Anterograde–retrograde method for harvest of distally based sural fasciocutaneous flap: Report of results from 154 patients

Distally based sural fasciocutaneous flap is traditionally raised by the retrograde method. This article introduces the anterograde–retrograde method for harvest of the flap and describes our experience on altering the flap plan. A total of 159 flaps in 154 patients were elevated by the anterograde–retrograde approach that harvest of the flap began with exploring the peroneal artery perforators nearby the pivot point before the upper and bilateral edges of the flap were incised. Partial necrosis occurred in 16 (10.1%) flaps, and marginal necrosis developed in 10 flaps. Nine flaps were redesigned with adjusted pivot point and skin island. The anterograde–retrograde approach for harvest of the flap can accurately locate the perforator, readily adjust both the pivot point and skin island if necessary, and thus improve reliability of the flap. This approach is particularly applicable for elevation of the flap without preoperative localization of the perforators by means of the Doppler. © 2012 Wiley Periodicals, Inc.     

小腿穿支血管筋膜蒂皮瓣修复下肢软组织缺损

目的:探讨小腿穿支血管筋膜蒂皮瓣转移的手术方法和临床效果.方法:1998年5月至2009年1月临床应用带小腿内、后、前外、后外侧穿支血管的筋膜蒂皮瓣邻近转位,对下肢皮肤软组织缺损创面进行修复共62例,男50例,女12例;年龄7～78岁.其中应用带胫后动脉穿支的小腿内侧筋膜蒂皮瓣23例,带腓动脉终末穿支小腿前外侧筋膜蒂皮辩9例,带腓动脉穿支腓肠神经营养血管筋膜蒂皮瓣22例,带腘外侧动脉小腿后外侧筋膜蒂皮瓣8例.结果:除2例术后皮辩远端表皮坏死结痂,1例皮瓣远端部分皮肤坏死行Ⅱ期植皮,其余皮瓣均完全成活.随访1个月～3年,皮瓣外观满意,功能良好.结论:小腿部单个穿支血管供血面积有限,应用带穿支血管营养血管链的筋膜蒂度瓣可扩大小腿皮瓣的裁取面积,保证皮瓣的血供及回流.     

Successful retrograde arterial inflow through a muscular branch in a free anterolateral thigh chimeric flap transfer

In this report, we present a case in which a free anterolateral thigh (ALT) flap was transferred for head and neck reconstruction after oropharyngeal cancer ablation, and a retrograde arterial inflow was used to salvage the flap when the main arterial pedicle showed usual repeated spasms. The flap was raised as a chimera flap comprising a fasciocutaneous flap and a vastus lateralis muscle flap. After reperfusion, the pedicle artery exhibited spasms repeatedly and vascular flow was unstable. Therefore, we performed arterial supercharge. In the distal portion of the muscle flap, a small arterial branch was dissected as a reverse-flow arterial pedicle. The recipient artery was also a retrograde limb of the superior thyroid artery. The flap survived; however, postoperative ultrasonographic echo evaluation revealed that the spastic descending branch of the lateral circumflex femoral artery was obstructed and that the reverse-flow muscular perforator alone nourished the whole flap. In free ALT flap transfer, a small perforator level artery was able to nourish a flap, even in a retrograde manner. Moreover, when the vasculature of the free flap is unstable, retrograde arterial supply to a small perforator can be an option to save the flap transfer.     

