Single-stage Achilles tendon reconstruction using a composite sensate free flap of dorsalis pedis and tendon strips of the extensor digitorum longus in a complex wound

The reconstruction of the posterior heel including a wide defect of the Achilles tendon is difficult as a result of complicated infection, deficient soft tissue for coverage, and functional aspects and defects of the tendon itself. As a single-stage procedure, various methods of tendon transfer and tendon graft have been reported along with details of local flaps or island flaps for coverage. With advances in microsurgical techniques and subsequent refinements, several free composite flaps, including tendon, fascia, or nerve, have been used to reconstruct large defects in this area without further damaging the traumatized leg. The authors report such a single-stage reconstruction of a composite Achilles tendon defect using the extensor digitorum longus tendon of the second to fourth toe in combination with a dorsalis pedis flap innervated by the superficial peroneal nerve. The follow-up of this case has proved a satisfactory outcome to date.     

The reverse sural flap: modifications to improve efficacy in foot and ankle reconstruction

The aim of this work is to evaluate the efficacy of the reverse sural flap in covering defects in the foot and ankle region when certain technical modifications are employed. We provide a retrospective review of 32 consecutive reverse sural flaps for foot and ankle defects, and compare the technique and results with other reports. There were 23 fasciocutaneous flaps, 7 fascial flaps, and 2 tissue-expanded flaps. Four flaps (12.5%) suffered significant flap loss, and 4 patients had delayed healing.Several modifications are suggested to increase the versatility of the sural flap in covering foot and ankle defects, including preserving the mesentery connecting the sural nerve to the deep fascia, inclusion of skin of the upper third of the leg, limiting pedicle width to 2 cm with preservation of a tongue-like skin process all along its length, and generous release of the fascia over the peroneal compartment. In addition, we describe the use of tissue expanded sural flaps.     

Lower leg reconstruction using a sural fasciocutaneous flap

The fasciocutaneous flap in the lower leg has been widely used since Pontén's 1981 report. The cutaneous artery running along the sural nerve--known as the superficial sural artery--has an important role in the blood supply of the fasciocutaneous flap in the lower leg as stated by Haertsch. The superficial sural artery has great variation with regard to its location and the origin of the vessel. The cutaneous artery is intimately connected to the sural nerve or the lateral sural nerve. It may run along the sural nerve or along the lateral sural nerve. We examined this vessel in 10 cadaver dissections and applied it in 17 clinical cases of pedicled, island, and free flaps. The island sural fasciocutaneous flap is particularly versatile for the reconstruction of the soft tissue defect around the knee joint. The operative procedure involving the island fasciocutaneous flap and the characteristics of this sural fasciocutaneous flap are described.     

小腿后侧岛状筋膜皮瓣血供的解剖观察及临床应用

目的 研究小腿后侧岛状筋膜皮瓣的血供基础,评价该岛状皮瓣修复膝关节前区组织缺损的临床效果.方法 通过文献回顾总结,在8具16侧尸体小腿后区解剖学研究基础上,临床应用以小腿外侧腓肠浅血管和外侧腓肠皮神经为蒂的岛状筋膜皮瓣,修复膝关节前区组织缺损共10例.结果 小腿后区浅层共有外侧、中间、内侧3套腓肠浅血管系统,它们分别从膪动脉直接发出,或从两侧供养腓肠肌的腓肠动脉发出,而小腿外侧腓肠浅血管的出现率为100%.临床共应用10例,9例完全成活,1例远端1/4部分坏死,经换药后愈合.术后随访6～12个月,皮瓣质地柔软,外形满意,感觉良好.结论 小腿后侧岛状筋膜皮瓣是一个血供稳定、丰富,含有丰富保护性感觉神经的皮瓣,是修复膝关节周围软组织缺损的较好方法.     

