The flexor digitorum brevis muscle island pedicle flap: a new dimension in heel reconstruction

Lower Extremity Soft Tissue Reconstruction Review Article

Reconstruction plays a valuable role in the management of lower extremity wounds for limb salvage. The goals of reconstruction are to improve function and quality of life, return to work, and pain reduction while providing a long-lasting durable reconstruction. The plastics and reconstructive surgical approach in conjunction with the orthopedic or trauma team, referred often as the "orthoplastic" approach, can yield the best outcomes for patients. The following sections discuss reconstruction principles and techniques that can be applied broadly for lower extremity wounds secondary to trauma, infection, and tumor resection.

Medial plantar artery-based perforator and island flaps: a case series of applications in sole defects

BACKGROUND

Soft tissue defects of the plantar foot pose a challenge to the reconstructive surgeon. The plantar region of the foot has a unique skin structure, which helps in its paramount functions of weight-bearing and providing protective sensation. It is best replaced with tissue of its own kind. The medial plantar artery (MPA) flap fulfils all the requirements of an ideal replacement for small-to-medium-sized defects in the mid plantar and heel region. This study describes our experience with MPA-based flaps for small-to-medium-sized defects of the plantar foot.

METHOD

The study was conducted in a tertiary referral hospital between April 2017 and March 2020 on patients who presented with defects on the mid plantar region and heel. MPA perforator (MPAP) flap or island flap were applied. The donor site was covered with split-thickness skin grafts.

RESULTS

The study included 21 patients. MPAP flap was applied in nine patients and the island flap was applied in 12 patients. The mean age of the patients was 37.95 years and the mean flap size was 36.6cm². All flaps survived well. In two patients, venous congestion developed which resolved spontaneously, while three patients had small graft loss which also healed with conservative treatment. All patients regained protective sensation within five months of flap coverage.

CONCLUSION

Based on the MPA, both perforator and island flaps can be raised due to the fairly constant position of the perforators. These flaps have the advantage of robust vascularity with the replacement of identical tissue for weight-bearing functions along with acceptable aesthetic outcomes. Since they also have the added advantage of conferring sensation, they can be used as a primary option in cases of small-to-medium-sized plantar foot defects.

The Treatment Experience of Different Types of Flaps for Repairing Soft Tissue Defects of the Heel

Objective

To summarize the clinical application effects of three different types of flaps for repairing soft tissue defects of the heel, and to discuss the importance of tissue repair and heel reconstruction.

Methods

A total of 46 cases with skin tissue defects of the heel with deep tissue exposure were treated. The reasons for the defect were trauma (n = 26), burns and electric shocks (n = 12), chronic ulcers (n = 2), postoperative infection of the calcaneus and Achilles tendon (n = 5), and tumor resection (n = 1). The scope of wound defect was 2.0×2.5 to approximately 15.0×20.0 cm. The flaps used were medial plantar island flaps (n = 9), distal pedicled sural neurovascular island flaps (n = 23), and free anterolateral thigh (perforator) flaps (n = 14). The flap cutting range was 3.0×3.5 to approximately 16.0×22.0 cm.

Results

After surgery, all 46 flaps survived. In two cases, patients experienced partial epidermal necrosis at the distal end of the flap that healed after local dressing exchange, and after this treatment, the complete skin grafts survived. Follow-up was conducted in 40 cases, with an average follow-up duration of 8.2 months (3-44 months) and the two-point discrimination of 5-14 mm. The average American Orthopaedic Foot and Ankle Society scale was 89.2 points with good flap color and texture, satisfactory appearance, and normal gait.

Conclusion

The repair method should be selected according to the"5-zone method": The plantar medial island flap is suitable for small area (<5 cm) of medial, posterior and plantar defects. The distal pedicled sural neurovascular flap is suitable for lateral, posterior, and medium-range (6-10 cm) joint area defects. The free anterolateral thigh perforator flap is suitable for large-scale (>10 cm) joint area defects.

Intrinsic Muscle Flaps for Coverage of Small Defects in the Foot

Exposure of critical structures such as joints, bones, ligaments, and tendons necessitates expeditious closure. The longer these structures remain open to the environment, the higher the risk is for that patient developing osteomyelitis and an amputation. Muscle flaps remain often first choice when dealing with bone infections associated with osteomyelitis, soft tissue infections, and large cavities. Foot defects are a challenge especially in the absence of microsurgical expertise. Intrinsic local flaps of the foot can be an option to cover defects. This article describes local intrinsic muscle flaps for coverage of foot defects.