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。     

小腿前外侧岛状皮瓣修复胫骨外露的解剖研究与临床应用

目的 探讨小腿前肌间隔动脉链为蒂的岛状皮瓣修复胫骨外露的术式及手术方法.方法 40侧成人尸体下肢标本经动脉灌注红色乳胶,4侧新鲜成人尸体下肢标本动脉造影,观测小腿前肌间隔内的胫前动脉穿支与腓动脉终末前穿支的位置、走行、外径及相互吻合.临床应用小腿前外侧岛状皮瓣转位修复胫骨外露11例.男7例,女4例;年龄20～59岁,平均36岁.结果 40侧标本腓骨长度为(32.3±2.4)cm.胫前动脉发出腓浅动脉、胫前动脉下段前肌间隔穿支,与腓动脉终末前穿支在小腿前肌间隔内相互吻合,形成动脉链,这三条动脉外径分别为(1.4±0.4)mm、(1.0±0.4)mm及(1.5±0.4)mm,动脉链吻合处外径为(0.6±0.2)mm.动脉链伴腓浅神经走行,营养神经和小腿前外侧皮肤.临床应用小腿前外侧岛状皮瓣修复胫骨外露的11例中,以胫前动脉下段前肌间隔穿支为蒂2例,以胫前动脉下段前肌间隔穿支的升支为蒂3例,以胫前动脉下段前肌间隔穿支的降支为蒂3例,以腓动脉终末前穿支升支为蒂3例.皮瓣切取面积7 cm×5 cm～13 cm×5 cm.随访1～3年,平均1.5年,11例皮瓣全部成活,无破溃、臃肿.结论 根据皮肤缺损部位、面积等灵活选用小腿前肌间隔内动脉链为血管蒂,设计前外侧岛状皮瓣修复胫骨外露,术式灵活,是修复胫骨外露的理想皮瓣.

Abstract：

Objective To explore surgical methods of repairing tibial skin defect using the anterolateral crural island flap.Methods The location,external diameters,anastomosis and distribution of perforators from the anterior tibial artery and the peroneal artery in the anterior septum were observed in 40 cadaveric specimens.Arterial angiography was performed in 4 fresh legs.Clinically,11 cases with tibial skin defect were repaired with the anterolateral crural island flap.There were 7 males and 4 females,with an average of 36 years (20-59 years).The area of the skin defect ranged from 6 cm×4 cm to 12 cm×4 cm.Results An arterial chain was formed by the interconnection of the superficial peroneal artery,the anterior septocutaneous perforator from distal part of the anterior tibial artery and the anterior end-perforator of the peroneal artery.It ran in the anterior septum and went along with the superficial peroneal nerve to supply blood to adjacent fascia and skin.The external diameters of the three perforators were (1.4±0.4) mm,(1.0±0.4) mm and (1.5±0.4) mm respectively,and the external diameter of the arterial chain was (0.6±0.2) mm.Clinically,we designed 4 methods to repair 11 cases of tibial skin defect successfully with the anterolateral cnnal island flap.The anterior septocutaneous perforator from distal part of the anterior tibial artery was used as pedicle in 2 cases;ascending branch of the anterior septocutaneous perforator from distal part of the anterior tibial artery was used as pedicle in 3 cases;descending branch of the anterior septocutaneous perforator from distalpart of the anterior tibial artery was used as pedicle in 3 cases;ascending branch of the anterior end-perforator of the peroneal artery was used as pedicle in 3 cases.The area of the flaps ranged between 7 cm×5 cm and 13 cm×5 cm.All patients were followed up with a mean time of 1.5 years.All flaps survived totally without diabrosis and swelling.Conclusion The anterolateral island flaps pedicled with perforators arising from the anterior septum of the lower leg is a good choice for surgeons to repair tibial skin defect.     

两种岛状皮瓣修复手指远节末端皮肤缺损的疗效比较

目的比较指固有动脉逆行岛状皮瓣和指固有动脉背侧穿支岛状皮瓣修复手指远节末端皮肤缺损的效果。方法将109例手指远节末端皮肤缺损患者根据修复方法不同分为逆行岛状皮瓣组(采用指固有动脉逆行岛状皮瓣修复,54例)和穿支岛状皮瓣组(采用指固有动脉背侧穿支岛状皮瓣修复,55例),比较两组皮瓣两点辨别觉及手指功能TAM评分。结果患者均获得随访,时间12~24(18.5±2.5)个月。皮瓣全部成活,伤口及供皮瓣区均一期愈合。手术时间、术中出血量、术后12个月皮瓣两点辨别觉及手指功能TAM评分两组比较差异均无统计学意义(P>0.05)。术后6个月,两组皮瓣外形及感觉均良好,质地柔软、耐磨、无触痛、耐寒冷;供区愈合好,外观平整,无瘢痕挛缩,主、被动活动良好。术后12个月两组手指功能TAM评分优良率比较差异无统计学意义(P>0.05)。结论指固有动脉逆行岛状皮瓣和指固有动脉背侧穿支岛状皮瓣修复手指远节末端皮肤软组织缺损都是较理想的方法,临床操作中宜优先选用指固有动脉背侧穿支岛状皮瓣。     

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.     

