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.     

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 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?%).     

The place of local/regional perforator flaps in complex traumas of the forearm

Background

Our aim was to conduct a retrospective study regarding the advantages of doing the all-in-one reconstruction in the same step with the debridement, and the possibility of using the local/regional perforator flaps to cover the tissue defects.

Methods

We reviewed a series of 137 cases from 1999 until now, for acute traumas with tissue defects of the forearm. We performed a regional perforator flap in 16 cases, and a local perforator flap in 121 cases. These flaps were used for both simple and complex defects coverage, including 26 cases with fractures and devascularization.

Results

The follow-up was between 2 months and 2 years. In all the cases the extremity was salvaged and an useful functional recovery was obtained. A very good evolution, with complete survival of the flap was recorded in 133 cases. We completely lost only one flap, and registered minor complications in three cases.

Conclusion

The local perforator flaps represent a good and safe indication for small and medium defects in the forearm.     

Reverse pedicle-based greater saphenous neuro-veno-fasciocutaneous flap for reconstruction of lower leg and foot

Introduction

Paucity of soft tissue available locally for reconstruction of defects in leg and foot presents a challenge for reconstructive surgeon. The use of reverse pedicle-based greater saphenous neuro-veno-fasciocutaneous flap in reconstruction of lower leg and foot presents a viable alternative to free flap and cross-leg flap reconstruction. The vascular axis of the flap is formed by the vessels accompanying the saphenous nerve and the greater saphenous vein. We present here our experience with reverse saphenous neurocutaneous flap which provides a stable cover without the need to sacrifice any important vessel of leg.

Patients and methods

The study is conducted from March 2003 through Dec 2009 and included a total of 96 patients with defects in lower two-thirds of leg and foot. There are 74 males and 22 females. Distal pivot point was kept approximately 5–6 cm from tip of medial malleolus, thus preserving the distal most perforator, and the flap is turned and inserted into the defect. Donor site is covered with a split thickness skin graft. Postoperative follow-up period was 6 weeks to 6 months.

Result

The procedure is uneventful in 77 cases. Infection is observed in 14 cases. Partial flap necrosis occurs in 2 cases. Total flap necrosis is noted in 3 cases.

Conclusion

Reverse pedicle saphenous flap can be used to reconstruct defects of lower one-third leg and foot with a reliable blood supply with a large arc of rotation while having minimal donor site morbidity.     

Free style perforator based propeller flaps: Simple solutions for upper extremity reconstruction!

Background:

The introduction of perforator flaps by Koshima et al. was met with much animosity in the plastic surgery fraternity. The safety concerns of these flaps following the intentional twist of the perforators have prevented widespread adoption of this technique. Use of perforator based propeller flaps in the lower extremity is gradually on the rise, but their use in upper extremity reconstruction is infrequently reported, especially in the Indian subcontinent.

Materials and Methods:

We present a retrospective series of 63 free style perforator flaps used for soft tissue reconstruction of the upper extremity from November 2008 to June 2013. Flaps were performed by a single surgeon for various locations and indications over the upper extremity. Patient demographics, surgical indication, defect features, complications and clinical outcome are evaluated and presented as an uncontrolled case series.

Results:

63 free style perforator based propeller flaps were used for soft tissue reconstruction of 62 patients for the upper extremity from November 2008 to June 2013. Of the 63 flaps, 31 flaps were performed for trauma, 30 for post burn sequel, and two for post snake bite defects. We encountered flap necrosis in 8 flaps, of which there was complete necrosis in 4 flaps, and partial necrosis in four flaps. Of these 8 flaps, 7 needed a secondary procedure, and one healed secondarily. Although we had a failure rate of 12-13%, most of our failures were in the early part of the series indicative of a learning curve associated with the flap.

Conclusion:

Free style perforator based propeller flaps are a reliable option for coverage of small to moderate sized defects.

Level of Evidence:

Therapeutic IV.KEY WORDS: Hand defects, perforator flaps, propeller flaps, perforator based propeller flaps, upper extremity, wrist defects     

Soft tissue coverage of war extremity injuries: the use of pedicle flap transfers in a combat support hospital

Purpose

Definitive management of extremity injuries including soft tissue coverage is seldom achieved in battlefield medical treatment facilities due to limited resources and operational constraints. The purpose of this study was to analyse the French Army Medical Service experience performing such reconstructive surgery in a Combat Support Hospital (CSH) in Afghanistan.

