Reconstruction of a lower extremity soft-tissue defect using the gastrocnemius musculoadipofascial flap

Use of the gastrocnemius as either a muscle or musculocutaneous flap has proved to be effective in the management of knee and lower leg soft-tissue defects because of its reliable constant vascular pedicle and ease of procedure with little or no functional deficit. As a muscle flap, the volume of the distal part of the muscle for coverage is small, and is even smaller when accompanied by posttraumatic disuse atrophy. Although there have been many modifications to increase the arc of rotation and dimensions of the muscle flap, the disadvantage is the skin graft on the flap donor site and the resulting deformity of the leg contour. Also, clinical limitations occur when the defect size is extensive or there is an inadequate arc of rotation or dimension. The authors present their clinical application of a gastrocnemius muscle flap with a distal adipofascial flap as a useful alternative for various sizes and types of defects. Between 1999 and 2000, gastrocnemius adipofascial flaps were used in 7 patients with various types of defects. This form of musculoadipofascial flap has not yet been described in the known literature. In the authors' opinion, this procedure is a valuable extension of local flap procedures in reconstructing relatively large defects in the region of the knee and lower extremity.     

Utility of both muscle and fascia flaps in severe lower extremity trauma

BACKGROUND: The evolving technology in trauma management today permits salvage of many severe lower extremity injuries previously even considered to be lethal. An essential component for any such treatment protocol must be adequate soft tissue coverage that often will use vascularized flaps. Traditionally, calf muscles have been used proximally and free flaps for the distal leg and foot. The reintroduction of reliable local fascia flaps has challenged this dictum, proving to be a simpler and yet versatile option. MATERIALS AND METHOD: The role of both muscle and fascia flaps in lower extremity injuries has been retrospectively reviewed from a 2-decade experience. Soft tissue deficits requiring some form of vascularized flap occurred in 160 limbs in 155 patients. The frequency of use of flap types, specific complications and benefits, effect of timing of wound closure, and rate of limb salvage were compared. RESULTS: Initial coverage after significant lower extremity trauma in these 160 limbs required 60 local muscle flaps, 50 local fascia flaps, and 74 free flaps. These flaps had been selected on a nonrandom basis according to wound location, its severity, and flap availability. Complications were directly related to the severity of injury, and for free flaps as a group (39%), although these were not independent variables. Local muscle (27%) or fascia flaps (30%) were similar with regard to this morbidity. Healing was more likely to be uneventful if coverage were accomplished during the acute period after injury, regardless of flap type. Muscle flaps were still used in two thirds of all cases, with the soleus muscle used as often for the distal leg as the mid-leg. Local fascia flaps were most valuable for smaller defects, especially in the distal leg or foot, and often as a reasonable alternative to a free flap. CONCLUSION: The traditional role of the gastrocnemius muscles for flap coverage of knee and proximal leg defects and the soleus muscle for the middle third of the leg was reaffirmed. The soleus muscle often also reached distal leg defects as could local fascia flaps, where classically, otherwise, a free flap would have been necessary. The largest or most severe wounds, irrespective of limb location, required free flap coverage. Local fascia flaps proved to be a valuable alternative.     

The cross-leg soleus muscle flap

Reconstruction of the lower limb can be a difficult problem, especially when located over the lower third of the leg, or when a large soft-tissue defect exists. When local flap coverage is not possible, a distant flap--free or pedicled--is indicated. There are, however, circumstances that preclude the use of a free flap, and in these situations cross-leg flaps remain a viable alternative. They have been proved to be safe, are usually quick to perform, and do not require specialized facilities for postoperative monitoring. A new variation of the soleus muscle flap--the cross-leg soleus muscle flap--is described. Using this modification, the authors successfully closed large defects of the lower limb in 9 patients. The donor site defect that is left on the contralateral limb is far more acceptable than that left by conventional cross-leg fasciocutaneous or musculocutaneous flaps. The authors prefer the cross-leg soleus flap to conventional cross-leg flaps in these situations.     