手掌掌侧远1/3部动脉穿支筋膜瓣的解剖及临床应用

目的:探讨手掌掌侧远1/3部动脉穿支筋膜瓣在指掌侧组织缺损修复中应用的可行性,为临床应用提供解剖和理论依据。方法:通过10例新鲜手部灌注标本解剖,在显微镜下观测手掌掌侧远1/3部动脉穿支数目、外径、分布范围,并据此设计以动脉穿支为蒂的掌远1/3部皮下筋膜组织瓣,修复近、中节指掌侧组织缺损。结果:掌远1/3部动脉穿支总数为(19.3±4.3)条,每条指总及指固有动脉每侧有3.25±1.19条动脉穿支,各动脉穿支起始处外径介于0.10～1.03mm,平均外径为(0.46±0.10)mm。穿支血管横行生长,相互吻合,形成横向血管吻合和纵向链型动脉弓,可营养长约4cm的横向或纵向筋膜组织瓣,可修复近侧指间关节周围,最远达中节指骨远端的指掌侧缺损创面。结论:手掌掌侧远1/3部动脉穿支吻合成网,应用局部动脉穿支筋膜瓣可Ⅰ期修复手指近、中节组织缺损,在功能和外观上取得良好效果。     

Reconstruction of full‐thickness cheek defect with chimeric facial artery free flap: A case report

Full‐thickness cheek defects represent a difficult challenge for reconstructive surgeons. Multiple techniques have been described, including local, regional, and free flaps. In this report, the reconstruction of a through and through left cheek defect, resulting from a self‐inflicted gunshot injury, with a chimeric facial artery free flap is presented. The patient underwent reconstruction with a chimeric full‐thickness facial artery free flap, with 9 × 3 cm diameter skin paddle and a 6 × 5 cm myomucosal paddle, was harvested on the contralateral cheek with a 7‐cm length of facial pedicle. The flap was transferred via a microsurgical technique and an end‐to‐end microsurgical anastomosis was performed between the donor and the contralateral facial vessels. The flap was transplanted successfully and there were no donor or recipient site complications with a satisfactory esthetic result 5 years after surgery. This technique may be a good reconstructive option for medium size, full‐thickness, cheek defects allowing a “like with like” reconstruction with minimal donor‐site morbidity.     

Perforator-to-perforator musculocutaneous anterolateral thigh flap for reconstruction of a lumbosacral defect using the lumbar artery perforator as recipient vessel

Reconstruction of large-sized lumbosacral or sacral defects often is not possible using local or regional flaps, making the use of free flaps necessary. However, the difficulty of any microsurgical procedure in this region is complicated by the need to search for potential recipient vessels to revascularize the flap. In the present case, a free musculocutaneous anterolateral thigh flap to cover a large-sized and deep lumbosacral defect was used. Arterial anastomosis was performed, connecting the cutaneous anterolateral thigh (ALT) perforator to the perforator of the second lumbar artery. In this fashion, the arterial circulation through the flap was flowing reversely through the muscle. The concomitant vein of the descending branch of the lateral circumflex femoral artery was hooked up to the thoracodorsal vein using a long interposition vein graft because the perforator of the second lumbar vein was too small. Postoperative healing was uneventful. In conclusion, a successful reconstruction of a lumbar defect has shown that local perforators in the lumbar area may be accessible for easier perforator-to-perforator anastomoses and that the muscular part of the musculocutaneous ALT flap can survive on retrograde arterial perfusion from a perforator of the skin island.     

