Distally based posterior tibial artery perforator flap for coverage of defects around the ankle,heel and lower third of leg

Introduction

Reconstruction of distal leg region remained a difficult task. Free flaps had long been considered as a gold standard for these regions. However, due to various limitations of the free flap, a local fasciocutaneous flap could be considered as a good alternative. In this study, the use of a distally based posterior tibial artery perforator flap had been evaluated in the coverage of defects around the ankle, heel, and lower third of a leg. The study also outlined the donor-site morbidity and the technical details of the surgical procedure.

Methods

In this prospective study, a total of 42 patients with distal lower leg defects were included. The defects were located on the lower third of the leg (n?=?23), ankle (n?=?11), and heel (n?=?8). Reconstruction was performed using distally pedicled posterior tibial artery perforator flaps. Patients were evaluated in terms of viability of the flap, functional gain, and donor-site morbidity. The technical details of the operative procedure have also been outlined.

Results

All the flaps survived well, with the exception of one patient, who experienced complete flap loss. Minor complications were, however, noted in four other patients: One patient developed superficial epidermolysis; one developed postoperative venous congestion, which subsided within 3 days by conservative means, and in two patients, partial loss of the skin graft occurred at the donor site but healed completely with dressing and antibiotics. The patients were followed up for an average period of 6 months, ranging from 1 to 13 months. Donor-site morbidity was minimal.

Conclusions

It was concluded that the distally based pedicled posterior tibial artery perforator flap was a reliable, easy, less time-consuming, and versatile procedure for covering the defects around the ankle, heel, and lower third a leg. Level of Evidence: Level IV, therapeutic study     

Experience with peroneus brevis muscle flaps for reconstruction of distal leg and ankle defects

Objective:

Peroneus brevis is a muscle in the leg which is expendable without much functional deficit. The objective of this study was to find out its usefulness in coverage of the defects of the lower leg and ankle.

Patients and Methods:

A retrospective analysis of the use of 39 pedicled peroneus brevis muscle flaps used for coverage of defects of the lower leg and ankle between November 2010 and December 2012 was carried out. The flaps were proximally based for defects of the lower third of the leg in 12 patients and distally based for reconstruction of defects of the ankle in 26 patients, with one patient having flaps on both ankles.

Results:

Partial flap loss in critical areas was found in four patients requiring further flap cover and in non-critical areas in two patients, which were managed with a skin graft. Three of the four critical losses occurred when we used it for covering defects over the medial malleolus. There was no complete flap loss in any of the patients.

Conclusion:

This flap has a unique vascular pattern and fails to fit into the classification of the vasculature of muscles by Mathes and Nahai. The unusual feature is an axial vessel system running down the deep aspect of the muscle and linking the perforators from the peroneal artery and anterior tibial artery, which allows it to be raised proximally or distally on a single perforator. The flap is simple to raise and safe for the reconstruction of small-to moderate-sized skin defects of the distal third of the tibia and all parts of the ankle except the medial malleolus, which is too far from the pedicle of the distally based flap. The donor site can be closed primarily to provide a linear scar. The muscle flap thins with time to provide a good result aesthetically at the primary defect.KEY WORDS: Ankle defects, lateral malleolus defects, lower leg defect, muscle flap, peroneus brevis flap, pedicle flap, tendo achilles defects     

Laterale Supramalleolarlappenplastiken zur Defektdeckung im Sprunggelenks- und Fußbereich

Objective

Defect reconstruction by transposition of well-vascularized thin and pliable skin.

Indications

Defect coverage involving the antero- and dorsolateral distal one third of the lower leg, the dorsolateral and dorsomedial hindfoot and dorsal midfoot.

Contraindications

Severe peripheral arterial occlusive disease (PAOD), previous trauma at the anterolateral aspect of the lower leg and foot.