Therapeutic failure and eventual solution for skin necrosis and exposed tendon of the dorsum of the foot: A case report

For the treatment of skin necrosis with exposed tendons in rheumatoid arthritis (RA) foot, we should perform microvascular free flap surgery at an early stage without conservative treatment considering the increased risk of infection and the decreased physical activity.

Reverse-Flow Intrinsic Fasciocutaneous Island Flaps in Foot Reconstruction

Reconstruction of soft tissue defects in the foot remains a challenge due to its specialized tissue for weightbearing and ambulation. Considering the principle of replacing "like with like," adjacent soft tissues would be a best option for a donor site. Although several kinds of reverse-flow island flaps for the lower leg have been well described, intrinsic foot reverse flow flaps have been rarely reported. We describe 3 kinds of reverse-flow intrinsic fasciocutaneous flaps (RIFFs) for foot reconstruction. From September 2012 to August 2015, a retrospective study was done on case notes of all patients who had a RIFF for coverage of soft tissue defects within the foot following trauma or tumor ablation. A total of 7 patients were included in this study, with an average of 5 × 3.5 cm sized defects in the forefoot, second and third web space, and sole, which were reconstructed with RIFF. All flaps were well perfused and recovered excellent function of the foot with satisfactory aesthetics and minimal limitations in range of motion. However, one case showed a complication of venous congestion, due to remnant scar tissues, which resolved after medical leech application. Donor defects healed completely with split thickness skin grafting in all cases. Soft tissue defects within the foot were repaired successfully by RIFF. In spite of its technical challenges, it is a reliable one-stage procedure requiring no microsurgical anastomosis. Precise vascular evaluation of the reverse inflow has to be preceded for satisfactory outcome of RIFF.

Reconstruction of Ankle and Heel Defects with Peroneal Artery Perforator-Based Pedicled Flaps

BACKGROUND

The reconstruction of ankle and heel defects remains a significant problem for plastic surgeons. The following options exist for reconstructing such defects: local random flaps, reverse flow island flaps, and free flaps. However, each of these methods has certain drawbacks. Peroneal artery perforators have many advantages; in particular, they are predictable and reliable for ankle and heel reconstructions. In this study, we report our clinical experience with peroneal artery perforator-based pedicled flaps in ankle and heel reconstructions.

METHODS

From July 2005 to October 2012, 12 patients underwent the reconstruction of soft tissue defects in the ankle and heel using a peroneal artery perforator-based pedicled flap. These 12 cases were classified according to the anatomical area involved. The cause of the wound, comorbidities, flap size, operative results, and complications were analyzed through retrospective chart review.

RESULTS

The mean age of the patients was 52.4 years. The size of the flaps ranged from 5×4 to 20×8 cm(2). The defects were classified into two groups based on whether they occurred in the Achilles tendon (n=9) or heel pad (n=3). In all 12 patients, complete flap survival was achieved without significant complications; however, two patients experienced minor wound dehiscence. Nevertheless, these wounds healed in response to subsequent debridement and conservative management. No patient had any functional deficits of the lower extremities.

CONCLUSIONS

Peroneal artery perforator-based pedicled flaps were found to be a useful option for the reconstruction of soft tissue defects of the ankle and heel.

The versatility of perforator-based propeller flap for reconstruction of distal leg and ankle defects

Introduction. Soft tissue coverage of distal leg and ankle region represents a challenge and such defect usually requires a free flap. However, this may lead to considerable donor site morbidity, is time consuming, and needs facility of microsurgery. With the introduction of perforator flap, management of small- and medium-size defects of distal leg and ankle region is convenient, less time consuming, and with minimal donor site morbidity. When local perforator flap is designed as propeller and rotated to 180 degree, donor site is closed primarily and increases reach of flap, thus increasing versatility. Material and Methods. From June 2008 to May 2011, 20 patients were treated with perforator-based propeller flap for distal leg and ankle defects. Flap was based on single perforator of posterior tibial and peroneal artery rotated to 180 degrees. Defect size was from 4 cm × 3.5 cm to 7 cm × 5 cm. Results. One patient developed partial flap necrosis, which was managed with skin grafting. Two patients developed venous congestion, which subsided spontaneously without complications. Small wound dehiscence was present in one patient. Donor site was closed primarily in all patients. Rest of the flaps survived well with good aesthetic results. Conclusion. The perforator-based propeller flap for distal leg and ankle defects is a good option. This flap design is safe and reliable in achieving goals of reconstruction. The technique is convenient, less time consuming, and with minimal donor site morbidity. It provides aesthetically good result.