The use of innervated radial artery superficial palmar branch perforator free flap for complex digital injuries reconstruction

Loco-regional flaps have been widely used for the reconstruction of digital injuries without requiring microvascular anastomosis, however, they result in scarring and compromised functional outcomes. This study demonstrates our experience utilizing the innervated radial artery superficial palmar branch (RASPB) perforator free flap for complex digital injury reconstruction. From May 2007 to March 2014, the innervated RASPB perforator free flap was used to reconstruct 79 distal complex hand and digital soft tissue defects of which 14 were used to re-vascularise the distal digit in a flow-through fashion. All free flaps were innervated by the palmar cutaneous branch of the median nerve. All 79 free flaps survived and all 14 digits re-vascularized successfully. One flow-through free flap developed distal skin necrosis which healed uneventfully without further procedure. The average follow-up was 21.5 months. Measurement of two-point discrimination ranged from 7 to 13?mm. All patients were satisfied with the aesthetic results. The innervated RASPB perforator free flap is a feasible and effective option for the reconstruction of complex digital defects and the flow-through concept, when utilized in cases with compromised vascularity, provides reliable re-vascularization. Level III, therapeutic study.     

第二掌背动脉岛状皮瓣的临床应用

目的：通过解剖学研究，设计第２掌背动脉岛状皮瓣，临床修复手部皮肤缺损，获得成功。方法：对５０只经动脉灌注红色乳胶的成人手标本，在放大镜下观察第２掌背动脉及伴行静脉的起端，皮支、终末支的走行；测量血管各部位的直径。结果：第２掌背动脉终末支分布于第２指蹼、示中指近节皮肤；皮支和其它掌背、掌指动脉间有丰富的吻合支。临床应用８例，顺行皮瓣７例，逆行１例。修复手背、拇指皮肤缺损，皮瓣全部成活。结论：临床应用第２掌背动脉为蒂的岛状皮瓣时，可设计成顺行或逆行皮瓣，均能成活。     

One‐stage reconstruction by dual‐innervated double muscle flap transplantation with the neural interconnection between the ipsilateral masseter and contralateral facial nerve for reanimating established facial paralysis: A report of 2 cases

The authors developed a one‐stage double‐muscle reconstruction technique for facial paralysis using a latissimus dorsi (LD) flap and a serratus anterior (SA) flap, which were dually reinnervated by the contralateral facial nerve (FN) and ipsilateral masseter nerve (MN). The procedure was performed for 61‐year‐old man 3‐years after resection of a malignant tumor and a 24‐year‐old woman 10‐years after temporal fracture with facial paralysis. A double‐muscle flap comprising left LD and SA flaps was harvested, a 15‐cm thoracodorsal nerve (TN) section was attached to the LD flap, and 5‐cm and 1‐cm sections of the long thoracic nerve (LTN) were attached to the proximal and distal sides of SA flap. The LD flap and SA flap were sutured along the direction of motion of the zygomaticus major and risorius muscles, respectively. The contralateral FN and ipsilateral MN were interconnected by nerve suturing: the medial branch of TN to the distal end of LTN, the proximal end of LTN to the ipsilateral MN, and the buccal branch of contralateral FN to the main trunk of TN. After surgery, good contraction of the transferred flaps resulted in reanimation of a natural symmetrical smile; no complications were observed during the 12‐month follow‐up period.     

Modification of pedicle lengthening through perforator transposition in free anterolateral thigh flaps with pedicle size discrepancy: A case report

In spite of thorough presurgical planning, emergency situations requiring longer pedicle length may arise during anterolateral thigh (ALT) free flap surgeries. While performing vessel graft for pedicle lengthening, discrepancy may occur because of a certain genetic predisposition or vascular variation at the anastomosis site of the graft vessel and the flap pedicle. A 76‐year‐old male patient with neurofibromatosis type I had a 15 x 10 cm defect, which was caused by radical excision of a malignant peripheral nerve sheath tumor on his back. A 15 x 10 cm sized free ALT flap was obtained. The distance between the recipient vessels and the defect area was 20 cm. The diameters of vessels in the harvested flap were as follows: proximal end of the descending branch of the lateral circumflex femoral artery (LCFA)—artery/vein: 3.0/2.5 mm, distal end of the descending branch of the LCFA—artery/vein: 1.0/1.0 mm, and perforator in the ALT flap—artery/vein: 0.8/1.0 mm. The conventional method requires transfer of the distal portion of the LCFA (below the bifurcation) which mandates us to perform anastomoses with a vessel diameter discrepancy of 2 mm. As an alternative, a bifurcating perforator‐including flap was transposed to the most distal part of the descending branch of the LCFA. An ALT flap with a pedicle having a total length of 20 cm was constructed. The flap survived without any complications. This technique may provide an option for resolving size discrepancy between the graft vessel and the ALT pedicle.     