The reverse sural fasciomusculocutaneous "mega-high" flap: a study of 20 consecutive flaps for lower-limb reconstruction

The reverse sural artery flap was initially described as a fasciocutaneous flap and has become an acceptable technique of lower-limb reconstruction. The flap was recently modified to include a midline gastrocnemius muscle cuff around the sural pedicle in the upper part of the leg, and hence improving its blood supply. Large lower-limb defects require "mega" flaps (including the whole width of the calf) harvested "high" all the way up to the popliteal fossa. The following study was designed to answer the following question: Is this "mega-high" reverse sural fasciomusculocutaneous flap reliable? A total of 20 consecutive male patients with large lower-limb defects who were reconstructed with this flap were included. The skin of the whole width of the upper calf (extending 2-3 cm below the popliteal fossa crease line) was harvested without delay in every case. Primary wound healing of the flap was noted in all patients confirming its reliability. Indications and technical hints to ensure successful reconstruction are discussed.     

Experience with the distally based posterior tibial island flap

A series of ten patients is presented to demonstrate the use of the distally based posterior tibial island flap with or without a muscle component for reconstruction of the foot. Six patients had defects due to a road traffic accident, two had defects due to a work accident, one had extensive scar contractures after a deep burn and advanced Buerger’s disease in another. There was complete survival of all the flaps but one. Four flaps were fasciocutaneous and six myofasciocutaneous, including the medial hemisoleus muscle. This flap is very useful in lower extremity reconstruction, particularly in the lower third of the leg and foot due to its long vascular pedicle, availability of skin and muscle and ease of elevation. All the island flaps were based on the anastomosis between posterior tibial and peroneal arteries above the medial malleolus. Received: 16 December 1997 / Accepted: 1 July 1998     

Retrograde-flow medial plantar island flap reconstruction of distal forefoot,toe, and webspace defects

Plantar forefoot defects have been reconstructed using a wide variety of techniques, including skin grafts, local flaps, and free tissue transfer. The distally based, retrograde-flow medial plantar island flap provides coverage with durable plantar skin from the nonweight-bearing instep area to reconstruct defects at the metatarsal heads. This technique requires careful flap dissection, and the anterior reach of the flap is limited by its pedicle length and vascular pivot point location. The authors describe two cases using this flap for reconstruction of tumor resection defects (5 x 6 cm and 5 x 8 cm) involving the distal forefoot, toes, and webspaces. One case required venous supercharging of a congested flap with an interpositional vein graft. Technical aspects of the design, elevation, and inset of the flap that enhance its versatility and reliability are presented. The reverse-flow medial plantar fasciocutaneous island flap should be considered an option for forefoot defects that extend anteriorly onto the metatarsal heads, including defects involving the toes and webspaces.     

Perforator Propeller Flap “Relay” for Distal Lower Extremity Soft Tissue Reconstruction

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.     

Transinterosseous transfer of a peroneal island flap for reconstruction of prepatellar skin defect: report of two patients.

We describe the use of a peroneal vascular transinterosseous island flap for the resurfacing of a prepatellar skin defect in 2 patients. Being a fasciocutaneous flap, the peroneal flap is thin, and the location of perforators is easily and safely detected with a Doppler flowmeter. When used as a vascular island flap, either a distal pedicle or a proximal pedicle can be used. The peroneal flap can be used as either a free flap or a vascularized fibular and fasciocutaneous flap. It may, therefore, be applied to compound skin, subcutaneous tissue, and bone defects in the lower extremities. A peroneal vascular transinterosseous island flap can reach a prepatellar skin defect, whereas the peroneal island flap with conventional proximal pedicle cannot.     

Comparison between distally based peroneal and posterior tibial artery perforator-plus fasciocutaneous flap for reconstruction of the lower extremity