Surgical technique

Lateral fasciocutaneous supramalleolar flap with orthograde blood flow, fasciocutaneous lateral supramalleolar perforator flap with orthograde blood flow, adipofascial lateral supramalleolar flap with orthograde blood flow, lateral fasciocutaneous supramalleolar flap based on the lateral tarsal artery with retrograde blood flow, lateral fasciocutaneous supramalleolar flap based on the anterolateral malleolar artery with retrograde blood flow according to Oberlin.

Postoperative management

“Tie over” dressing for grafting site for 5 days (healing of split/full-thickness skin graft), complete immobilization of the lower leg for 7 days in a dorsal plaster splint (ensure that there is no pressure on the flap), progressive increase of range of motion after 1 week, postoperative standardized compression therapy, combined with scar therapy (silicone sheet).

Results

Reliable, excellent functional and aesthetic results with thin skin in small to midsize defects. Increasing morbidity of grafting site in larger flaps and risk of neuroma when the superficial peroneal nerve was exposed.     

Der distal gestielte adipofasziale Suralislappen zur Rekonstruktion von Defekten der distalen unteren Extremität

Objective

Problematic tissue defects in the distal one-third of the lower leg represent a special challenge for the operative therapy. The distally based adipofascial sural artery flap is a safe and effective modification of the classical fasciocutaneous sural artery flap technique and makes the reconstruction in this problematic area more feasible. The surgical aim is soft tissue reconstruction with local tissue avoiding free tissue transfer.

Indications

Complex or chronic wounds (maximum width of 8 cm) of the distal lower leg with exposed bone, joints, tendons, and/or neurovascular structures, especially in cases of missing skin perforators.

Contraindications

Arterial vascular disease (stage III–IV), especially peroneal artery occlusion. Postthrombotic syndrome with occlusion of the small saphenous vein. Chronic lymphedema.

Surgical technique

Preparation of the vascular pedicle of the distally based flap (including small saphenous vein, sural artery and nerve), the adjacent crural fascia and the subcutaneous fat without a skin island. The pivot point is about 6 cm cranial to the malleolus lateralis. The flap can be raised proximally up to the heads of the gastrocnemius muscle. After harvesting the flap there will be a change in blood flow direction in the small saphenous vein. The donor site can be closed primarily. The flap is covered with meshed split skin graft at the end of surgery.

Postoperative management

Strict elevation of the extremity for 5 days, then flap conditioning.

Results

Between 1997 and 2012, this technique was used in 104 consecutive patients with soft tissue defects in the distal one-third of the lower leg. Flap survival was achieved 91 patients. In 2 patients amputation of the lower leg was necessary at the mid tibia level. In 3 cases flap necrosis occurred, requiring free tissue transfer.     

Der ein- und zweizeitige distal gestielte Suralislappen

Background

The distally pedicled suralis flap is used to cover local defects of the distal lower leg, ankle and hind foot. It is a local flap with no need for microvascular anastomosis, a constant blood supply and ease of elevation. Disadvantages are lack of sensation, donor site morbidity and venous congestion.

Methods and material

This study includes 25 patients. Apart from the defect extent, cause and location, complications were also determined.

Results

The defect site was located in the hind foot in 5 cases and the distal lower leg in 14 cases. In four patients the soft tissue of the lateral calcaneal region and in two cases the sole of the foot were affected. Severe venous congestion, which was only detected in 180° turned flaps, was seen in five cases. In five patients we successfully performed a two-stage flap transposition procedure to avoid venous congestion.

Conclusion

The sural flap remains a reliable solution for soft tissue defects. Under inappropriate circumstances (small pedicle or severe torque of pedicle) venous congestion or even thrombosis is possible. A two-stage approach with conditioning of venous drainage can have a positive effect on these problems.     

Die Musculus-peroneus-brevis-Lappenplastiken

Objective

Soft tissue defect reconstruction by transposition of well-vascularized muscle tissue with a muscle flap and as an osteomuscular flap together with a fibular bone segment for combined skeletal and soft tissue defects.

Indications

Small- and medium-sized defects of the hindfoot, around the ankle and the distal and middle third of the lower leg, skeletal reconstruction of underlying small- and medium-sized bone defects.

