Abductor digiti minimi muscle flap in reconstruction of diabetic foot ulcers: A case series

Background

Diabetic foot ulcers (DFUs), a leading cause of amputations, affect 15 % of people with diabetes. Wound coverage in these patients is changelling due to concurrent infection, neuropathy and vascular compromise. Though local muscle flaps were described by Ger et al. and popularized by Attinger et al., these small muscle flaps should be more routinary than they are now.

Methods

A retrospective review of all patients with DFUs with exposed bone and osteomyelitis reconstructed by abductor digiti minimi muscle flaps and free skin grafting between January 2010 and December 2011 was conducted.

Results

This study included eight patients. Six patients had ulcers over the heel and two on the lateral aspect of the forefoot. All flaps survived well with no donor site complications. There was partial loss of skin graft in three cases and infection and total loss in one other case.

Conclusions

Abductor digiti minimi is a safe and reliable flap that provides a durable cover. Level of evidence: Level IV, therapeutic study.     

Versatility of the lateral circumflex femoral arterial (LCFA) system flaps for lower extremity soft tissue reconstruction

Background

Complex and extensive limb defects involve difficult reconstructive problems, and lateral circumflex femoral artery (LCFA) system flaps provide an adequate reconstructive answer for these challenging wounds.

Methods

A retrospective review on 50 patients treated with LCFA system flaps to cover lower extremity wounds was carried out. Data collected included age, gender, defect size, defect location, flap size, flap composition, anatomical findings, donor site closure, secondary procedures, and complications.

Results

The overall flap survival rate was 96 %. We performed three flap re-explorations with two subsequent failures. Four different combinations of tissues from LCFA system flaps were employed to restore defects produced by open fractures in tibia (16), severe crushing or avulsion injury (15), chronic posttraumatic osteomyelitis (13), and others (6). The mean size of the skin flap was 162.56 cm² (range 54–312 cm²) and the volume of the muscle flap was 160 cm³ (range 44–250 cm³). Debulking procedures were performed in seven patients. Donor sites were closed primarily in all but five patients who required a skin graft.

Conclusions

The LCFA system is efficient and its use, versatility, and reliability in lower limb reconstruction have been proven. No other donor site in the body offers such a large amount of tissue with minimal donor morbidity. Level of Evidence: Level IV, therapeutic study.     

Primary thinning of the anterolateral thigh flap in Caucasians is a safe technique

Background

The anterolateral thigh (ALT) perforator flap is a well-described and versatile flap, regularly used for resurfacing and reconstructing soft tissue defects, but it is often too bulky to produce an aesthetically satisfactory result. Although primary thinning of the ALT has been successful in Eastern populations, studies have demonstrated that this may be inadvisable in Caucasians. This is the biggest clinical study demonstrating the clinical safety of primary thinning of ALT flaps in Caucasians.

Methods

A retrospective analysis was performed between January 2009 and August 2011 on 57 patients (mean age 43) undergoing ALT free flap reconstruction by three surgeons. They were all thinned via sharp dissection using loupe magnification except for 1–2 cm around the perforator by removing the larger fat globules of deep fascia and preserving the superficial fat layer. The resultant flap thickness was approximately 6 mm.

Results

In 77 % of cases, the flap was used for lower limb, 16 % for upper limb and 7 % for head and neck reconstruction. The mean flap surface area was 124 cm². There was one flap loss (1.8 %) and three flaps returned to theatre for perioperative complications.

Conclusions

Careful primary thinning of ALT flaps is safe in Caucasian populations and can achieve improved cosmetic results. Level of Evidence: Level IV, risk/prognostic study.     

Supratrochlear island flap for reconstruction of the periorbital and nasal defects

Background

The reconstruction of nasal and periorbital defects has been a challenging task for plastic surgeons in terms of obtaining aesthetic and functional results. So far, many surgical methods have been described for the closure of these defects; however, the lack of sensation and inadequate cosmetic appearance were the main disadvantages of these procedures.

Methods

This study involved all patients who underwent reconstruction of nasal and periorbital defects due to tumor resection by means of a supratrochlear artery island flap, between 2007 and 2011. Doppler USG on the frontal region was routinely performed on all of the patients.

Results

This technique was used in six male patients with a mean age of 59.6 years (ranged, 44–68 years).The flap sizes ranged from 3?×?2.2 to 5?×?4.5 cm (mean 3.83?×?3.13 cm). The mean follow-up period was 23.6 months. All of the flaps survived without any problem, and no total or partial loss of flap was observed. The defects were closed with sensate and durable skin. Temporary loss of sensation on frontal regions was observed on all of the patients, but it decreased within 8–12 months in the follow-ups.

Conclusions

The supratrochlear artery island flap is a good alternative for the reconstruction of small- and medium-sized periorbital and nasal defects that offers a single-stage procedure, good perfusion and drainage, reliability, technical easiness, and sensorial superiority. Level of Evidence: Level IV, therapeutic study.     

Reconstruction of soft tissue defects in the Achilles tendon region with perforator-based fasciocutaneous flaps

Background

Reconstruction of soft tissue defects in the Achilles tendon region can be technically demanding. Perforator-based flaps can be an effective local solution, replacing like-for-like skin. We report our experience with perforator-based flap reconstruction of the Achilles tendon region with or without rupture of the Achilles tendon.

Methods

Between January 1999 and 2011, 11 patients had perforator-based flaps based on peroneal and posterior tibial perforators. There were six V-Y advancement flaps, four propeller flaps and one peninsular flap. The mean defect size was 19.3 (range 9–36)?cm². One patient had reconstruction of a composite Achilles tendon defect.