Methods

A clinical study was performed in the KaIA (Kabul International Airport) CSH from July 2012 to January 2013.

Results

During this period 23 Afghan patients treated for soft tissue coverage of combat-related extremity injuries were included. They totalled 28 extremity injuries including 18 blast trauma (BT) and ten non blast trauma (NBT). Overall, 35 extremity pedicled flaps were performed. There were 26 fasciocutaneous flaps, eight muscle flaps and one composite flap. Soft tissue coverage was achieved on all patients reviewed with a mean follow-up of 59 days. Five postoperative complications occurred including two deep infections, one partial flap necrosis and two flap failures, without difference according to injury mechanism.

Conclusion

Reconstruction of traumatic soft tissue defect can be achieved in CSHs for local nationals. Pedicle flap transfers provide simple and safe coverage for war extremity injuries in this challenging environment whatever the injury mechanism.     

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.     

Reverse sural rotational flap in the coverage of the lower leg after musculoskeletal oncologic resection

Background

The coverage of soft tissue defects in the lower extremity has proven to be challenging. The reverse sural flap provides reliable coverage with minimal complications.

Methods

Six patients with sarcomas at the distal leg, ankle, and foot were treated with the reverse sural artery flap. Data was gathered for demographics, comorbidities, type of tumor, size of defect, flap viability, healing time, donor-site morbidity, recurrence, functional outcome, and range of motion.

Results

All patients possessed a primary sarcoma that traditionally would have required a free flap for coverage. The average size of defect was 94 cm² (range 50–143) and was covered by flaps that ranged between 10?×?13 cm and 10?×?5 cm. Flap viability was 100 %, with healing occurring by 18 weeks (range 4–32 weeks). Donor-site morbidity was 0 %. Average revised MSTS score was 80 % or 24/40 (range 15–29). Average ROM for dorsi flexion was 0 ° and plantar flexion was 17.5 ° (range 10–25). Average time of follow-up was 8.75 months (range 4–14).

Conclusions

In most patients without associated risk factors such as diabetes, the reverse sural flap can be performed safely. However, in patients with identifiable risk factors for partial flap failure, consideration should be given to alternative options such as free flap reconstruction in order not to delay or interrupt adjuvant radiotherapy. Level of Evidence: Level IV, therapeutic study.     

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.     

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.     

Thoracodorsal artery perforator fasciocutaneous flap: A versatile alternative for coverage of various soft tissue defects

Objective:

The thoracodorsal artery perforator (TDAP) flap has contributed to the efficient reconstruction of tissue defects that require a large amount of cutaneous tissue. The optimal reconstruction method should provide thin, and well-vascularized tissue with minimal donor-site morbidity. The indications for the use of this particular flap with other flaps are discussed in this article.

Materials and Methods:

Thirteen patients underwent soft tissue reconstruction using TDAP flaps between 2009 and 2011. Of those, there were four cases of antecubital burn contracture, three cases of axillary burn contracture, two cases of giant hair cell nevus of upper extremity, two cases of axillary reconstruction following severe recurrent hidradenitis, and two cases of crush injury. All patients were male and their ages ranged from 20 to 23 (average, 21 years). The mean follow-up period was 8 months (range, 4-22 months).

Results:

All reconstructive procedures were completed without any major complications. Minor complications related to transfered flaps were wound dehiscence in one case, transient venous congestion in two cases. Minor complication related to the donor site was seroma in one case. The success rate was 100%, with satisfactory cosmetic results.

Conclusions:

The TDAP flap is a safe and extremely versatile flap that offers significant advantages in acute and delayed reconstruction. Although the vascular anatomy may be variable, free and pedicled TDAP flap is a versatile alternative for soft tissue defects. It adapts very well to the soft tissue defects with acceptable donor site scar.KEY WORDS: Burn contracture, hidradenitis suppurativa, soft tissue defects, the thoracodorsal artery perforator, thoracodorsal artery perforator flap     

Freestyle facial perforator flaps—a safe reconstructive option for moderate-sized facial defects

Background

Perforators are a constant anatomical finding in the facial area and any known flap can in theory be based on the first perforator located at the flap rotation axis.

Methods

A case series of single stage reconstruction of moderate sized facial defects using 21 perforator based local flaps in 19 patients from 2008–2013.