Reconstructive options for defects after melanoma excision in the foot and ankle region

Cutaneous wounds created by excision of primary cutaneous melanoma localized to the foot and ankle can be challenging to reconstruct. A wide range of coverage techniques are available for wound coverage. The techniques we have found useful in this regard include skin grafts and flaps, as well as specialized wound dressings. In this techniques report, we describe the specialized anatomic surface subunits of the foot and ankle and the reconstructive coverage methods we have found useful for each site.

Functional reconstruction of the diabetic foot

The diabetic triad of neuropathy, vasculopathy, and foot deformity can be surgically challenging to the reconstructive surgeon. Soft tissue deficits must be closed to protect underlying structures from infection and to provide a stable environment for healing. It is critical to have adequate blood flow and to debride the wound to clean healthy tissue before considering reconstruction. Surgical options commonly used include healing by secondary intention, local flap closure, skin grafts, pedicled flaps, and free tissue transfer. Despite a surgeon's best operative efforts, these strategies may fail perioperatively due to postoperative shear forces created by premature joint motion and/or pressure (either weight bearing or decubitus). In the properly selected patient population, external fixators serve as an indispensable adjunct to wound healing in the Charcot foot by providing temporary but reliable offloading and/or immobilization of joints. Using a team approach is critical to the success of diabetic limb reconstruction.

Innervation of three weight-bearing areas of the foot: An anatomic study and clinical implications

The aim of this cadaver study is to improve our knowledge on the anatomy of the sensory fibres of the three weight-bearing areas of the plantar region. Previous studies mainly focused on the innervation of the heel but the innervation of the other two weight-bearing areas over the most medial and lateral metatarses have been neglected and are not well known. The study was carried out on 10 feet of five male cadavers. The tibial nerve was dissected down to the fat pads over the heel and the first and fifth metatarsal heads under the microscope. The distances of the branching point of the tibial nerve and origins of the medial and inferior calcaneal nerves to a line drawn from the centre of the medial malleolus to the centre of the calcaneous were all measured. The tibial nerve was divided into two branches called the lateral and medial plantar nerves 23.45 mm proximal to the predefined axis. The medial plantar nerve passed underneath the abductor hallucis muscle and gave two sensory branches to the fat pad over the first metatarsal head. The lateral plantar nerve coursed beneath the abductor hallucis and flexor digitorum brevis muscles and supplied innervation of the fat pad over the fifth metatarsal head. The sensory innervation of the heel was provided by medial calcaneal and inferior calcaneal nerves. The medial calcaneal nerve originated from the tibial nerve 41.89 mm proximal to the axis. It divided into two or three branches innervating the fat pad over the heel. The inferior calcaneal nerve originated from the lateral plantar nerve (70%) or the medial calcaneal nerve (30%) 10.66 mm proximal to the axis. This study describes the sensory fibres to the heel and the previously neglected weight-bearing areas over the first and fifth metatarses. Reconstruction of defects in these areas is very difficult so every attempt should be made to protect the sensory fibres during any surgical procedure.

Soft tissue defects of the heel: a surgical reconstruction algorithm based on a retrospective cohort study

The hindfoot is a special anatomical location, requiring unique forms of reconstruction of the thick, durable heel pad, the underlying calcaneus, and the Achilles tendon and its thin, pliable soft tissue envelope. Perhaps more than in any other region of the foot, the heel poses a reconstructive challenge to the surgeon who must consider both form and function when repairing wounds in this location. There are many possible reconstructive options, including local, distant, and free flaps. These flaps could be of muscular, myocutaneous or fasciocutaneous tissues. We reconstructed heel defects in 46 consecutive patients using several reconstructive options, and reviewed the results. Patients were classified according to preoperative demographic variables, including size, depth, site, etiology, age, vascularity, sensation, Achilles tendon condition, bone exposure or bone loss, and the patient's functional needs. Neither partial nor total flap losses were observed; the reconstructions were evaluated and considered satisfactory both by surgeons and patients if they fulfilled certain criteria, namely complete coverage, durability upon weight bearing and walking, sensation, donor site morbidity, and cosmetic appearance. No recurrences of the defects were observed during the follow-up period. Heel reconstruction is a challenging task for foot and ankle reconstructive surgeons. Every step should be taken to avoid recurrences and ulcerations. In this article we present a surgical reconstruction algorithm that may allow easy and reliable decision making based on the preoperative assessment of the defect and other clinical features.