手指皮瓣分类和急诊修复

目的选择应用伤指本体皮瓣和邻指皮瓣重建指端缺损的方式,总结临床应用疗效。方法2001年8月~2005年6月,收治108例112指手外伤,其中男68例71指,女40例41指;年龄16~63岁。损伤原因:均为切削、挤压和撕脱伤,伤后2 h内手术。采取9种皮瓣,对手指指端的急性软组织损伤缺损进行修复.将皮瓣分为两大类:①指动脉主干血管营养皮瓣,包括:指神经血管束V-Y岛状提升瓣,指动脉逆行皮瓣,改良M oberg皮瓣和指神经血管束蒂双翼皮瓣,皮瓣范围2.0 cm×1.5 cm;②指动脉侧支血管营养皮瓣,包括:拇指尺背侧动脉逆行皮瓣,皮瓣范围:1.5cm×1.5 cm~3.0 cm×2.5 cm,指动脉背侧支逆行皮瓣,皮瓣范围1.7 cm×1.0 cm~4.5 cm×3.0 cm;指掌横支皮瓣,其皮瓣范围:2.0 cm×1.0 cm~2.5 cm×2.0 cm;食指背岛状皮瓣和手指局部皮瓣。结果术后3指坏死,3指浅表性坏死。其余106指移位完全成活。术后随访2周~8个月,皮瓣两点辨别觉5~10 mm,指活动良好,外观令人满意。结论选择上述皮瓣可修复所有的末节指端软组织缺损创面,并获得良好的修复外形。     

改良邻指指动脉逆行岛状皮瓣的应用

目的 探讨改良邻指指动脉逆行岛状皮瓣修复手指中节以远掌侧皮肤软组织缺损的手术方法。方法 以指总动脉作为邻、患指指掌侧固有动脉逆行供血通道，在患指近侧指间关节近侧平面为旋转点，设计邻指指动脉岛状皮瓣逆行翻转，修复10例手指中节以远掌侧皮肤软组织缺损，同时将皮瓣上的感觉神经与患指远端指神经缝合。结果 10例皮瓣全部成活，术后随访6～15个月。手指外观饱满，皮瓣颜色与正常手指相似，皮瓣质软，两点分辨觉为4mm。供区手指功能无影响。结论 改良邻指指动脉逆行岛状皮瓣适用于修复手指中节以远掌侧皮肤软组织缺损创面的覆盖，术后疗效满意。     

Reconstruction of soft tissue defects of the Achilles tendon with rotation flaps,pedicled propeller flaps and free perforator flaps

Introduction. Soft tissue defects exposing the Achilles tendon are challenging. Local perforator flaps represent a valuable option gaining increasing popularity. Despite preoperative planning an adequate perforator cannot always be found intraoperatively. The free peroneal artery perforator flap can serve as a back‐up option limiting the donor site morbidity to the same extremity without sacrificing major vessels or nerves. Methods. Nine patients with soft tissue defects exposing the Achilles tendon were treated with local perforator flaps, seven were scheduled for 180° propeller flap coverage after Doppler‐ultrasound examination. However, in two patients (22%) no adequate perforators were found intraoperatively. As the perforators for the free peroneal artery perforator flap were routinely mapped out, this flap was harvested for microsurgical reconstruction. Results. One patient with a 180° propeller flap developed a partial flap necrosis, another patient developed superficial epidermolysis, both requiring skingrafting. No complications were seen with free tissue transfer. Conclusion. Pedicled perforator flaps as propeller flaps add options to the armamentarium of microsurgeons. Despite thorough preoperative planning the surgeons must be prepared to perform a different method of reconstruction if inadequate vessels are encountered. To limit additional donor site morbidity, local options are preferred. The free peroneal artery perforator flap represents a good option as it matches the original tissue properties closely. The complication rate of propeller flaps in this series is tolerable. Propeller flaps should therefore be considered an alternative but not as a replacement of local fasciocutaneous flaps. © 2010 Wiley‐Liss, Inc. Microsurgery 30:608–613, 2010.     

