The anatomic basis and clinical applications of flaps based on the posterior tibial vessels

The Reversed Flow Hemisoleus Propeller Muscle Flap

BACKGROUND

Soleus muscle flap can be used in different modifications to reconstruct lower limb defects. It can be proximally based, distally based, island or reversed flow flap. The first description of the soleus muscle as an island flap supplied by one distal perforator was reported by Yajima et al (Plast Reconstr Surg. 1995;96:1162-1168). However, its use as a propeller flap supplied by the distal perforators and rotated for more than 90 degrees was not described yet.

OBEJECTIVES

The aims of the study are to study the detailed vascular anatomy of the distal perforators of the soleus muscle flap and to demonstrate the applicability of using it as a propeller flap.

PATIENTS AND METHODS

A total number of 42 patients were included in this study. These patients had various distal leg and foot defects. All patients were assessed preoperatively by Doppler study and computed tomography angiography to define the vascular status of the leg. The muscle was raised as a reversed flow flap, based on 1 or more distal perforators and its feeding vessel (posterior tibial artery) after being dissected and divided proximally. The muscle was rotated for more than 90 degrees to reach distal leg defects and approximately 180 degrees to reach the foot defects.

RESULTS

All flaps survived completely with good and durable coverage. The vascularity of the limb was not affected in all patients. There was no functional donor site morbidity.

CONCLUSIONS

The reversed flow hemisoleus muscle flap supplied by the distal perforators and the posterior tibial artery has a great arc of rotation that can cover all distal leg, ankle, and foot defects. Therefore, it can be used as alternative to free flap in lower extremity reconstruction. A new nomenclature is suggested for this flap which is the propeller hemisoleus muscle flap.

The posterior tibial artery free flap for head and neck reconstruction

PURPOSE

The posterior tibial artery free flap (PTAFF) has been a mainstay of lower extremity reconstruction. Over the past 30 years, it has been intermittently used for head and neck reconstruction with recent renewed interest given its versatility.

RECENT FINDINGS

Use of the PTAFF in head and neck reconstruction is expanding along with the continued evolution of microvascular techniques. Differences in overall health, incidence of smoking, and body habitus can impact the utility of this flap and should be taken into consideration when choosing to use it.

SUMMARY

The PTAFF for head and neck reconstruction is a useful tool for the head and neck/reconstructive surgeon. Understanding the potential pitfalls and caveats to use of the PTAFF is important for successful use of this versatile flap.

Propeller Flaps

A propeller flap is an islanded flap that reaches the recipient site through an axial rotation around its vascular axis. The degree of rotation varies from 90 degrees to 180 degrees. It is a highly reliable local reconstructive option. These flaps are simple, single-stage, easy to harvest, and not constrained by routine length-to-width ratios. Since their introduction, the technique has continued to evolve and more applications for the use of propeller flaps are being explored. In spite of their growing use in clinical practice in recent years, many reconstructive surgeons are unaware of their versatility, unsure of their safety, and apprehensive about using propeller flaps confidently. This article aims at understanding the nomenclature, key principles, biogeometry and planning, operative technical details, applications, and complications of propeller flaps.

The Clinical Outcome of Perforator Based Sural Artery and Propeller Flaps in Reconstruction of Soft Tissue of Extremities

BACKGROUND

The reconstructive options for the soft tissues in extremities present serious challenges due to thin non-expendable soft tissues and predisposition to massive edema formation, thus frequently requiring flap cover. This study was undertaken to assess the outcome of a modified version of the sural artery flap with that of propeller perforator flaps for the reconstruction of lower extremities, particularly the heel defects.

METHODS

This prospective study was conducted on 40 consecutive patients, of which 20 treated with sural artery flap and another 20 with perforator based propeller flap cover for soft tissue reconstruction in extremities based on predefined inclusion criteria. The clinical outcome of the flap was assessed after three months.

RESULTS

Inclusion of the posterior tibial perforators (along with the sural artery and the peroneal artery) was shown to enhance the flap territory. The raising of the flap was quick with minimal blood loss and the modified flap had a wide arc of rotation for reconstruction of the heel defects. The younger patients regained sensation on the flap earlier, while the durability of the fasciocutaneous flap was excellent in the heel weight bearing areas. The success rate was 95% flap take.

CONCLUSION

Careful selection of the perforator and optimal designing of the flap result in favorable outcomes with the use of local perforator flaps for reconstruction in extremities. It provides predictable clinical outcomes with minimal donor site morbidity, is cost-effective, relatively easy technique and requires no special microsurgical setup or instruments.