Contraindications

Lesions of the proximal anterior tibial artery (proximal pedicled flap), combined lesions of the distal peroneal artery including the communicating branch with the posterior tibial artery (distal pedicled flap); lesion or paralysis of the peroneus longus muscle in an intact ankle joint.

Surgical technique

Distally pedicled flap: blunt separation between the peroneus longus and brevis muscle, subperiosteal release with isolation on a distal septocutaneous branch of the peroneal artery. To increase perfusion, the proximally released branch of the anterior tibial artery may be re-anastomosed in the recipient site. Proximally pedicled flap: dissection of distal peroneus brevis muscle tendon and subperiosteal release in a proximal direction with ligation of the segmental peroneal artery branches until the flap is isolated on its proximal anterior tibial artery branch. For an osteomuscular flap, simultaneous harvest of a fibula segment underneath the muscle origin with preservation of the intimate periosteal relationship between muscle and bone.

Postoperative management

Complete immobilization and elevated leg position for 5 days, followed by successive orthostatic training for 10 days. Postoperative standardized compression garments for 6 months, eventually combined with silicone sheet scar therapy.

Results

Reliable, excellent functional and aesthetic results with very low donor site morbidity.     

Der temporoparietale Faszienlappen zur Rekonstruktion von Weichteildefekten

Objective

Soft tissue reconstruction with a temporoparietal fascial flap (TPFF).

Indications

Defect coverage with thin, pliable, and well-vascularized tissue. A bilayered TPFF provides a gliding surface in tendon reconstruction. Further options include TPFF harvest with overlying skin or subjacent bone for composite tissue reconstruction or the application as a sensate local fascial flap. Maximum defect dimensions: 17?×?14?cm.

Contraindications

Absolute: prior injury to the flap or flap pedicle, temporal arteritis, Moyamoya syndrome, defects with volume deficit. Relative: alopecia along the planned incision.

Surgical technique

Pedicle location is outlined using Doppler ultrasound. Injection of the incision line with diluted epinephrine solution. Skin incision with subsequent visualization of the temporoparietal fascia and supplying vessels. Skin flaps are raised carefully paying special attention to the hair follicles (CAVE: postoperative alopecia). Primary closure of the donor site. Defect coverage with pedicled or free TPFF with subsequent full or split-thickness skin grafting. Dressing: Bolster or V.A.C.

Postoperative management

Immobilization/elevation in the setting of extremity reconstruction. Removal of bolster dressing or V.A.C. on postoperative day?5. Dangling protocol instituted on postoperative day?7. Removal of sutures/staples at the donor site on postoperative day?5?C7 and at the recipient site on postoperative day?12?C14.

Results

The TPFF was utilized for soft tissue reconstruction in 8?patients. A pedicled TPFF was used in 2?patients. Mean time to healing was 16.3?days. Mean follow-up was 13.4?months. Successful reconstructive results with satisfactory functional and aesthetic appearance were obtained in all patients. Complications were encountered in 3?patients and included alopecia at the donor site and iatrogenic injury to the frontal branch of the facial nerve. Vascular compromise was observed in the early postoperative period in a third patient. However, operative revision resulted in successful flap salvage.     

Möglichkeiten und Ergebnisse der Lappenlastiken aus dem Arteria-interossea-System zur Defektdeckung im Handbereich

Introduction

Intensive anatomical studies of the anterior ulnar artery system have given rise to many new options for reconstruction of soft tissue or bone defects of the hand using local proximal and distal pedicle flap transfer.

Patients and Method

In 21 patients, consisting of 19 males and 2 females aged between 11 and 71 years, a flap transfer from the interosseus artery system has been performed. In a retrospective clinical study the following criteria were examined: type and size of flap, complications and subjective judgement of the donor site by the patient (very good, good, acceptable or fair).