BackgroundDistally based peroneal artery perforator-plus fasciocutaneous (DPAPF) flaps and distally based posterior tibial artery perforator-plus fasciocutaneous (DPTAPF) flaps are widely used to reconstruct soft-tissue defects of the distal lower leg, ankle, and foot. However, a comparative study of both flaps in a considerable sample size is lacking. This retrospective study aimed to compare the efficacy of the flaps and provide referential evidence for selection of flaps.MethodsBetween April 2001 and October 2016, 227 patients underwent reconstruction with DPAPF flaps (peroneal group; n = 150) or DPTAPF flaps (posterior tibial group; n = 82). The distal lower leg, ankle, and foot were divided into Zones I and II. Flap viability-related complications and their risk factors, reconstruction outcomes, and donor-site morbidities were compared.ResultsIn Zone I, the partial necrosis rate was lower in the peroneal group than in the posterior tibial group (p > 0.05). In Zone II, the partial necrosis rate was significantly lower in the peroneal group (p < 0.05). Significantly lower incidences of donor-site morbidities in terms of hypertrophic scarring, itching, and pigmentation were observed in the peroneal group (p < 0.05).ConclusionsThe DPAPF flap was superior to the DPTAPF flap with respect to reliability and decreased donor-site morbidities. The former is the recommended preferential choice between the two.     

逆行腓肠神经营养血管皮瓣的感觉重建

目的 探讨逆行腓肠神经营养血管皮瓣切取后皮瓣与足外侧的感觉重建方法和临床疗效.方法 对足跟软组织缺损病例13例,应用逆行腓肠神经营养血管皮瓣修复的同时,将皮瓣内的腓肠神经近端与腓浅神经吻合,重建皮瓣和足外侧感觉,术后9～15个月随访,测试皮瓣和足外侧的痛觉、触觉、温度觉和两点辨别觉恢复情况.结果 13例皮瓣全部成活,皮瓣血运良好,修复创面一期愈合,随访9～15个月,皮瓣感觉恢复优良率为53.85%,足背外侧皮肤恢复保护性感觉,感觉恢复优良率61.54%.结论 应用逆行腓肠神经营养血管皮瓣修复足跟软组织缺损时,将腓肠神经近端与腓浅神经吻合,可改善皮瓣和足背外侧皮肤感觉功能恢复.

Abstract：

Objective To explore the method of sensory reconstruction after the operation of reversed island pedicled sural flap and evaluate its therapeutic effect of clinical application. Methods Thirteen clinical cases with traumatic soft tissue defects in heel had recepted the treatment of reversed island pedicled sural flap. All flaps were innervated by anastomosing the distal end of the sural nerve in the flaps and the recipient nerve (superficial peroneal nerve) in end to end or end to side. All patients were evaluated at 9-15 months on the postoperative follow-up parameters, including flap contour, flap stability, locomotor activity,touch sensation, pain sensation, static two-point discrimination, thermal sensibility, and the skin sensory recovery level in lateral dorsutn of foot. Results Thirteen cases flaps had good blood supply and primary healing. All cases were followed up 9-15 months, the rate of good sensory recovery was 53.85%. All pa tients had protective sensory in lateral dorsum of foot, the rate of good sensory recovery was 61.54%. Conclusion Anastomosing the proximal end of sural nerve and superficial peroneal nerve together will be good for the sensory recovery in flap and lateral foot in repairing soft tissue defects in heel with reversed island pedicled sural flap.     

Fasciocutaneous flaps in reconstruction of soft tissue defects below the knee

Reconstruction of soft tissue defects of the lower leg from 1966-2003, using fasciocutaneous flaps is discussed in this paper. Our experience with soft tissues defects in 69 patients is shown here. Different types of fasciocutaneous flaps were used (proximally and distally based fasciocutaneous flap, island, fasciosubcutaneous) based on septocutaneous perforators of all 3 main arterial trunks of the lower leg. We had complete or almost complete necrosis in only 4 patients, whereas in other patients flaps survived. Results obtained using fasciocutaneous flaps, even in reconstruction of war wounds convinced us that fasciocutaneous flaps are reliable method of reconstruction of the soft tissue defects of the lower leg, especially its distal third and regions of malleoli.     

