the 16 patients.

CONCLUSIONS

It is reasonable to repair the small-sized wounds of Achilles tendon exposure with proximal pedicled cutaneous neurovascular flap of dorsolateral foot due to its effective repair of the wound, relatively uncomplicated surgery, and had satisfactory healing recovery.

Perforator Detection by Thermographic Imaging Augmented With Tourniquet-Reperfusion: A Modified Approach and Preliminary Report in Distal Lower Leg Reconstruction

BACKGROUND

Dynamic infrared thermography provides a new imaging method of perforator detection. This study introduces an augmented technique to improve its accuracy by tourniquet-reperfusion and reports its preliminary use in the distal lower leg reconstruction.

METHODS

A tourniquet (450 mm Hg) was applied for 3 minutes on proximal thighs. After the tourniquet release, the rewarming rate and pattern of hotspots were observed by thermography to delineate the location and quality of perforators. The results were compared with those detected by computed tomographic angiography. Clinically, the local transferred posterior tibial artery or peroneal artery propeller perforator flap was performed in 9 patients for the distal lower leg reconstruction.

RESULTS

There was a 20- to 140-second "perforator observing window" after the tourniquet release. Tourniquet-reperfusion augmented thermal imaging method (TRATIM) had a sensitivity of 90.3% and a positive predictive value of 93.3%. The TRATIM and computed tomographic angiography had an excellent concordance with a kappa index value of 0.839 (P < 0.001). Based on the TRATIM, 9 propeller perforator flaps were successfully designed and raised for the distal lower leg resurfacing. All flaps survived entirely, except one with size of 1.0 cm × 2.0 cm that had terminal necrosis.

CONCLUSIONS

The TRATIM is a quick, easy, cheap, and reliable approach for perforator detection in the lower leg. With the aid of TRATIM, a customized propeller perforator flap could be raised efficiently for the distal lower leg reconstruction.

[Clinical study of modified technique to reduce partial necrosis rate of distally pedicled sural flap]

Objective

To investigate whether the technical modifications regarding the risk factors related to the partial necrosis of the distally pedicled sural flap could reduce the partial necrosis rate of the flap.

Methods

A clinical data of 254 patients (256 sites) (modified group), who used modified technique to design and cut distally pedicled sural flaps to repair the distal soft tissue defects of the lower limbs between April 2010 and December 2019, was retrospectively analyzed. Between April 2001 and March 2010, 175 patients (179 sites) (control group) who used the traditional method to design and cut the skin flap to repair the distal soft tissue defects of the lower limbs were compared. Various technical modifications were used to lower the top-edge of the flap, reduce the length-width ratio (LWR) of the flap and width of the skin island. There was no significant difference in gender, age, etiology, duration from injury to operation, site and area of the soft tissue defect between groups ( P>0.05). The length and width of the skin island and adipofascial pedicle, the total length of the flap and LWR, and the pivot point position were measured and recorded. The top-edge of the flap was determined according to the division of 9 zones in the posterior aspect of the lower limb. The occurrence of partial necrosis of the flap and the success rate of defect reconstruction were observed postoperatively.

Results

There was no significant difference in the length and width of the skin island, the length of the adipofascial pedicle, total length and LWR of the flap, and pivot point position of the flap between groups ( P>0.05). The width of the adipofasical pedicle in modified group was significant higher than that in control group ( t=-2.019, P=0.044). The top-edge of 32 flaps (17.88%) in control group and 31 flaps (12.11%) in modified group were located at the 9th zone; the constituent ratio of the LWR more than 5∶1 in modified group (42.58%, 109/256) was higher than that in control group (42.46%, 76/179); and the constituent ratio of width of skin island more than 8 cm in control group (59.78%, 107/179) was higher than that in modified group (57.42%, 147/256). There was no significant difference in the above indicators between groups ( P>0.05). In control group, 155 flaps (86.59%) survived completely, 24 flaps (13.41%) exhibited partial necrosis. Among them, 21 wounds healed after symptomatic treatments, 3 cases were amputated. The success rate of defects reconstruction was 98.32% (176/179). In modified group, 241 flaps (94.14%) survived completely, 15 flaps (5.86%) exhibited partial necrosis. Among them, 14 wounds healed after symptomatic treatments, 1 case was amputated. The success rate of defect reconstruction was 99.61% (255/256). The partial necrosis rate in modified group was significantly lower than that in control group ( χ ²=7.354, P=0.007). There was no significant difference in the success rate between the two groups ( P=0.310). All patients in both groups were followed up 1 to 131 months (median, 9.5 months). All wounds in the donor and recipient sites healed well.