Results

A total of 15 fascio-cutaneous posterior interosseous flaps, 1 anterior interosseus flap and 5 proximally based pronator quadratus flaps (3 muscle and 2 muscle-bone flaps) were carried out. The mean flap size was 12x6 cm for the posterior interosseus flaps and 7x4 cm for the anterior interosseus flaps. The entire pronator quadratus muscle was used for proximally based muscle flaps. The size of each of the distally based myo-osseus pronator quadratus flaps was 1x 2 cm. In 14 patients primary healing was achieved. The donor site was judged by 13 patients to be good, by 6 as acceptable and by 2 as fair.

Discussion

The posterior interosseus flap transfer is the preferred method of choice for defect reconstruction in the region of the distal third of the forearm, the first commissure of the hand and the metacarpal region because of its constant anatomy and minor functional donor site defects. The anterior interosseus flap technique has proven to be of minor value because of the large functional and aesthetic donor site defects compared to other treatment options. The proximally based pronator quadratus muscle flap is an elegant variation for defects of the distal forearm down to the rasceta. The distally based myo-osseus variation is one of the possible vascularized bone grafts in exceptional circumstances for reconstruction of therapy-resistant atrophic fractures at the carpal level. Because of the small vessel size distally based interosseous flaps seem to be contraindicated in patients with pre-existing trauma of the distal forearm and wrist level.     

Clinical and anatomical study of the distally based lesser saphenous veno-lateral sural neurocutaneous flap for lower extremity coverage

Background

The distally based sural flap has been widely and successfully used to reconstruct soft tissue defects of the distal third of the lower leg and foot. Sensory loss and venous congestion are possible complications of this treatment, but there has been limited research focused on improving the sensory loss and veneous congestion. This study aimed to determine the spatial relationship between the lesser saphenous vein and the cutaneous nerves, the venous anatomy in the lower leg, and the nerve distribution in the lateral dorsum of the foot, and we presented our clinical experience.

Materials and methods

Twenty freshly amputated lower limbs were dissected in the 2 h following amputation. The lesser saphenous vein, medial/lateral sural nerve, and sural nerve were identified. Based on the anatomical studies, an island flap supplied by the vascular axis of the lesser saphenous vein and the lateral sural nerve was designed for clinical reparative applications in 24 cases.

Results

We indicated the spatial relationship between the lesser saphenous vein and the cutaneous nerves and the venous anatomy in the lower leg. Among 24 flaps, 21 showed complete survival (87.5 %), while marginal flap necrosis occurred in two patients (8.33 %) and distal wound dehiscence in another (4.17 %). No symptomatic neuromas were observed. Their appearance and functioning were satisfactory, with filling maintained in the heel and lateral side of the foot.

Conclusion

The distally based lesser saphenous veno-lateral sural neurocutaneous flap provides effective coverage of variable-sized soft tissue defects on the lower third of the lower leg and foot, without sensory loss and venous congestion.     

The distally based lateral sural neuro-lesser saphenous veno-fasciocutaneous flap: anatomical basis and clinical applications

Background

Soft tissue management around the lower third of the leg and foot presents a considerable challenge to the plastic surgeon. The aim of this research was to investigate the anatomical relationships of artery, nerve, vein and other adjacent structures in the posterolateral region of the calf, and our experience with using a distally based island flap pedicled with the lateral sural nerve and the lesser saphenous vein for soft tissue reconstruction of lower third of leg, foot, and ankle defects in 15 patients.

Materials and methods

Five fresh cadavers (ten lower limbs) were infused with colored red latex. The origin of the nutrient vessel of the lesser saphenous vein and the lateral sural nerve was identified. Based on the anatomical studies, an island flap supplied by the vascular axis of the lesser saphenous vein and the lateral sural nerve was designed for clinical reparative applications in 15 cases.