Retrograde vascularisation of fibula free flap in composite oro-mandibular reconstruction

We present a case of composite oromandibular reconstruction with fibula free flap in which the vascularity to the flap was established in a retrograde direction through the distal end of the peroneal pedicle vessels. The flap was initially designed in such a way so as to anastomose with superior thyroid artery. However after initial good flow, the superior thyroid artery flow became insufficient. Therefore, an attempt was made to vascularise the flap by anastomosing the distal end of peroneal vessels with the facial artery and a tributary of the internal jugular vein so that the flap was perfused in a retrograde direction. This was successful and the retrograde flow was adequate to ensure flap survival. We believe this to be the first successful case of reverse vascular flow reported for composite oromandibular reconstruction with the fibula free flap.KEY WORDS: Composite oromandibular defects, fibula free flap, oromandibular reconstruction, retrograde vascularisation     

Outcome of free digital artery perforator flap transfer for reconstruction of fingertip defects

Background:

Fingertip defect can be treated with many flaps such as random pattern abdominal flap, retrograde digital artery island flap, V-Y advancement flap, etc. However, swelling in the fingertip, dysfunction of sensation, flexion and extension contracture or injury in the hemi-artery of the finger usually occurs during the recovery phase. Recently, digital artery perforator flaps have been used for fingertip reconstructions. With the development of super microsurgery techniques, free flaps can be more effective for sensory recovery and durability of the fingertip.

Materials and Methods:

Six cases (six fingers) of fingertip defects were treated with free digital artery perforator flaps of appropriate size and shape from the proximal phalanx. During surgery, the superficial veins at the edge of flap were used as reflux vessels and the branches of the intrinsic nerve and dorsal digital nerve toward the flap were used as sensory nerves. The proximal segment of the digital artery (cutaneous branches) towards the flap was cut off to form the pedicled free flap. The fingertips were reconstructed with the free flap by anastomosing the cutaneous branches of digital artery in the flap with the distal branch or trunk of the digital artery, the flap nerve with the nerve stump and the veins of the flap with the digital artery accompanying veins or the superficial veins in the recipient site.

Results:

Six flaps survived with successful skin grafting. Patients were followed up for 6-9 months. The appearance and texture of the flaps was satisfactory. The feeling within the six fingers recovered to S4 level (BMRC scale) and the two point discrimination was 3-8 mm.

Conclusion:

Free digital artery perforator flap is suitable for repairing fingertip defect, with good texture, fine fingertip sensation and without sacrificing the branch of the digital artery or nerve.     

The supramalleolar flap. Our experience in 35 cases

The authors report 35 cases of use of the supramalleolar flap described by Masquelet et al. in 1988. In 27 cases, the arterial blood supply was in a mixed (anterograde and retrograde) fashion since the perforating branch of the peroneal artery was spared. In eight cases the arterial blood supply was in a retrograde fashion due to the location of the skin loss. As described by Valenti et al. In 1991, the authors recommend the use of a distal subcutaneous pedicled to avoid skin grafting over the tendons at the distal part of the lag. In main cases of anterograde blood supply the superficial peroneal nerve could be spread. In 33 cases the plastic result was assessed as satisfactory. The coverage of the weight-bearing portion of the heel was done two times with no satisfactory result. Coverage of the medial malleolus area, Achilles tendon and dorsal skin of the foot represent the main indications and the best results. Five times, a venous congestion was observed with three cases of partial necrosis of the flap. The use of a large subcutaneous pedicle did not always prevent such venous problems, though this technical aspect improves the vascular reliability of the flap. The main local alternative is the distal pedicled sural flap that needs to divide the sural nerve and not allows coverage as distal as the supramalleolar flap. Except the distal coverage of the foot, the indications of these previous both flaps are similar. In case of foot coverage, the medial plantar flap based on the lateral plantar vascular bundle, as described by Martin et al. in 1991, is the other one local alternative. Free flaps are indicated for extensive skin losses, or when a poor distal vascularity of the leg does not allow reliability of distal pedicled flaps.