Der Einsatz des Neuro-Fasziokutanen Suralisinsellappens zur Defektdeckung im Bereich des Unterschenkels und des Fußes

BackgroundThe closure of soft tissue defects in areas of the distal third lower leg anterior, ankle, heel and foot dorsum especially with exposed bony or tendinous tissue, in case of infections or difficult healing tendency is still challenging. These defects need a stable and sufficient soft tissue cover.With the introduction of the Neuro-Fasciocutaneus suralis island flap (hereinafter called suralis flap) we do have a good alternative with stable results and less operation complexity.Material and methodsSince 2005 we are using this technique for the coverage of complicated defect wounds, especially for complete heel and extensive foot dorsum defects.The most frequent area was the lateral malleolus and the Achilles tendon area with and maximum dimension of 7 cm by 11 cm.Results2 suralis flaps get lost; in 6 cases we saw superficial skin necrosis.In most of the harvest areas we could directly close the defects, in 7 cases we had to close the defects with split skin grafts.Technically it is easy to learn the harvest of the suralis flap and none of ourpatient's complaint about the reduces sensitivity after necessitated cutting of the suralis nerve.ConclusionDefects in areas of the distal third lower leg anterior, ankle, heel and foot dorsum does need a stable and sufficient soft tissue cover, especially with exposed bony or tendinous tissue or in case of infections or difficult healing tendency.The suralis flap as an alternative to the commonly used free flaps and reduces the surgical effort.     

The Distally Pedicled Peroneus Brevis Muscle Flap Anatomic Studies and Clinical Applications

Defects in the distal third of the lower leg with bone or tendon exposure may require local or free flap reconstruction. For small and moderate lesions, the distally pedicled peroneus brevis muscle flap may be an effective procedure with less morbidity than a free tissue transfer. Six cadaveric specimens were dissected to determine the location of distal pedicles and the flap type. This flap was found to be a Type IV flap, and the location of distal pedicle was always located within 6 cm from the fibula tip. This flap was performed on 6 patients to cover defects in the distal third of the lower leg. The defect areas were the pretibial region in 2 cases, the lateral malleolus in 3 cases, and the Achilles tendon in 1 case. The peroneus brevis muscle was detached from the uppermost point of the fibula to obtain enough length to cover the defect. All flaps survived except 1 that experienced distal flap necrosis. Minor complications included skin graft failure in 2 cases. However, the final results demonstrated a smooth contour that eliminated dead space. Limited donor site morbidity was obtained in all cases. The distally peroneus brevis muscle flap therefore offers an alternative for reconstructive surgeons dealing with soft tissue defects of the lower leg.     

Reconsidering the soleus muscle flap for coverage of wounds of the distal third of the leg

Traditionally, cross-leg flaps and microsurgical flaps have been used to reconstruct defects of the distal third of the leg. In the authors' experience, the soleus muscle has also provided suitable tissue for coverage of these lesions in a notable number of cases. During a 2-year period, the authors treated 28 patients who required flap coverage of defects of the lower third of the leg. In this group, the soleus muscle was used successfully in 8 patients. All of these procedures resulted in healed wounds. The remaining patients underwent reconstruction with microsurgical flaps, fasciocutaneous local flaps, and a gastrocnemius muscle flap. Their experience has demonstrated that the soleus muscle is a valuable tool and should be included in the treatment algorithm for reconstructing lesions of the distal third of the lower extremity.     

腓肠内侧动脉穿支皮瓣修复上下肢创面

目的介绍吻合血管的腓肠内侧动脉穿支皮瓣修复上下肢创面的临床方法和经验。方法采用吻合血管的腓肠内侧动脉穿支皮瓣修复上下肢创面11例，女6例，男5例。皮瓣设计区域为同侧小腿，腓肠内侧肌肌腹以远1／2的表面部分，前内界为胫骨的内后缘，后外侧界为小腿后正中纵轴线，皮瓣的轴行线为前内界和后外侧界的中线。皮瓣长8～15cm，宽6～14cm。结果10例皮瓣成活，皮瓣质地柔软，富有弹性，不臃肿，恢复了一定的触觉；1例皮瓣全部坏死，经扩创、断层皮片修复创面；不影响供区的运动功能。结论腓肠内侧动脉穿支皮瓣可以用来修复上下肢创面，尤其对手足部创面的修复有较为满意的临床疗效。     

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.     

Reconstructive implications of adipofascial flaps in limb defects

Today a great variety of techniques are available to reconstruct any limb defect. Because of this, one should select an appropriate method and not use a particular technique for all defects. We found the adipofascial flap to be suitable and advantageous for many defects. This paper describes the anatomical basis, planning, technique, and variations of the adipofascial flap. The majority of these flaps are defect-based hinge flaps incorporating perforators in the base, and hence they are perforator-perfused flaps. A skeletonized perforator flap has increased malleability and achieves more distal reach. These can also be used as a free flap. An adipofascial flap has several advantages, e.g., minimal donor site morbidity, greater mobility, and more refined reconstruction, and it provides a good gliding surface for the tendons and avoids hair bearing skin transfer. A series of 32 cases performed over 5 years is presented.     