Results

The nutrient vessel of the lesser saphenous vein and the lateral sural nerve originates from the superficial sural artery, musculocutaneous perforators of the posterior tibial artery, and septocutaneous perforators of the peroneal artery in different segment of the calf. Meanwhile, these vessels have many sub-branches nourishing subcutaneous tissue and skin, form a favorable vascular chain around the nerve and the vein, and also communicate with vascular plexus of superficial and deep fascia. Among 15 flaps, 13 showed complete survival (86.66 %), while marginal flap necrosis occurred in one patient (6.67 %) and distal wound dehiscence in another (6.67 %). Their appearance and function were satisfactory, with feeling maintained in the heel and lateral side of the foot.

Conclusions

The distally based flap pedicled with the lateral sural nerve and lesser saphenous vein was a reliable source for repairing soft tissue defects in the lower leg and foot due to its advantages of infection control, high survival rate, and sufficient blood supply without the need to sacrifice a major blood vessel.     

Defektdeckung durch freie Lappenplastiken am Fußrücken

Background

Large complex soft-tissue defects on the dorsum of the foot, with exposed tendons, joints, bones, nerves and vessels, have to be reconstructed by transplantation of free tissue grafts with good blood flow.

Patients and methods

Evaluation of 19 patients with an average age of 38 years who underwent closure of defects on the dorsum of the foot with free muscle flaps (with split-thickness skin grafts) in 14 cases and with free fasciocutaneous flaps in 5 is presented. In 10 patients a gracilis muscle flap was used, in 4 patients a latissimus dorsi flap, and in 2 patients a groin flap, while in 1 patient each an anterolateral thigh flap, an anteromedial thigh flap and a lateral arm flap was used. The aesthetic outcome was evaluated with reference to skin texture, pigmentation, thickness of the free flap and scar formation. The Stanmore system was used to determine the postoperative functional results.

Results

On average, patients were followed up for 29 months. We had no flap loss. A flap debulking procedure was performed in 6 patients. Better aesthetic results were obtained with muscle flaps plus skin graft than with fasciocutaneous flaps. Functional results were excellent in 6 patients, good in 5 and poor in 8 patients.

Conclusion

Free muscle flaps with skin grafts, particularly the free gracilis muscle flap, are superior to fasciocutaneous flaps and perforating flaps in aesthetic outcome and donor site morbidity.     

Der Saphenusperforatorlappen

Objective

Replacement of full thickness soft tissue defects in the lower leg and ankle, appropriate to the defect and following the course of blood vessels feeding the skin of a distally hinged fasciocutaneous flap most reliably based on the individual anatomy of distal perforators of the posterior tibial artery.

Indications

Full thickness soft tissue defects, up to 12 cm in length and up to 8 cm in width. Sufficient vascularization of the foot required, in osteomyelitis, and when joints, fractures, implants and tendons are exposed and when a split skin graft, a local flap, a suralis perforator flap or a free flap is not indicated.

Contraindications

For patients, in whom a 1–2 h operation is not possible; necessity of angioplasty; decollement or scars around the distal perforators of the posterior tibial artery; local infection or necrosis of soft tissues and/or bone, which cannot be totally excised.

Surgical technique

Radical debridement; flap dissection without tourniquet; microdissection; design of the flap on the skin: pivot point ~?10 cm (6–14 cm) proximal of the tip of the medial malleolus; base ~?5 cm in width, between the course of the saphenous nerve and of the great saphenous vein and the Achilles tendon; adipofascial pedicle up to 15 cm in length sited over the septum between soleus and flexor digitorum muscles, following the course of the saphenous nerve, with a central skin stripe, which expands into a proximal skin island; skin island is outlined similar to the defect, but larger by 1 to 2 cm, surrounded by an adipofascial border: adjustment of the planning as well as of the elevation of these flaps according to the individual position and the caliber of perforators requires in each case the search for a perforator at the estimated pivot point. Delay of transposition, if the division of more than one perforator proximal to the pivot point obviously diminishes circulation. No “tunnelling “of the pedicle; defects of skin due to the elevation of the flap are replaced by split and meshed skin grafts or temporary by “artificial skin”. A gap in the bandage over the skin island allows for observation.