LEVEL OF CLINICAL EVIDENCE

2.

Distally based fasciocutaneous sural flap for foot reconstruction: a retrospective review of 10 years experience

BACKGROUND

The treatment of soft tissue defects of the foot is a problem mainly connected to the thickness of the coverage tissues, to the poor circulation, and to the frequent involvement of muscle, tendon, and bone. The authors present their experience with the sural flap, also in some particular cases.

MATERIALS AND METHODS

The authors treated 33 patients for small- and medium-size defects of the foot, caused by work, home, and road accidents, and by venous or diabetic ulcers. In all cases, the flap was cut in its fasciocutaneous variant; an extension of the sole portion of fascia was added in 5 patients. The flap was transferred under a subcutaneous tunnel in 10 cases, with an open incision in 20 cases, and in 3 cases the pedicle was kept external for 4 weeks, then resected.

RESULTS

One patient showed a complete necrosis of the flap and another showed a superficial necrosis preserving the deep fascia; in the remaining 31 cases, the flap incorporated without any major complication. The flap provided proper coverage of the defects from both an aesthetic and functional point of view as evidenced clinically and through a baropedographic test.

CONCLUSION

The advantages of this flap include: dissection is fast and easy, it is not necessary to sacrifice important arterial pedicle or muscular units as it can be used in traumatized limbs without further damage to main arteries, and a wide rotation arc is possible. Disadvantages include the sacrifice of the sural nerve and the covering of the donor region with skin grafts.

Lateral Retromalleolar Perforator???Based Flap: Anatomical Study and Preliminary Clinical Report for Heel Coverage

BACKGROUND

Repair of heel soft-tissue defects remains a challenging problem in reconstructive surgery. The distally based sural neurofasciocutaneous flap is among the flaps of choice for coverage of this difficult region. The authors describe a modified lateral retromalleolar perforator-based neurocutaneous flap with a lower pivot point.

METHODS

This study was divided into two parts: anatomical study and clinical application. In the anatomical study, 12 cadavers were injected with red gelatin, and all fasciocutaneous perforators between the lateral malleolus and Achilles tendon (called the lateral retromalleolar space) were identified. Clinically, based on the anatomical study, five cases of heel soft-tissue defects were reconstructed with the modified lateral retromalleolar perforator-based sural neurofasciocutaneous flap.

RESULTS

The anatomical study showed that there are usually two to three retromalleolar cutaneous perforators arising from the terminal part of the peroneal artery in the lateral retromalleolar space. Their outer diameters range from 0.1 to 0.8 mm. A direct venous communicator, usually accompanied by the larger perforator, connected the superficial lesser saphenous vein and the deep peroneal venae comitantes. Five patients with heel soft-tissue defects were treated with flaps ranging from 3 x 6 cm to 5 x 12 cm. The distal pivot point was designed at 1 to 3 cm above the tip of the lateral malleolus. All flaps survived without complications.

CONCLUSIONS

The lateral retromalleolar perforator is predictable and reliable for the design of a lower pivot point, distally based sural neurocutaneous flap. The procedures are simple and rapid, and the flap can be rotated easily without dog-ear deformity. This flap should be considered among the preferred flaps for heel reconstruction.

Heel Reconstruction with a Medial Plantar V-Y Flap

BACKGROUND

Full-thickness defects to the plantar surface of the foot present a challenge to the reconstructive surgeon. Skin grafts and a variety of flap procedures have been described to resurface this site, but not all achieve a return to normal foot function. For the plantar surface of the heel, the previously described medial plantar flap can produce successful results. However, this method leaves a donor site, which requires skin grafting. This is a report of a modification of the medial plantar flap into a V-Y configuration that allows direct closure of the donor site.

METHODS

Three defects of the plantar surface of the heel were resurfaced: case 1, a spina bifida patient with a 45-mm-wide debrided pressure sore; and cases 2 and 3, patients with defects resulting from wide excisions of melanomas that were 47 and 57 mm wide, respectively. Patients in cases 2 and 3 were reviewed at 1 year for mobility, gait, and sensation in the flap.

RESULTS

The patients in cases 2 and 3 were able to attain full, unrestricted mobility and objectively near-normal sensation of the resurfaced skin. In the patient in case 1, a problematic pressure sore was healed after an intermediate period of wound dehiscence, with a robust, bulky flap.