Free posterior tibial artery perforator flap for 2-stage tracheal reconstruction in patients after resection of well-differentiated thyroid carcinoma invading the trachea

Background

The present study was conducted to explore the efficacy of using a free posterior tibial artery perforator flap (FPTAPF) for trachea reconstruction after resection of well‐differentiated thyroid carcinoma (WDTC) invading the trachea.

Methods

We retrospectively collected and analyzed clinical and surgical data from 14 patients who underwent tracheal reconstruction using a FPTAPF after resection of WDTC invading the trachea between August 2014 and July 2017.

Results

Satisfactory tracheal structure and functional recovery were obtained in 11 of the 14 patients. One patient had breathing difficulties after tracheostomy closure tests because of bilateral recurrent laryngeal nerve damage caused by disease invasion. Tracheostomy incision was not closed in 2 patients because they received postoperative adjuvant radioactive iodine 131 treatment.

Conclusion

Satisfactory tracheal reconstruction results were achieved in patients with resection of WDTC invading the trachea, indicating that a FPTAPF is a safe and reliable choice for management.

The Clinical Outcome of Perforator Based Sural Artery and Propeller Flaps in Reconstruction of Soft Tissue of Extremities

BACKGROUND

The reconstructive options for the soft tissues in extremities present serious challenges due to thin non-expendable soft tissues and predisposition to massive edema formation, thus frequently requiring flap cover. This study was undertaken to assess the outcome of a modified version of the sural artery flap with that of propeller perforator flaps for the reconstruction of lower extremities, particularly the heel defects.

METHODS

This prospective study was conducted on 40 consecutive patients, of which 20 treated with sural artery flap and another 20 with perforator based propeller flap cover for soft tissue reconstruction in extremities based on predefined inclusion criteria. The clinical outcome of the flap was assessed after three months.

RESULTS

Inclusion of the posterior tibial perforators (along with the sural artery and the peroneal artery) was shown to enhance the flap territory. The raising of the flap was quick with minimal blood loss and the modified flap had a wide arc of rotation for reconstruction of the heel defects. The younger patients regained sensation on the flap earlier, while the durability of the fasciocutaneous flap was excellent in the heel weight bearing areas. The success rate was 95% flap take.

CONCLUSION

Careful selection of the perforator and optimal designing of the flap result in favorable outcomes with the use of local perforator flaps for reconstruction in extremities. It provides predictable clinical outcomes with minimal donor site morbidity, is cost-effective, relatively easy technique and requires no special microsurgical setup or instruments.

Posterior tibial perforator-based flaps for leg and foot defects: Indications, limitations, and technical considerations

BACKGROUND

Covering defects at the lower leg and foot is a common challenge in reconstructive surgery. A flap is often required, and free flaps are widely used. The posterior tibial perforator-based flap constitutes a valuable option in this situation. The objectives of this study were to evaluate the reliability of the posterior tibial perforator-based flap, report any complications, and describe the outcomes, with the goal of defining the indications of this flap in the treatment of lower limb defects.

HYPOTHESIS

The posterior tibial perforator-based flap is a useful and reliable option for soft-tissue defect reconstruction at the leg and foot.

MATERIAL AND METHOD

Patients managed using a posterior tibial perforator-based flap to cover soft-tissue defects of the leg and foot were reviewed retrospectively. A physical examination was performed and radiographs obtained at the last postoperative follow-up visit.

RESULTS

Thirteen patients with a mean age of 46.9 years (range: 25-73 years) were reviewed after a mean follow-up of 19.5 months (range: 16-63 months). The tissue defects were due to compound fractures in 10 patients and to postoperative complications in 3 patients. Mean flap size was 12.3cm by 6.2cm. The donor site was covered by a skin graft in 12 patients and closed primarily in 1 patient. The procedure was successful in 11 (85%) patients.

DISCUSSION

The posterior tibial perforator-based flap is a method of choice for covering soft-tissue defects at the leg and foot. Careful patient selection and flawless technique contribute to minimise the failure rate.

LEVEL OF EVIDENCE

IV, retrospective study.