Postoperative management

Protocol of controls of vascularization: color and time for revascularization; antibiotic treatment according to bacteriological testing. In case of edema or discoloration of the flap: immediate removal of sutures, administration of leeches, operative revision. Split skin graft 1 week after flap transposition, if the skin had been temporary substituted.

Results

Retrospective uncontrolled study with over 70 saphenous perforator flaps from 1995–2011. Full soft tissue defects 62 times with osteomyelitis, 3 times with endoprothesis, 3 times with fractures, 2 times with exposed tendons. From 1995–2006, 44/50 (88?%) flaps healed completely or at least to 3/4 without the necessity of further flaps; from 2007–2011, 13/20 (65?%) flaps healed completely and 6/20 (30?%) flaps healed at least to 3/4 without the necessity of further flaps, loss of one flap (5?%).     

Non-microsurgical skin flaps for reconstruction of difficult wounds in distal legand foot

Purpose

To express the versatility of a variety of non-microsurgical skin flaps used for coverage of difficult wounds in the lower third of the leg and the foot over 4 years period. Five kinds of flaps were used. Each flap was presented with detailed information regarding indication, blood supply, skin territory and technique.

Gefäßgestielte Arteria-peronea-Perforatorlappenplastik

Objective

Defect reconstruction at the distal lower extremity by transposition of a vascularised fasciocutaneous flap.

Indications

Reconstruction of defects at the lateral aspect of the middle and distal third of the lower leg, the lateral ankle and achilles tendon region.

Contraindications

Lesions or occlusion of the peroneal artery, traumatized skin and soft tissues at the donor site of the flap, deep vein thrombosis of the ipsilateral leg.

Surgical technique

Preoperative localisation of the dominant perforator using Duplex or Doppler ultrasound or CT-angiography. Initially limited skin incision and identification and microsurgical dissection of the dominant perforator up to its origin from the peroneal artery. Completion of skin incision and mobilisation of the flap while the secondary perforans vessels are still preserved. Evaluation of flap perfusion and transfer of the flap into the defect by advancement or 180° rotation as a propeller flap. Closure of the donor site defect by direct suture or skin grafts.

Postoperative management

Elevation of the extremity for 5 days. Elastocompressive garments and orthostatic training with increasing intensity. Standardised postoperative compression therapy and scar therapy if necessary.

Results

Minimal functional donor site defect and optimal functional and aesthetic results.     

Split-Thickness Skin Graft Urethroplasty and Tunica Vaginalis Flaps for Failed Hypospadias Repairs

Purpose

Via a 2-stage procedure, 10 patients with failed hypospadias repairs were treated by a varied combination of split-thickness mesh graft urethroplasty and tunica vaginalis flap.

Materials and Methods

A bed for the mesh graft in 3 patients was provided by a tunica vaginalis flap. Tunica vaginalis flaps were also used as an intermediate layer during stage 2 of the repair.

Results

No strictures or fistulas occurred in 8 patients. Two patients await stage 2 repair after successful stage 1 placement of the mesh graft.

Conclusions

The combination of split-thickness mesh graft urethroplasty and a tunica vaginalis flap appears to achieve success in the difficult patient with complex hypospadias subsequent to multiple failed repairs.     

Instep split skin grafts on muscle flaps to reconstruct pressure exposed soft tissue parts at the lower extremity

Background

Reconstructed mechanically stressed zones of the lower extremity frequently suffer from problems such as hyperkeratotic edges or chronic ulcerations in the transition zone between conventional thigh skin grafts and normal skin. Defect coverage with skin grafts harvested from the instep region and placed on muscle flaps is not yet an established alternative.

Methods

This is a retrospective study of a series of 12 clinical applications of soft tissue reconstruction at mechanically exposed zones of the lower extremity. Locally transposed or transplanted muscle flaps were covered with meshed instep skin instead of meshed thigh skin for the purpose to gain a superior stable skin surface and transition zones adjacent to normal skin.