Conclusion

The partial necrosis rate of the distally based sural flap can be decreased effectively by applying personalized modified technical for specific patients.

A randomized trial of use of a modified reverse sural neurofasciocutaneous flap to extend the reconstruction range

Background

When a reverse sural neurofasciocutaneous flap is used to reconstruct a forefoot defect, usually, the transverse length of the flap is increased or the pivot point is lowered to ensure the reconstruction range. Therefore, proximal partial necrosis leading to surgery failure is sometimes caused by insufficient arterial supply if the flap is too long or the pivot point is too low and has no a reliable perforator in the pedicle. Herein, we describe a new method for extending the reconstruction range of the reverse sural neurofasciocutaneous flap that can provide a higher survival rate.

Methods

Between July 2010 and July 2014, 24 patients with forefoot defect were randomly assigned into two groups. In the research group, 12 modified reverse sural neurofasciocutaneous flaps with extended reconstruction range were used to reconstruct forefoot defect. We dissected the septum along the last perforator to locate the main trunk of the peroneal artery, disconnected the proximal end of the peroneal artery at the root of the perforator, and separated the peroneal artery more distally to obtain a lower rotation point to extend the reconstruction range. The last perforator and a section of the peroneal artery were contained in the pedicle. In the control group, 12 traditional reverse sural neurofasciocutaneous flap procedures were performed.

Results

In the research group, 11 flaps survived with good quality and esthetic contours. Partial distal necrosis occurred in 1 flap. In the control group, 7 flaps survived. Partial necrosis occurred in the other 5 flaps. Compared with control group, the survival rate in the research group was significantly higher while the healing time was significantly shorter. All patients were satisfied with the therapeutic outcome in the research group.

Conclusions

Our modified method proved efficacious in extending the reconstruction range of the reverse sural neurofasciocutaneous flap. Meanwhile, partial necrosis was avoided because the length of the flap was shortened, and a reliable perforator was preserved in the artery pedicle.

Trial Registration

Chictr.org Identifier: ChiCTR2100046323.

Distally Based Sural Adipofascial Turnover Flap for Coverage of Complicated Wound in the Foot and Ankle Region

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.

Reliability of distally based sural flap in elderly patients: comparison between elderly and young patients in a single center

Background

Reconstructions the soft-tissue defects of the distal lower extremities in the elderly patients (≥ 60 years old) are full of challenges because of many comorbidities. The purpose of this study was to report the clinical application of the distally based sural flap in the elderly patients, and to verify the reliability of this flap in the elderly patients.

Methods

Between March of 2005 and December of 2019, 53 patients aged over 60-year-old and 55 patients aged 18 to 30-year-old who underwent the procedure have been included in this study. The reconstruction outcomes, medical-related complications, flap viability-related complications and potential risk factors are compared between the group A (≥ 60 years old) and group B (ranging from 18 to 30 years old).

Results

The partial necrosis rate in group A (9.43%) is higher than group B (9.09%), but the difference is not significant (P > 0.05). The constitute ratio of the defects that were successfully covered using the sural flap alone or combining with simple salvage method (i.e., skin grafting) is 96.22% and 98.18% in group A and B, respectively (P > 0.05). The differences of the risk flaps factors that affected the survival of distally based sural flap were not significant between group A and B (P > 0.05).

Conclusions

The distally based sural flap can be effectively used to repair the soft-tissue defect of the lower extremity in the elderly patients. It is safe and reliable to harvest and transfer the flap in one stage, and the delay surgery is not necessary.

Modified Anterior Tibial Artery Perforator-Pedicled Propeller Flap for Soft-Tissue Coverage of the Ankle and Heel

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.

A Retrospective Study of an Updated and Traditional Surgical Approach of the Distally Based Sural Flap

BACKGROUND

 The distally based sural flap (DBSF) is one of the armamentarium in the lower limb reconstruction. However, the flap has not gained popularity due to concerns about its reliability and donor site morbidity. Based on the anatomy characterization, we combined and developed five modifications to improve the vascular supply and reduce donor site morbidity.

PATIENTS AND METHODS

 The authors performed a comparison of retrospective study that included patients who underwent either traditional distally based sural flap (tDBSF) or modified distally based sural flap (mDBSF) surgery approach for ankle, heel, and dorsal foot coverage between January 2007 and May, 2019. The five modifications developed to improve the reliability of the flap include: 1. shift the pivot point more proximally 7.0 cm above the lateral malleolus, 2. preserve the lesser saphenous vein and include branches that communicates with the flap, 3. harvest thinner fascial pedicle, 4. change the skin incision to "S" shape, 5. closure of the donor site with a propeller flap.