Changes in the peroneal flap and its use in reconstructive surgery of the lower limb. Apropos of an experience of 10 cases]

A peroneal fasciocutaneous flap supplied by the peroneal septocutaneous vessels and raised from the lateral side of the lower leg was reported by Yoshimura in 1983. This flap which can be used as a proximally or distally pedicled or free flap is very useful for leg skin coverage. This flap has a great potential for skin cover and composite reconstruction of the lower limb due to its multiple structural facets (cutaneo-aponevrotic or composite flap), its possible extensions to other vascular territories and the variable geometry of its mode of transfer. 8 reconstructions have been performed. Their indications are described: 4 proximally pedicled flaps (3 with the fibula), 4 reverse-flow island flaps (1 with Soleus and Peroneus longus muscles). The authors stress the importance of preoperative assessment of the feasibility of a given flap which may be limited by post-traumatic, surgical or anatomic modifications. In particular, the uppermost septocutaneous artery which corresponds inconstantly to the "circumflex peroneal artery" can only be visualized by preoperative arteriography. This artery supplies a proximal peroneal flap which can be used as an island or a free flap. We have used this new variety as a free flap in 2 cases and were satisfied with the results. These various clinical applications without any significant complication or flap failure confirm the biological performance and the safe procedure of peroneal flaps.     

小隐静脉-腓肠神经营养血管逆行岛状皮瓣修复儿童足部软组织缺损

目的 探讨小隐静脉-腓肠神经营养血管逆行岛状皮瓣在修复儿童足部软组织缺损中的应用特点.方法 2006年7月至2008年6月,应用小隐静脉一腓肠神经营养血管逆行岛状皮瓣修复儿童足背、足跟及足踝部软组织缺损8例,皮瓣切取范围6 cm×5 cm～9 cm×7 cm,除2例足踝部外,6例修复足背、足跟,皮瓣上界超过小腿中上1/3交界处,其中1例接近胭窝横纹.结果 8例皮瓣全部成活良好.经1-17个月的随访,皮瓣外观满意,感觉功能有部分恢复,足跟处亦未出现溃烂,供区无功能障碍,双小腿发育未见明显差异,外观稍受影响.皮瓣上界可超过小腿中上1/3交界处达胭窝横纹,皮瓣旋转点位于外踝尖后上方4～6 cm.结论 儿童小隐静脉一腓肠神经营养血管逆行岛状皮瓣存活的范围与成人相比差异不大,操作简单,对小腿发育未见明显影响.是修复足部软组织缺损的较好方法.     

Reconstruction of finger pulp defect with reversed fasciocutaneous island flap from same finger

Objective:To investigate the clinical curative effect of reconstruction of finger pulp defect by anastomosis of reversed fasciocutaneous island flap with dorsal branch of the digital nerve of the same finger. Methods: The restoration of finger pulp defect with fasciocutaneous island flap from the same finger was conducted in 25 cases (30 fingers) from January 2002 to June 2003. Nine patients (11 fingers) whose flaps with dorsal branch of the digital nerve anastomosed with the digital inherent nerve around the surface of the wound were Group A and the others were Group B. The follow-up was carried out at 3 and 9 months after the operation to observe the shape of finger pulp and the sense restoration between two groups. Results: All flaps of 25 cases (30 fingers) survived. Three months after operation, the patients had fully grown finger pulps and recovered the superficial sensation and tactile sense of finger pulps. The two point discrimination on average was 5. 00 mm±0. 23 mm in Group A and 6.00 mm±0.30 mm in Group B. The difference between two groups was highly significant. Nine months later, their senses of finger pulps between two groups were recovered basically. Conclusions: The reversed fasciocutaneous island flap from the same finger is the first choice to reconstruct the finger pulp defect, and the anastomosis of dorsal branch of the digital nerve shall be determined according to the specific condition.     

小腿内侧皮瓣在修复口底癌术后缺损中的应用

目的 研究小腿内侧皮瓣在口底癌术后缺损修复中的应用.方法 应用该修复方法,共进行了5例口底癌术后缺损的修复,并对该皮瓣的应用解剖,制作技术及其优缺点进行了讨论.结果 7侧小腿内侧皮瓣均获得成功.口内外伤口均愈合良好,取得了良好的修复效果.覆盖于小腿内侧皮肤缺损区的皮片全部成活.结论 小腿内侧皮瓣适用于口底癌术后组织缺损的修复.对于口腔颌面部肿瘤术后的软组织缺损可利用携带部分比目鱼肌的小腿内侧皮瓣修复软组织缺损.小腿内侧游离皮瓣的皮下脂肪薄,皮瓣较柔软且远离术区,术后供区隐蔽,损伤小.     