Results

There is no ulceration found at follow-up from 6 to 72?months. Only one case presented with delayed graft take. Different thicknesses of the corneal layers of the healed instep versus thigh skin grafts were verified histologically. Instep skin grafts showed substantial durability as well as advantageous aesthetic appearance with respect to texture and coloring. All donor sites healed without notable scars or sensitivity disorders.

Conclusions

The instep split skin graft is particularly well suited for defect coverage of muscle flaps transposed or transplanted to mechanically stressed zones of the foot or lower leg. The paramount advantage of transplanted instep skin as compared to thigh skin is given by the feasibility to create a durable graft with a thick horny layer and a stable transition zone at its periphery that is bordering normal skin.     

Der gestielte Pectoralis-major-Lappen zur Behandlung der eitrigen Arthritis des Sternoklavikulargelenks

Objective

Closure of the wound defect with a pedicled pectoralis major muscular flap after successful surgical treatment of septic arthritis of the sternoclavicular joint (SCJ).

Indications

Defect of the thoracic wall after septic arthritis of the SCJ.

Contraindications

Persistent infection of bony or soft tissue structures; persistent septicemia; persistent mediastinitis.

Surgical technique

After successful treatment of the local infection and radical debridement of the wound, the incision is expanded parallel to the clavicle and to the sternum. The neurovascular pedicled pectoralis flap is mobilized and a resection of the muscular attachment at the humerus is performed. Finally, the flap is rotated at the pedicle and attached to the defect zone.

Postoperative management

Anticoagulation with low molecular weight heparin and possibly aspirin (100 mg/day); short-term immobilization of the involved upper extremity. Avoidance of major weight bearing for a period of 6 weeks.

Results

Over a period of 4 years, 18 patients suffering from septic arthritis of the SCJ underwent surgical treatment. Of these, 9 patients were treated with pedicled muscular flap. In all patients, uneventful wound healing was observed with no further revision operations being required. The functional and optical results were satisfactory.     

The surgical management of angiosarcoma of the breast—a single institution experience

Background

Angiosarcoma of the breast is a rare and aggressive tumour of the vascular endothelium. It may arise spontaneously or secondary to radiation. We present our experience of managing breast angiosarcoma, the largest single institution case series from the UK to date along with a summary of the relevant literature.

Methods

Data on all patients with breast angiosarcoma treated in our unit were prospectively recorded (2002–2014). Demographics, surgical details and outcomes were analysed.

Results

Eighteen female patients presented with breast angiosarcoma. Sixteen patients previously underwent adjuvant radiotherapy following surgery for breast carcinoma; the mean duration between radiotherapy and angiosarcoma development was 8.4 years (range 3–21). Resections were as follows: radical mastectomy (n?=?14), simple mastectomy (n?=?1) and wide local excision (n?=?3). Reconstruction was undertaken as follows: pedicled lattisimus dorsi (LD) musculocutaneous flap (n?=?5), pedicled LD muscle flap and split skin graft (n?=?7), free deep inferior epigastric perforator (DIEP) flap (n?=?1), pedicled vertical rectus abdominus muscle (VRAM) flap and split skin graft (n?=?1), pedicled LD muscle and pedicled VRAM muscle flaps and split skin graft (n?=?1), pedicled LD muscle and pedicled (contralateral) pectoralis major muscle flaps and split skin graft (n?=?1) and direct closure (n?=?2). Three patients developed local recurrence; mean duration from resection to recurrence was 12 months (range 9–19). Three patients developed metastasis. Seven patients (38.8 %) died; median survival from presentation was 19 months (range 2–55 months). The remaining eleven patients remain well with no disease recurrence; mean follow-up was 38 months (range 4–125). The estimated 5-year survival (Kaplan-Meier equation) in our cohort was 49 %.

Conclusions

Breast angiosarcomas are rare and challenging to manage. Successful outcomes can be achieved by early, aggressive resection and appropriate reconstruction. Level of Evidence: Level IV, therapeutic study.