RESULTS

 Thirty-one patients underwent mDBSF, and 23 received tDBSF. There were no significant differences in the size of the DBSF. Mean pedicle width was significantly narrower in mDBSF (1.63 ± 0.52 cm vs. 3.81 ± 0.70 in tDBSF). The pivot point was also found to be higher in mDBSF (8.01 ± 0.63 cm vs. 5.46 ± 0.56 cm) above the lateral malleolus. In mDBSF, the size of the propeller flap required for donor site closure was 53.45 ± 19.06 cm² (range 33-80 cm²). The rate of partial necrosis between mDBSF and tDBSF was significantly different (9.68 vs. 34.78%). While the other complications had no difference.

CONCLUSION

 The modifications applied to the harvesting of the DBSF have achieved higher survival rate, lower dehiscence rate, and shorter hospital stay time in comparison with traditional approach in our retrospective study.

Free perforator flaps vs propeller flaps in lower limb reconstruction: A cost/effectiveness analysis on a series of 179 cases

PURPOSE

The aim of this report is to compare free perforator flaps and propeller flaps in the coverage of lower limb soft tissue defects.

PATIENTS AND METHODS

179 patients (age between 5 and 92 years old), underwent soft tissue reconstruction of the lower limb between January 2009 and January 2015, either by free flap or propeller flap. The two groups were retrospectively evaluated in order to assess the outcome, complications and potential risk factors. Correlations between risk factors and presence/absence of failure or complications have been evaluated with descriptive statistical analysis and a set of logistic regression models. Finally, an economic analysis was conducted to evaluate the different tecniques.

RESULTS

In a simple descriptive statistical analysis, the overall failure rate is 6% for free flaps and 3.7% for propeller flaps; the complication rates are 14% vs 21.5% and it increases as dimension increases. The logistic models relating failure and complications with potential risk factors do not show significant differences, whereas the economic analysis show that the average expense of free flaps is 5077.5€ per patient, 1595.6€ per patient for propeller flaps.

CONCLUSIONS

Our results do not demonstrate significant differences between the two groups about correlation of risk factors or flap size with complication or failure. The surgical option choice should be taken only after accurate evaluation of the soft tissue surrounding the defect. Propeller flaps should be preferred in case of small/medium size defects in otherwise healthy extremities. Free perforator flaps should be the choice in large defects due to trauma or vascular diseases. The economic analysis suggests that propeller flap should be considered when possible.

Double-pedicle propeller flap for reconstruction of the foot and ankle: anatomical study and clinical applications

Objective

Reconstruction of soft tissue defects in the foot and ankle remains challenging. This study was performed to investigate the technical points and clinical effects of a double-pedicle propeller flap for repair of foot and ankle soft tissue defects.

Methods

We used five fresh calf specimens to investigate the anatomical and operative aspects of a double-pedicle propeller flap. Eighteen patients with soft tissue defects in the foot and ankle subsequently underwent defect repair with double-pedicle propeller flaps.

Results

The anatomical study showed that the peroneal artery perforators and the sural nerve bundle (two blood supply systems) provided the theoretical anatomical basis for the double-pedicle propeller flap. The relative positions of the peroneal artery perforators and the sural nerve bundle differ according to the peroneal artery perforating level. Flap rotation in different directions can reduce or prevent the pedicles from compressing each other. All flaps survived, and three flaps developed local epidermal necrosis at the proximal end; these flaps healed after 1 to 2 weeks of dressing changes. The other 15 patients healed well.

Conclusions

The double-pedicle propeller flap can enhance the blood supply and venous return in the “big paddle” region of the flap, reducing the distal necrosis rate.

Skin fiducial markers enable accurate computerized navigation resection of simulated soft tissue tumors: A static cadaveric model pilot study

BACKGROUND

This static cadaveric model pilot study evaluated the agreement between planned and resected margins of simulated soft tissue tumors (SSTT) using skin fiducial markers for computerized navigation registration.

METHODS

Markers were applied before magnetic resonance imaging scans of lower extremities implanted with SSTT. A navigation pointer was used for registration and to guide SSTT resection with approximately 10 mm planned margins. Digital calipers were used to measure resection margins. Kolmogorov-Smirnov tests were used to confirm measurement normality. A one-sample t test was used to determine measurement group differences (P ≤ 0.05). Bland-Altman analysis and histogram plots compared planned and resected margins.