Results

There were no flap failures. Mean follow-up was 26.4 (range 3–120)?months. Post-operative complications included haematoma in one patient and dehiscence of wound because of further sloughing of the tendon—at the distal edge of a V-Y advancement flap. This patient needed a second local flap. There were no wound breakdowns, painful sensitivity or difficulty with walking. All patients who had skin and soft tissue reconstruction only were partially weight bearing by 2 weeks and gradually increased weight bearing and fully weight bearing by 4 weeks.

Conclusions

Perforator-based flaps are a robust method of covering small- to medium-sized defects in the Achilles tendon region. Presence of multiple perforators on either side of the Achilles tendon invites a number of flap designs, tailored to the defect. Level of Evidence: Level IV, Therapeutic study.     

Usefulness in combined free anterolateral thigh and vastus lateralis muscle flaps

Background

The anterolateral thigh flap has been a popular flap in reconstructive surgery. However, the details concerning the anterolateral thigh flap combined with the vastus lateralis muscle flap have not been reported. We described the surgical procedures, complication of the donor site, and advantages and disadvantages of this combined flap.

Methods

We analyzed 29 patients who underwent reconstruction with an anterolateral thigh flap–vastus lateralis muscle flap.

Results

The recipient sites were in the head and neck area (n?=?25), extremities (n?=?3), and trunk (n?=?1). The vastus lateralis was used as a muscle flap in 28 cases. The rectus femoris was harvested in one case because the vastus lateralis could not be harvested with a skin flap. Four cases required two vastus lateralis muscle flaps with a skin flap. Partial ischemia of the muscle flap occurred in one case. Additional donor-site surgery was required in two cases. No donor-site dysfunction was observed in our series.

Conclusion

This combined flap is advantageous in that the volume and number of muscle flaps can be adjusted and the skin and muscle flaps can be placed in separate positions. Although harvesting this flap is safe and not difficult, attention should be paid to anatomical variations of the vascular pedicle supplying the skin and muscle flap and to the circulation of the muscle flap. Level of Evidence: level IV, therapeutic study.     

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.     

Free scapular flap and platysmaplasty for severe neck scar contractures

Background

Anterior cervical hypertrophic scars caused by severe burn are prone to contracture deformation. Even after multiple skin graft procedures, limitation of neck motion still occurs, especially in patients with hypertrophic scarring. This study examines the feasibility of associating the free scapular flap and platysmaplasty for reconstruction of recurrent neck contracture.

Methods

Patients with severe scar contracture after multiple skin grafting and with hypertrophic scarring were under investigation. After complete release of the anterior cervical scar, a transection of platysma combined with suture fixation of platysma muscle flap to the surface of chin bone was performed, and the vascular anastomotic free scapular flap was covered. Functional exercise was strengthened postoperatively.

Results

All flaps (12 cases) survived well with obvious improvement of neck motion and satisfactory appearance.

Conclusions

Free scapular flap associated to platysmaplasty is one of the preferred alternatives for scar reconstruction in patients with recurrent neck contracture or severe hypertrophic scarring. Level of Evidence: Level IV, therapeutic study.     

Die Musculus-soleus-Lappenplastik

Objective

Defect coverage especially in exposed bone of the lower leg by pedicled muscle flaps in association with a split-thickness skin graft. Defect coverage oropharyngeal or at the upper extremity by free soleus flaps.

Indications

Defects of the proximal and middle thirds of the anterior lower leg for the proximally pedicled soleus flap; defects of the middle and distal third of the anterior lower leg for the distally pedicled soleus flap. The free flap is almost ubiquitously useable.

Contraindications

Primary diseases that makes a 2-h operation impossible, relevant affection of supplying vessels (the posterior tibial artery and/or the peroneal artery). Inadequate perfusion of the lower leg due to angiopathy, extensive soft-tissue infection, and wound contamination.

Surgical technique

Medial, longitudinal incision, slightly posterior to the tibia, according to the desired flap elevation (distally or proximally pedicled). Preparation of relevant vessels, mobilization of the muscle and transposition into local defects or use as a free graft. The pedicled flaps usually need a split-thickness skin graft to cover.

Postoperative management

Close monitoring of blood flow, temperature and swelling situation (hourly). Pressure-free wound-dressing of the leg, no circular or constricting dressings. Bedrest for 10 days, then start of flap training with intermittent circular compression, thrombosis prophylaxis, nicotine abstinence, physiotherapy, which depends on the bony situation, compression stocking after 3 weeks.

Results

Reliable results achieved at the middle and distal lower leg.     

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     

Anteriorly based pudendal thigh flap for scrotal reconstruction based on the deep external pudendal artery (DEPA) flap

Background

Major scrotal skin loss represents a significant challenge for reconstructive surgeons. Although many therapeutic methods have been established for the treatment of such defects, each technique has its own advantages and disadvantages. A posteriorly based pudendal thigh fasciocutaneous flap at the perianal region has been described for reconstruction of genital organs, but an anteriorly based pudendal thigh fasciocutaneous flap has not been described for scrotal reconstruction.

Aim

The aim of this study was to introduce and evaluate the use of an anteriorly based pudendal thigh flap for scrotal reconstruction.

Methods

Twenty flaps in 15 patients with major scrotal defects were subjected to reconstruction using this flap. The etiology of scrotal loss was Fournier gangrene in all cases. Five patients each underwent bilateral and ten patient unilateral reconstructions, by the anteriorly based pudendal thigh flap, based on the deep external pudendal artery (DEPA).

Results

All 20 flaps survived completely. Additionally, the donor site was closed directly, and the scar was hidden in the perineal crease. The donor site healed uneventfully, as one patient required a secondary procedure for healing.

Conclusion

An anteriorly based pudendal thigh flap is highly reliable for coverage of major scrotal defects. This flap allows adequate coverage with excellent aesthetic appearance of the scrotum.Level of Evidence: Level II, therapeutic study.