CONCLUSIONS

This modified flap retains the advantages of the traditional medial plantar flap while minimizing its donor-site problems. It has permitted satisfactory long-term functional results, optimizing restoration of foot function, and is a useful option that can be considered for resurfacing the problematic plantar surface of the heel.

Medial plantar artery (instep flap) flap

Provision of sensation to the weightbearing surface of the heel is very vital in the sensate foot. Hence, resurfacing the weightbearing surface of the heel requires provision of stable skin cover and sensation. We have many options to fulfill the above requirements. Skin of the instep area can be raised as an island fasciocutaneous flap based on medial plantar vessels, with the branch of medial plantar nerve supplying the instep skin to provide the sensation. Medial plantar artery (instep) flap provides similar tissue with sensation and reaches the posteriormost part of the weightbearing surface of the heel with ease. We present in this article the relevant surgical anatomy, technique, and the clinical experience of 12 patients.

Functional Total and Subtotal Heel Reconstruction With Free Composite Osteofasciocutaneous Groin Flaps of the Deep Circumflex Iliac Vessels

Functional and esthetic reconstruction of the bony and tendinous structures with a stable, sensate soft tissue integument after complex posttraumatic defects of the heel is demanding. Cases are rare in the literature and hardly comparable due to their heterogeneity. The reconstructive approach has to consider both patient profile and the reconstructive tree, with free microvascular flaps playing a primary role. The goals are the reconstruction of both osteotendinous structures and slender soft tissue lining for proper shoe fitting for ambulation and mechanical and thermal protection. The flap should be sensate in weightbearing areas to optimize gait and to prevent long-term complications by ulcers. The osteofasciocutaneous deep inferior circumflex artery (DCIA) flap is especially suitable for complex heel defects with subtotal or total loss of the calcaneal bone as all components (iliac bone, groin skin, and fascia lata) can have a wide range of size and shape. We operated on 2 cases with this variable composite flap. One patient had a complete heel defect by war shrapnel. The complete calcaneus, soft heel, and Achilles tendon were reconstructed. The second patient had an empty os calcis after a comminuted fracture and a lateral crush-induced soft tissue defect. In both patients, a stable wound closure, osseous integration, and weightbearing ambulation could be achieved.

Versatility of the Abductor Hallucis Muscle as a Conjoined or Distally-Based Flap

Soft tissue coverage of the medial ankle and foot remains a difficult, challenging, and often frustrating problem to patients as well as surgeons. To our knowledge, the abductor hallucis muscle flap is not frequently used and only a few well documented cases were found in literature. The purpose of this paper is to report and to present the long-term results of a series of four patients who underwent reconstruction of foot and ankle defects with the abductor hallucis muscle flap. In two cases, the abductor hallucis muscle flap was transposed in combination with a medialis pedis flap to cover a medial ankle defect, whereas in another case it was combined with a medial plantar flap. In this latter case, the muscle flap served to fill up a calcaneal dead space after osteomyelitis debridement, whereas the cutaneous flap was used to replace debrided skin at the heel. The abductor hallucis flap was used as a distally-based turnover flap to cover a large forefoot defect in a fourth case. Follow-up period ranged between 18 and 64 months (mean 43.3). In the early postoperative period, two flaps healed completely In two patients marginal flap necrosis occurred which was subsequently skin grafted. No donor-site complication occurred in any of the patients. In all cases, protective sensation of the skin was satisfactory as early as 6 months. In two cases mild hyperkeratosis at the skin graft border to the sole skin (non-weight bearing area of medial plantar and medialis pedis flap donor site) was present, but probably related to poor foot care. All patients were fully mobile as early as 3 months after treatment. In the long-term follow-up (43.3 months), all flaps provided with durable coverage. Functional gait deficit due to consumtion of the abductor hallucis muscle was not apparent. Our long-term results demonstrated that the abductor hallucis muscle flap is a versatile, and reliable flap suitable for the reconstruction of foot and ankle defects. Utilizing the abductor hallucis muscle as a pedicled flap (distally or proximally-based) with or without conjoined regional fasciocutaneous flaps offers a successful and durable alternative to microsurgical tree flaps for small to moderate defects over the calcaneus region, medial ankle, medial foot, and forefoot with exposed bone, tendon, or joint.