Anterior tibial artery flap: anatomy and case report

A simple, large fasciocutaneous flap based on the perforating branches of the proximal anterior tibial artery and venae comitantes can be raised which is particularly suitable as an inferiorly based island pedicle flap to cover cutaneous defects of the lower third of the lower leg, an area notoriously difficult to cover with local flaps. The flap has an extremely wide arc of rotation and can reach from the knee superiorly to the sole inferiorly. It can be transferred as a fascial flap or as a free flap. The secondary donor site defect overlies muscle bellies, lies well away from bone and readily accepts split skin grafts.     

小隐静脉-腓肠神经逆行筋膜瓣的临床应用

目的 探讨应用小隐静脉-腓肠神经筋膜瓣联合全厚皮片移植修复小腿远段及足踝部软组织缺损的临床疗效. 方法 在小腿后侧设计小隐静脉-腓肠神经的筋膜瓣联合全厚皮片移植治疗小腿远段及足踝部单纯软组织缺损12例,软组织缺损伴胫骨骨髓炎3例、跟骨骨髓炎2例,皮肤缺损范围3cm×5 cm～9 cm×13 cm,切取筋膜瓣最大13 cm×18 ca.供筋膜瓣区保留皮肤及髂腹股沟取皮区皮肤均直接缝合. 结果 术后17例筋膜瓣联合全厚植皮均完全成活,成功治愈软组织缺损及骨髓炎,筋膜瓣供区、受区以及髂腹股沟取皮区均一期愈合,所有病例获得随访,随访时间为6～12个月,平均9个月,外形平整美观,供区保留皮肤感觉正常. 结论 带小隐静脉-腓肠神经筋膜瓣联合全厚皮片移植既能充分治愈小腿远段及足踝区软组织缺损以及骨髓炎,同时也能最大程度保护患肢功能及整体外观.     

小腿内侧游离皮瓣修复舌根癌切除后缺损

目的 探讨小腿内侧游离皮瓣在舌根癌术后缺损修复中的应用.方法 应用小腿内侧游离皮瓣,对4例舌根癌切除术后缺损进行修复,对该皮瓣的应用解剖,制作技术及其优缺点进行了阐述.结果 4侧小腿内侧皮瓣均获得成功.口内外伤口均愈合良好.移植于小腿内侧供区皮肤缺损区的皮片全部成活.结论 小腿内侧皮瓣适用于舌根及口咽部组织缺损的修复,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肌皮瓣修复并填充软组织缺损.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.     

Changes in donor site selection in lower limb free flap reconstructions

Since 1973 we have performed over 1,000 free flap reconstructions mainly in head and neck, breast, and upper and lower limb surgery. In lower leg reconstructions, changing indications for flap selection were not only correlated to new anatomical developments, but mainly due to a better understanding of adaptability of known muscle or fascial free flaps. Reducing donor site morbidity and planning for saving donor sites for future reconstructions are important. Morbidity is reduced by selection of free flaps ideally adjusted to the shape of the defect. Innervated free flaps or functional muscle transplants are rarely indicated in the lower leg. In the early years of microsurgical free flaps, soft tissue reconstruction or bone coverage was the primary indication. Later improving the vascularity of the wound bed by free flap cover increased the indication to chronic infected leg ulcers, osteomyelitis, diabetes, or artheriosclerotic wound defects or pressure sores due to lack of sensibility. Reconstruction of the foot and restoring its weight-bearing capacity is one of the more challenging applications of free flap cover. © 1997 Wiley-Liss, Inc. MICROSURGERY 17:380–385 1996     

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.     

Reconstruction of distal lower extremities defect using the free peroneal artery perforator vessel based flap

Soft tissue defects of the distal lower extremities are challenging. The purpose of this paper is to present our experiences with the free peroneal artery perforator flap for the reconstruction of soft tissue defects of the distal lower extremity. Nine free peroneal artery perforator flaps were used to reconstruct soft tissue defects of the lower extremities between April 2006 and October 2011. All flaps were used for distal leg and foot reconstruction. Peroneal artery perforator flaps ranged in size from 2 cm × 4 cm to 6 cm × 12 cm. The length of the vascular pedicle ranged from 2 to 6 cm. Recipient vessels were: medial plantar vessels in seven cases, the dorsalis pedis vessel in one, metatarsal vessel in one. All flaps survived completely, a success rate of 100%. Advantages of this flap are that there is no need to sacrifice any main artery in the lower leg, and minimal morbidity at the donor site. This free perforator flap may be useful for patients with small to medium soft tissue defects of the distal lower extremities and feet. © 2014 Wiley Periodicals, Inc. Microsurgery 34:629–632, 2014.     