RESULTS

Ninety-eight resection margins were measured. The planned margin mean was 10.0 mm (95% confidence interval [CI] = 9.8-10.2 mm) and the resected margin mean was 11.5 mm (95% CI = 11.0-12.1 mm). One-sample t test results identified a 0.75 mm, 95% CI = 0.5-0.99 mm difference (P < 0.001). Good measurement agreement was observed with 94.9% (93/98) of resections occurring within two standard deviations of the mean measurement difference.

CONCLUSIONS

Skin fiducial marker use for computerized navigation system registration displayed promising results. With further research, these markers may become an effective, noninvasive method for aiding in soft tissue tumor resection.

Reconstruction of foot and ankle defects with a superthin innervated anterolateral thigh perforator flap

BACKGROUND

An anterolateral thigh (ALT) perforator flap can be thinned to an extent to which it is vascularised only by the subdermal plexus. This study presents an innervated flap thinning technique and its application for dorsal foot and ankle resurfacing.

METHODS

A superthin innervated ALT perforator flap was used to repair the dorsal foot and ankle of 12 patients. The perforators were classified according to their variations in the adipose layer, and the corresponding microdissection technique was then applied. The branch of the lateral femoral cutaneous nerve and its accompanying vessels were adopted to construct a sensory flap.

RESULTS

The flap thickness before defatting, which was measured immediately after flap elevation, ranged from 25-45 mm. The average flap thickness after defatting was 4.55 mm (range = 3-6 mm). A total of 11 flaps completely survived, and one flap presented superficial necrosis within a small area (2 cm ×2 cm) in the distal part of the flap. No further flap revision or defatting procedures were required for these patients during an average follow-up period of 16.5 months (range = 10-24 months). In the transferred flap, protective sensibility existed in all cases, and the static two-point discrimination was 13-16 mm.

CONCLUSIONS

The superthin innervated ALT perforator flap may be considered as an ideal strategy for foot and ankle reconstruction.

A Systematic Review and Meta-Analysis of Perforator-Pedicled Propeller Flaps in Lower Extremity Defects: Identification of Risk Factors for Complications

BACKGROUND

Currently, increased interest in the perforator-pedicled propeller flap should not obscure the fact that it is, in reality, a complex procedure requiring experience and monitoring similar to free flaps. Through a meta-analysis, the authors aimed to identify the risk factors of perforator-pedicled propeller flap failure in lower extremity defects.

METHODS

The MEDLINE, PubMed Central, Embase, and Cochrane databases were searched from 1991 to May of 2014 for articles describing perforator-pedicled propeller flaps in the lower extremity. The study selection met the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Fixed-effects models were used.

RESULTS

Forty articles complied with the inclusion criteria, representing 428 perforator-pedicled propeller flaps. The most common cause was posttraumatic (55.2 percent). Most of the defects were at the distal third of the lower leg (45.6 percent). The arc of rotation was 180 degrees for 34.3 percent. Complications were found in 25.2 percent, including partial necrosis (10.2 percent) and complete necrosis (3.5 percent). Complete flap survival was found in 84.3 percent. The authors identified three significant risk factors: age older than 60 years (relative risk, 1.61; p = 0.03), diabetes (relative risk, 2.00; p = 0.02), and arteriopathy (relative risk, 3.12; p = 0.01). No significant results were found regarding smoking status other than a tendency (p = 0.06), acute cause (p = 0.59), posttraumatic cause (p = 0.97), distal third of the lower leg (p = 0.66), fascia inclusion (p = 0.70), and pedicle rotation greater than 120 degrees (p = 0.41).

CONCLUSION

Age older than 60 years, diabetes, and arteriopathy are significant risk factors of perforator-pedicled propeller flap complications in the lower extremity.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, IV.

Free versus perforator-pedicled propeller flaps in lower extremity reconstruction: What is the safest coverage? A meta-analysis

INTRODUCTION

Currently, increasingly reconstructive surgeon consider the failure rates of perforator propeller flaps especially in the distal third of the lower leg are too important and prefer to return to the use of free flap at first line option with failure rates frequently lower than 5%. So, we performed a systematic review with meta-analysis comparing free flaps (perforator-based or not) and pedicled-propeller flaps to respond to the question "what is the safest coverage for distal third of the lower limb?"

METHODS

This review was conducted according to PRISMA criteria. From 1991 to 2015, MEDLINE®, Pubmed central, Embase and Cochrane Library were searched. The pooled estimations were performed by meta-analysis. The homogeneity Q statistic and the I² index were computed.