Gastrocnemius perforating artery flap including vascularized sural nerve

A degree of communication was found between the superficial sural artery (the concomitant vessel of the sural nerve) and the muscle perforators from the gastrocnemius muscle, together with the cutaneous branches of the peroneal artery. A fasciocutaneous flap designed in the posterior calf region, including the vascularized sural nerve, was elevated based on the perforating artery of the gastrocnemius. This compound flap was used to reconstruct facial nerves and soft-tissue defects created by resection of malignant tumors in three patients. The results were satisfactory, and facial animation returned in two patients, who were followed-up for more than 6 months. This compound flap offers several advantages, such as a long vascular pedicle with a sufficient diameter and a rich blood supply for the sural nerve and fasciocutaneous flap. This new technique should become another choice for vascularized sural nerve grafts, when the superficial sural artery or the cutaneous branches of the peroneal artery are not adequate for flap elevation or microsurgical anastomoses.     

岛状股前外侧皮瓣修复腹股沟及会阴部创面

目的探讨一种皮瓣修复会阴部及腹股沟创面的方法。方法设计以旋股外侧动脉降支为血管蒂的岛状股前外侧皮瓣,掀起皮瓣后经过皮下隧道将其转移至会阴部及腹股沟创面。结果临床治疗12例,皮瓣面积为8cm×11cm～18cm×20cm。除1例皮瓣靠近肛门处部分表皮坏死外,其余成活良好,外形恢复满意。结论以旋股外侧动脉降支为血管蒂的岛状股前外侧皮瓣是修复会阴部及腹股沟创面较好的方法。     

Two modifications of the radial forearm flap for reconstruction of complex facial defects

The free radial forearm flap has been one of the most common free flaps of recent decades. This flap is employed predominantly in head and neck reconstruction. The possibility of combining bone, muscle, and nerves with the fasciocutaneous flap greatly enhanced reconstructive options. However, the frequently unsightly donor site and the development of other readily available free flaps have led to a decline in the use of the radial forearm flap. Nevertheless, for reconstruction in head and neck surgery, with the need for thin, pliable tissues and a long vascular pedicle, the radial forearm flap still remains a prime choice. Two modifications of the standard forearm flap are presented. The first patient had two large defects at the nose and mental area after radical resection of a basal-cell carcinoma. Soft-tissue reconstruction was achieved with a conventional forearm flap and a second additional skin island based on a perforator vessel originating proximally from the pedicle. Both skin islands were independently mobile and could be sutured tension-free into the defects after tunneling through the cheek, with vascular anastomosis to the facial vessels. The second patient required additional volume to fill the orbital cavity after enucleation of the eye due to an ulcerating basal-cell carcinoma. In this case, the body of the flexor carpi radialis muscle was included in the skin flap to fill the defect. The skin island was used to reconstruct the major soft-tissue defect.     

Experience with the distally based sural neurofasciocutaneous flap supplied by the terminal perforator of peroneal vessels for ankle and foot reconstruction

The distally based sural fasciocutaneous flap has been proved an excellent option for coverage of the soft tissue defects of the lower third of the leg, ankle, and foot. In this article, we reported on a series of foot and ankle reconstructions with a distally based sural neurofasciocutaneous flap supplied by the terminal perforating branch of the peroneal artery. The vascular pedicle of the flap includes the terminal perforator branch of the peroneal artery and concomitant veins. The pivot point is approximately 5 cm above the tip of lateral malleolus. Fifteen patients with soft tissue defects of the foot and/or ankle underwent the procedures of reconstruction. The flaps were designed with the size measuring 8 x 9 cm to 13 x 31 cm. Thirteen flaps survived completely and 2 with partial or margin necrosis. Our experience has demonstrated that this sural flap with a thin perforator pedicle can be easily rotated, used for coverage of a large tissue defect including the forefoot area, and provide a good texture match and contour for the recipient area.