Reverse sural artery flap: caveats for success

Complex open wounds of the distal third of the leg and ankle remain a reconstructive challenge for the plastic surgeon. In many cases, these wounds are best addressed with a free tissue transfer. Although this group has performed more than 400 free flaps to the leg during the past 6 years, free tissue transfer can be an arduous operation that requires a team approach and substantial donor site morbidity for the patient. In recent years, the authors have favored the reverse sural artery fasciocutaneous flap in 11 patients for its ease of dissection, limited morbidity, and preservation of major vessels to the limb. Caveats for successful performance of the reverse sural artery flap include Doppler evidence of patent peroneal perforators, placement of a lazy T-shape skin paddle over the distal gastrocnemius muscle bellies, inclusion of the lesser saphenous vein to augment venous drainage, and, lastly, careful dissection to provide a wide adipofascial pedicle.     

Wound coverage considerations for defects of the lower third of the leg

Anatomical features of the lower third of the leg like subcutaneous bone surrounded by tendons with no muscles, vessels in isolated compartments with little intercommunication between them make the coverage of the wounds in the region a challenging problem. Free flaps continue to be the gold standard for the coverage of lower third leg wounds because of their ability to cover large defects with high success rates and feasibility of using it in acute situations by choosing distant recipient vessels. Reverse flow flaps are more useful for the coverage of the ankle and foot defects than lower third leg defects. The perforators in the lower third leg on which these flaps are based are often damaged during the injury. In medium-sized defects of less than 50 cm² size, local transposition flaps, perforator flaps, or propeller flaps can be used. Preoperative identification by the Doppler is essential before embarking on these flaps. Of the muscle flaps, the peroneus brevis flap can be used in selected cases with small defects. In spite of all recent developments, cross-leg flaps continue to remain as a useful technique. In rare occasions when other flaps are not possible or when other options fail it can be a life boat. In the author''s practice free flaps continue to be the first choice for coverage of wounds in the lower third leg with gracilis muscle flap for small and medium defects, latissimus dorsi muscle flap for large defects and anterolateral thigh flap when a skin flap is preferred.KEY WORDS: Free flaps, perforator flaps, lower leg defects     

游离胸背动脉穿支皮瓣桥式移植修复小腿软组织缺损

目的总结游离胸背动脉穿支皮瓣或肌瓣桥式移植修复小腿软组织缺损的临床应用效果。方法自2006年9月至2009年1月,应用游离胸背动脉穿支皮瓣或肌瓣桥式移植修复小腿软组织缺损11例,缺损范围4cm×8cm至8cm×22cm。皮瓣切取连带肩胛下与旋肩胛血管,血管蒂呈T形,与健侧小腿胫后动脉行端端吻合,血管蒂用中厚网状游离植皮覆盖。结果除1例术后皮瓣远端发生小的表浅感染,经换药后愈合外,本组皮瓣全部成活。术后随访9个月至3.6年(平均2.9年),没有发现明显的供区功能障碍,供区与受区外形较好,健侧小腿经临床观察与Doppler检查,胫后动脉通畅。结论本方法适用于修复四肢软组织缺损后,患者仅存1条主要动脉者;行桥式游离胸背动脉穿支皮瓣或肌瓣移植不损伤健侧小腿胫后动脉,降低了对供区的损伤。     

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.     

Distally based sural fasciomyocutaneous flap: Anatomic study and modified technique for complicated wounds of the lower third leg and weight bearing heel

The reconstruction of the distal third leg and weight‐bearing heel, especially when complicated with infection and/or dead space, remains a challenge in reconstructive surgery. The distally based sural neurofasciomyocutaneous flap has been proved a valuable tool in repair of the soft tissue defects of those areas. In this report, we present the results of the anatomical study on vascular communication between the suprafascial sural neurovascular axis and the deep gastrocnemius muscle and a modified technique in clinical applications for reconstruction of the soft tissue defects in the distal lower leg and heel. Six lower limbs of fresh cadavers were injected with red gelatin and dissected. A constant vascular connection with average four musculo‐fasciocutaneous perforators with diameter 0.2–0.5 mm was identified in the overlapping area between the suprafascial sural neurovascular axis and the deep gastrocnemius muscle. Based on these findings, a modified distally based sural neurofasciomyocutaneous flap including the distal gastrocnemius muscle component was designed and used for repairs of the soft tissue defects in the distal lower limb and plantar heel pad in six patients. The blood supplies of flaps comprised either the peroneal perforator and adipofascial pedicle or the peroneal perforator only. The average size of the fasciocutaneous flap was 51 cm², and the muscle component 17.7 cm². All flaps survived uneventfully. Our results suggest that this technical modification could provide wider range for applications of the distally based sural neurofasciomyocutaneous flap in repair of the soft tissue defects of the lower extremity and heel. © 2008 Wiley‐Liss, Inc. Microsurgery, 2009.