Distally Based Sural Fasciomusculocutaneous Flap for Chronic Calcaneal Osteomyelitis in Diabetic Patients

Chronic calcaneal osteomyelitis is a difficult surgical problem, especially in diabetic patients. After aggressive surgical eradication of nonviable soft tissue and infected bone, there will be a large soft-tissue and bony defect. A distally based sural fasciomusculocutaneous flap including the sural nerve and a midline cuff of the gastrocnemius muscle can be useful for covering the defect. This flap is designed on the proximal half of the posterior calf and has an adequate blood supply derived from retrograde perfusion of the vascular axis of the sural nerve to the musculocutaneous perforators of the gastrocnemius muscle. The patency of the peroneal artery should be confirmed by Doppler ultrasound or angiography before surgery. If there are any vascular problems, this flap will not be used to avoid complications resulting from poor flap circulation. This approach has been used for 11 diabetic patients in the past 2 years. All flaps survived completely and all wounds healed uneventfully. The authors found that the flap was reliable and technically simple to design and execute. This 1-stage procedure not only preserves the major arteries of the injured leg but has also proved valuable for filling bony defect and treating bony infection because it provides a well-vascularized muscle fragment. Compared with other tissue transfers, this flap has special characteristics for use on diabetic patients with chronic calcaneal osteomyelitis.

Modified distally based peroneal artery perforator flap for reconstruction of foot and ankle

The distally based sural fasciocutaneous flap has been used widely for reconstruction of foot and ankle soft-tissue defects. Here we report on a series of cases of foot and ankle reconstruction with a modified distally based sural flap. The vascular pedicle of the flap includes an axial perforator branch of the peroneal artery and two concomitant veins. This modified distally based perforator flap, measuring around 17 x 6 cm to 30 x 10 cm in size, was transferred for coverage of foot and ankle soft-tissue defects in 7 cases. All flaps survived completely. Neither arterial ischemia nor venous congestion was noted. As compared to other distally based sural flaps with neuro-veno-adipo-fascial pedicles, this modified sural flap with a thin perforator pedicle is easily rotated. The flap can obtain abundant blood supply through both axial perforator and longitudinal chain-linked vascular plexuses, and does not have the venous reflow problem. In conclusion, the invention of this perforator fasciocutaneous flap provides a valuable tool for repair of foot and ankle soft-tissue defects.

The simple and effective choice for treatment of chronic calcaneal osteomyelitis: neurocutaneous flaps

The authors describe their experience with the use of distally based saphenous and sural neurofasciocutaneous flaps for the treatment of calcaneal osteomyelitis in nine cases. Aggressive débridement of all nonviable and poorly vascularized tissue and coverage with a distally based neurofasciocutaneous flap were coupled with a thorough antibiotic course in all cases. The deepithelized peripheral parts of all flaps were buried in the bone cavities after bone débridement. Follow-up periods ranged from 15 to 27 months. All flaps survived completely. All of the wounds except one healed completely. These flaps have adequate blood flow for the management of chronic bone infections. They also have many advantages, such as easy quick elevation, short operative time, and acceptable donor-site morbidity. Moreover, patients treated with neurocutaneous flaps do not require debulking procedures or special shoes. Reconstruction with neurocutaneous flaps after radical débridement is a versatile alternative to the use of local or distant muscle flaps and calcanectomy procedures for patients with osteomyelitis of the os calcis.

[Evaluation of sensitivity in the fasciocutaneous neurovascular medial plantar island flap in reconstruction of soft tissue defects in the calcaneal region]

The soft tissue cover in the calcaneal region represents one of the great problems in the reconstructive surgery. The distant skin, muscle and musculocutaneous flaps are subjected to ulcers even with the orthopedic shoes. The island fasciocutaneus mid sole neurocutaneous flap can be a good substitute for the soft tissue cover due to its anatomic structure. The flap has the required dimensions, sticks well to the bone and the movements and mobility of the patient is unrestricted. This paper analyses the sensitivity of the transposed flap and the sole distal to the secondary defect observed in 30 patients. The evaluation was made after tactile tests, two-point discrimination test, the warm-cold test, the electrostatus of medial plantar nerve (MPN), and the ninhydrin test. All the tests, including the electrostatus MPN, done after 3 weeks and 3 months after the surgery, showed successful recovery of sensitivity in the transposed medial plantar flap. The results monitored after three months showed that the speed of the neural conduction recovery was 70% of normal neural reaction speed of the MPN. The modified operative techniques provide safe dissection of the plantar nerve with minimal neuropraxia. The postoperative recovery of sensitivity was more rapid, and without loss of sensitivity on the sole.

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.