Results

A sufficient perforator was located in every case and the flap rotated along its axis (76 %) or advanced (24 %). Reconstruction was successfully achieved with a high self reported patient satisfaction. Two minor complications occurred early on in the series and corrective procedures were performed in four patients.

Conclusions

The random facial perforator flap seems to be a good and reliable option for the reconstruction of facial subunits, especially the periorbital, nasal and periocular area with a minimal morbidity and a pleasing result in a one stage outpatient setting. Level of Evidence: Level IV, therapeutic study     

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.     

Thoracodorsal artery perforator (TDAP) flap in immediate breast reconstruction and the role of preoperative mapping: a clinical experience

Background

Oncoplastic approach to reconstruct partial breast resection is always challenging. Nowadays, pedicle perforator flaps have been described for partial breast mastectomy reconstruction

Methods

The study comprised all patients who received partial breast resection due to external quadrant breast cancers and who were reconstructed with thoracodorsal perforator flap between August 2010 and August 2011. Twenty-two patients received the thoracodorsal artery perforator (TDAP) for breast reconstruction. The mean surgical time (including oncology resection and reconstruction) was 160 min. Eleven patients (50 %) underwent Doppler and Computed tomographic angiography (AngioCT) presurgical planning, the rest Doppler alone.

Results

The mean stay was 3.27 days. Seroma formation in the donor site was found in five cases. No flap failures were detected. No breast size changes were observed after surgical and radiotherapy treatment.

Conclusions

We conclude that TDAP flap is suitable for partial breast reconstruction (quadrantectomy) in moderate breast cancer. Level of Evidence: Level IV, therapeutic study.     

An innovative design for reconstruction of plantar heel by split partially overlapping anterolateral thigh flap

Introduction

Reconstruction of the weight bearing, thick and durable heel, in soft tissue injuries of the foot remains a difficult and challenging problem. The thick glabrous epidermis and dermis, and the fibrous septae of the subcutaneous layer provide unique properties for withstanding pressure and shock associated with gait.

Materials and Methods

Here, the authors put forward an innovative method for a one-stage reconstruction of the weight bearing heel using a partially overlapping split anterolateral thigh perforator flap in a patient with a degloving injury of the foot.

Results

The patient was allowed partial weight bearing at one month and full weight bearing at two months postoperatively. Sensation tested using Semmes-Weinstein filaments was noted at six months, and at two years revealed 12-mm two-point discrimination of her normal heel and 15-mm two-point discrimination of her reconstructed heel. No ulcerations of the flap were observed at two years.

Discussion

There are a myriad of choices to reconstruct the hindfoot, which include local, distant and free flaps. Microvascular reconstruction is required for more extensive defects of the foot. The ideal reconstruction should achieve durable coverage, adequate contour and solid anchoring to resist shearing forces and to withstand weight bearing. We advocate the use of the split overlapping anterolateral thigh perforator flap when two reliable perforators can be identified and the patient desires a one stage procedure, in selected cases of complex defects of the heel and sole, without the need for debulking. This restores foot function, has minimal donor-site morbidity and achieves satisfactory long-term functional results.     

Lambeau neurocutané sural à pédicule distal dans la couverture des pertes de substance des segments distaux du membre inférieur. À propos de 25 cas

Introduction

Since it was described for the first time by Masquelet and colleagues in 1992, the distally-based sural neurocutaneous flap has become a technique that has enriched the armamentarium of repairing soft tissue defects in the distal third of the leg which continues to be a difficult area.

Patients and methods

Twenty-five patients with an average age of 46.36 years, with defects due to varied etiologies dominated by trauma (52%), were treated by the distallybased sural neurocutaneous flap.

Results

Half of our patients had a vascular field, diabetes or smoking. Cover interested in 7 cases the lower third of the leg, the heel area in 7 cases, the instep in 5 cases, the malleolar region in 5 cases and and in one case a flap for amputation stump of the forefoot. A mean of 22 months follow up, with a range from 6 months to 5 years, has allowed to make a point on the rate of complications found and the functional and aesthetic outcomes of the reconstruction as well as the donor site.

Discussion

The authors went through the presentation of their experience, and put the focus on the ease of harvesting the flap, on its high reliability even on people with vascular issues, and the importance of the contribution that tissue provides in repairing extensive defects in the lower third of the leg, the ankle and the heel region.