RESULTS

We included 36 articles for free flaps (1,226 flaps) and 19 articles for pedicled-propeller flaps (302 flaps). The overall failure rate was 3.9% [95%CI:2.6-5.3] for free flaps and 2.77% [95%CI:0.0-5.6] for pedicled-propeller flaps (P = 0.36). The complication rates were 19.0% for free flaps and 21.4% for pedicled-propeller flaps (P = 0.37). In more detail, we noted for free flaps versus pedicled-propeller flaps: partial necrosis (2.70 vs. 6.88%, P = 0.001%), wound dehiscence (2.38 vs. 0.26%, P = 0.018), infection (4.45 vs. 1.22%, P = 0.009). The coverage failure rate was 5.24% [95%CI:3.68-6.81] versus 2.99% [95%CI:0.38-5.60] without significant difference (P = 0.016).

CONCLUSION

In the lower limb the complications are not rare and many teams consider the free flaps to be safer. In this meta-analysis we provide evidence that failure and overall complications rate of perforator propeller flaps are comparable with free flaps. Although, partial necrosis is significantly higher for pedicled-propeller flaps than free flaps, in reality the success of coverage appears similar. © 2016 Wiley Periodicals, Inc. Microsurgery, 38:109-119, 2018.

A convenient flap for repairing the donor area of a distally based sural flap: Gastrocnemius perforator island flap

OBJECTIVE

The reconstruction of complex lower leg and foot defects is difficult for plastic surgeons. The distally based sural flap (DBSF) is an option for non-free flap lower leg reconstruction. However, one of the major drawbacks of the DBSF is its aesthetically non-acceptable donor area scarring.

MATERIALS AND METHODS

Eight patients (six men and two women) who had lower leg or foot defects were evaluated in this study. We used an ipsilateral or cross-leg DBSF to repair the defect. A medial or lateral gastrocnemius perforator island flap (average size 8.1 × 6.1 cm) was used to cover the donor area of the DBSF in a two-stage operative procedure.

RESULTS

We did not observe any complications with the gastrocnemius perforator island flap. Two patients had local infections under the DBSF and were treated with bacteria-specific antibiotherapy. All patients were followed up for 1 year postoperatively. The donor areas of the distally based sural flaps were aesthetically acceptable. Patients gained ambulatory status during the follow-up period.

CONCLUSIONS

Reconstruction of the donor area of a DBSF with a gastrocnemius perforator island flap allows for more acceptable aesthetics and functional results than do other reconstructive procedures.

Distally based perforator sural flaps for foot and ankle reconstruction

Distally based perforator sural flaps from the posterolateral or posteromedial lower leg aspect are initially a neurofasciocutaneous flap that can be transferred reversely to the foot and ankle region with no need to harvest and sacrifice the deep major artery. These flaps are supplied by a perforating artery issued from the deep peroneal artery or the posterior tibial artery, and the chain-linked adipofascial neurovascular axis around the sural/saphenous nerve. It is a versatile and reliable technique for soft-tissue reconstruction of the heel and ankle region with 180-degrees rotation. In this paper, we present its developing history, vascular basis, surgical techniques including flap design and elevation, flap variations in pedicle and component, surgical indications, and illustrative case reports with different perforating vessels as pivot points for foot and ankle coverage.

Risk factors associated with complications in lower-extremity reconstruction with the distally based sural flap: a systematic review and pooled analysis

The distally based sural fasciocutaneous flap is one of the few options available for local flap reconstruction of soft-tissue defects in the lower one-third of the leg. Few studies have assessed risk factors associated with poor outcomes in this flap. A literature search was performed of MEDLINE, EMBASE, CINAHL and the Cochrane Library for articles evaluating the use of sural artery fasciocutaneous flaps for soft-tissue reconstruction of the leg. Data were pooled and a univariate analysis was performed to identify characteristics associated with increased morbidity. A logistic regression model was created, and odds ratios and p values associated with the development of complications were calculated. Sixty-one papers were identified which included data on 907 patients. The majority of sural flaps were used to cover defects of the heel (28.2%), foot (14.4%) or ankle (25.8%). Trauma was the most common indication, followed by ulcers and open fractures. Flap complications were recorded in 26.4% of cases with a flap loss rate of 3.2%. With multivariate analysis, venous insufficiency and increasing age were independent risk factors for complications. Patients with venous insufficiency had nine times the risk of developing a complication compared to patients without venous insufficiency.