Soft tissue coverage of the extremely traumatized foot and ankle

The development of microsurgery and the expansion of plastic surgery techniques have led to a significant increase of surgical options for the salvage of the lower extremity. The traditional methods still have a role, but many authors have demonstrated a superiority of free and sophisticated regional flaps. This article gives an overview of treatment algorithms and surgical options. A therapeutic goal for the surgeon is to select the appropriate procedure with respect to the patient's medical condition and rehabilitation potential, the defect, and the surgeon's technical skills to achieve durable, permanent, pain-free, and functionally and aesthetically satisfying defect coverage.

Distally based sural fasciomuscular flap: anatomic study and application for filling leg or foot defects

Since 1995, the authors have created 32 distally based superficial sural artery flaps based on the vascular axis of the sural nerve. The creation of the first 18 flaps permitted the authors to view perforators that issued from the gastrocnemius muscles to the vascular axis of the sural nerve. This led to the development of an anatomic study involving 25 cadaveric dissections to establish a relationship between the gastrocnemius muscles and the vascular axis of the sural nerve, with two to three constant and direct perforators from the gastrocnemius to the neurovascular axis. In this article, the technique for harvesting this new muscular flap is described. Between June of 1997 and March of 1998, three patients underwent flap operations. Two fasciomyocutaneous flaps and one fasciomuscular flap were created and were followed by uncomplicated postoperative courses in terms of flap viability and donor sites. In all cases, the flap created was designed to fill bone defects of the leg (one case) or of the foot (two cases). The results were considered to be excellent and stable over time, with follow-up periods ranging from 9 months to 18 months in duration.

Effect of increased compartment pressure on the microcirculation of skeletal muscle

To determine the changes in capillary perfusion, which occur with elevated tissue pressure, and to highlight the relationship between systemic blood pressure and compartment pressure, we designed an experiment that allowed direct observation of the microcirculation of skeletal muscle under normal and increased compartment pressures. In each of 10 anesthetized rats, the cremaster muscle was exposed and suspended in a transparent pressure chamber. In vivo videomicroscopy was then performed and blood pressure was monitored via left carotid artery cannulation. Two sets of data for each animal were obtained: deltaP (mean arterial pressure compartment pressure) at which the muscle capillary blood flow was completely arrested, and the number of capillaries per 10,000 square micrometers of skeletal muscle with blood flowing at compartment pressures of 0, 15, 30, 45, and 60 mm Hg. Capillary blood flow stopped at a deltaP of 25.5 mm Hg +/- 14.3 SD. We found that capillary blood flow, as measured by the number of capillaries with blood flow per 10,000 square micrometers, decreased significantly (P < 0.05) as compartment pressure reached 15, 30, 45, and 60 mm Hg, when compared to 0 mm Hg; there was no vessel collapse at these pressures. These data show that increasing compartment pressure reduces the number of perfused capillaries per unit area, and that there is complete cessation of muscle capillary blood flow when the compartment pressure is within about 25 mm Hg of the mean arterial pressure.

Lateral calcaneal V-Y advancement flap for repair of posterior heel defects

We obtained favorable results in reconstruction of the posterior heel with a lateral calcaneal V-Y advancement flap. This technique simplifies the operative procedure and eliminates the disadvantages of the original lateral calcaneal flap and its island version while retaining the advantages of these methods.

Stepladder V-Y advancement flap for repair of postero-plantar heel ulcers

Random fasciocutaneous flaps with bilateral adipofascial pedicles were elevated from the posterior heel and transferred distally to defects of the postero-plantar heel in 4 patients, using a stepped incision technique, in combination with the V-Y advancement principle. In all cases the flap was successfully transferred without any linear scar or scar contracture in the posterior heel. The absence of recurrence of ulcers during the postoperative follow-up between 1.5 and 4 years indicated the reliability and durability of the flaps. Application of this procedure permits rapid resurfacing and excellent recontouring of small to moderate-sized defects of the heel with minimal donor site morbidity.

Long-term results of weight-bearing foot reconstruction with non-innervated and reinnervated free flaps

Twenty one patients underwent reconstruction of the weight-bearing portion of the foot with 22 free flap transfers: 12 free flaps were skin-grafted muscle flaps and 10 were fasciocutaneous flaps. Twelve flaps were reinnervated by nerve coaptation (n = 10) or an 'onlay' nerve graft (n = 2). Follow-up ranged from 1.5 to 7 years (mean 38.5 months). Five flaps (23%) developed full thickness ulcers that required surgical treatment. All ulcers occurred in patients who had an underlying neuropathy. Most complications occurred early in the series. No significant difference was found in the incidence of complications and functional outcome between fasciocutaneous and skin-grafted muscle flaps. There was no significant difference between reinnervated and non-innervated flaps. Both fasciocutaneous and skin-grafted muscle flaps, whether reinnervated or non-innervated, can be successfully used for weight-bearing foot reconstruction. Neither type of flap should be considered permanent in the presence of peripheral neuropathy. Appropriate selection of patients, extensive education about foot care and frequent follow-up visits are essential to maintain a healthy, intact flap and reconstructed foot.

Island adipofascial flap for resurfacing of the Achilles tendon

Satisfactory replacement of soft-tissue defects over the Achilles tendon remains a difficult challenge for plastic surgeons. Flap coverage is vital to preserve an exposed tendon as well as to supply a gliding surface. Ten patients were selected for this study who had sustained exposed Achilles tendons either after trauma or after excision of burn scar. The island adipofascial flap was used based on the most distal two to three septocutaneous perforators of the posterior tibial artery that are located 3.7 to 5.5 cm proximal to the tip of the medial malleolus, as confirmed by my anatomic study. The island adipofascial flap provides a durable and thin coverage for the Achilles tendon, as well as a good vascularized bed for skin grafting.

Lateral calcaneal artery flap for coverage of a posterior heel defect in a child

The lateral calcaneal artery fasciocutaneous transpositional flap is utilized for coverage in a case presentation of a 6-year-old child with an insensate posterior heel defect. The procedural technique and 32-month follow-up is described. Advocacy of this flap, for this patient, and potential detriments of alternative coverage options are discussed.

The lateral calcaneal artery adipofascial flap

The lateral calcaneal artery adipofascial flap is a modification of the lateral calcaneal artery skin flap. It has been used successfully in five patients. In comparison to the skin flap, it has the advantages of more versatile clinical applications, better aesthetic result of the donor site and sural nerve preservation.

Anatomic study of a new axial skin flap based on the cutaneous branch of the medial plantar artery

A new axial skin flap based on the middle cutaneous branch of the medial plantar artery was evaluated in 33 fresh cadaver legs. The vascular pedicle of the skin flap is based on the middle cutaneous artery, its venae comitantes, and segments of the great saphenous vein, if necessary. The middle cutaneous artery is the largest cutaneous branch, arising from the medial plantar artery 2.5 cm distal to its origin. The diameter of its origin is 1.2 mm, and its pedicle is 2 cm long. The midline of the flap runs from the first web space to the heel tip. The upper and lower borders of the flap are 3 to 4 cm on either side of this line. The upper border is medial to the extensor hallucis tendon, and the lower border is medial to the abductor hallucis. Distally, the border begins 2 cm proximal to the metatarsalphalangeal joint; proximally, the border is at the middle of the medial malleolus. The flap diameter can be up to 8 x 12 cm. The middle cutaneous branch of the medial plantar artery was found in all cadaver specimens, except for one with a common trunk. The new flap design leaves the major blood supply to the foot and the plantar aponeurosis intact. It is easy to harvest and may be used either as an island flap or free flap.

Reconstruction of the foot with microvascular free flaps

Reconstruction of the foot using microvascular flaps has been widely performed in the last 15 years but the choice of flap to repair some areas in the foot remains controversial. We present a series of 128 free flaps to the foot performed during the period of 1975-1990. One hundred and seventeen had a successful outcome (91%). The etiology of the problem was traumatic in 94, congenital in 10, tumor in 9, and chronic ulcerations due to vascular problems in 15. The indications for a specific flap depended on the site and extension of the foot problem, and were divided into four groups: 1. Dorsum of the foot. Cutaneous parascapular flap was the best choice. 2. The sole-weight-bearing area. We favored the use of the latissimus dorsi muscle flap covered with a split thickness skin graft, done immediately. A proper tailoring of the flap and postoperative care by the patient are very important to maintain the result without ulceration. Tactile sensation does not seem to be essential. 3. The area over the calcaneus tendon. We have used cutaneous flaps such as the parascapular and lateral arm flap or fascial flaps covered by split thickness skin grafts (STSG). The fascia used were the serratus or the parascapular. 4. Complex trauma problems with extensive skin loss or chronic ulcerations due to vascular diseases: the latissimus dorsi musculocutaneous or muscle plus STSG was mostly used. The overall number of donor areas were 5 groins, 48 parascapular, 2 gluteal fold flaps, 4 lateral arm, 61 latissimus dorsi, and 8 fascial flaps.