Redefining Vascular Anatomy of Posterior Tibial Artery Perforators: A Cadaveric Study and Review of the Literature

INTRODUCTION

Perforator flaps whether in a free or pedicled form are essential in leg reconstruction, requiring meticulous dissection based on a detailed understanding of vascular topographic anatomy. Numerous investigators have addressed this issue. However, the directionality of their fascial exit has not been greatly discussed in the literature. Subfascial course of the perforating vessel is a crucial determinant for optimal perforator selection especially when the propeller perforator flap option is considered, because an angulated fascial penetration would eventually result in perforator kinking which would additionally compromise vascular patency. The aim of the current study was to investigate the vascular anatomy of posterior tibial artery evaluating a wide range of parameters, including perforators' subfascial directionality, to precisely determine constant reliable perforator sites, in relation to surface landmarks on the medial aspect of the lower leg.

MATERIAL AND METHODS

Dissections in 30 lower legs from 25 fresh cadavers were performed. The lower leg was divided into 3 equal vascular zones. Measurements were taken in reference to anatomical landmarks. Perforator clusters to 5-cm intervals from medial malleolus were recorded and analyzed. Vessels with external diameter less than 0.5 mm were excluded. Data regarding the number, distribution, type, external diameter, length from posterior tibial artery, distance, and subfascial directionality were collected and treated.

RESULTS

A total of 155 perforators were identified (average number, 5 per leg; average diameter, 1.0 mm). Septocutaneous (127/155) perforators predominated, followed by musculocutaneous (19/155) and septomusculocutaneous (9/155). Most was concentrated in the middle (73/155) and distal (64/155) tertile. There were no septomusculocutaneous perforators at the distal third of the leg, whereas septocutaneous perforators were encountered into all vascular tertiles. An average of 2 comitant veins accompanied each perforator. Length and diameter related to the perforators' location. There was a significant association between perforator length and type. Cluster analysis revealed that reliable perforators were identified within the 21 to 25, 26 to 30, and 16 to 20 cm intervals.

CONCLUSIONS

Clinically optimal perforators for the first time were precisely located in relation to subfascial directionality, vascular diameter, and length from the source artery. Continuous improving details of vascular anatomy will further evolve perforator flaps' applications.

Free posterior tibial flap reconstruction for hypopharyngeal squamous cell carcinoma

OBJECTIVES

The aim of this article was to determine outcomes in patients with squamous cell carcinoma of the hypopharynx (SCCHP) in whom the free posterior tibial flap was used for primary reconstruction of hypopharynx defects after cancer resection.

SUBJECTS AND METHODS

Between August 2009 and February 2012, 10 patients with SCCHP underwent posterior tibial flap reconstruction for hypopharynx defects. The corresponding clinical data were retrospectively collected and analyzed.

RESULTS

Despite the multistep and time-consuming procedure, the posterior tibial flap survival rate was 100%. Operation-induced complications did not occur in four patients. Six patients developed postoperative hypoproteinemia, four patients developed postoperative pulmonary infections, and four patients developed pharyngeal fistula. The pharyngeal and laryngeal functions of all patients were preserved.

CONCLUSION

Our experience demonstrates that the posterior tibial flap is a safe and reliable choice for the reconstruction of hypopharynx defects.

Can we consider standard microsurgical anastomosis on the posterior tibial perforator network? An anatomical study

PURPOSE

The main vessels in an injured leg can be spared with perforator-to-perforator anastomosis. However, supermicrosurgery is not a routine procedure for all plastic surgeons. Our objective was to establish if the diameter of the perforators of the leg could allow anastomosis with standard microsurgical procedures.

METHODS

Twenty lower legs harvested from ten fresh cadavers were dissected. Arterial and venous vessels were injected with colored latex. The limbs were then dissected in a suprafascial plane. All the perforating arteries of a diameter >0.8 mm were located and their external diameter, the number and external diameter of the venae comitantes were reported.

RESULTS

We found at least three tibial posterior artery perforators with diameters >0.8 mm per leg with a mean external diameter of 1.1 mm and one vena comitans in almost all cases (96 %). The vena comitans was usually bigger than the perforating artery with a mean diameter of 1.6 mm. After statistical analysis, we were able to locate two main perforator clusters: at the junctions of the upper two-thirds of the leg and of the lower two-thirds of the leg.

CONCLUSION

The low-morbidity concept of perforator-to-perforator anastomosis can apply to posterior tibial artery perforators without using supermicrosurgical techniques. This is of high interest for open leg fractures where main vessels could be injured. We hope that the results of our study will incite surgeons to consider sparing of main vessels for coverage of open leg fractures whether surgical teams master supermicrosurgery or not.

The use of propeller perforator flaps for diabetic limb salvage: a retrospective review of 25 cases

Background

Peripheral vascular disease and/or diabetic neuropathy represent one of the main etiologies for the development of lower leg and/or diabetic foot ulcerations, and especially after acute trauma or chronic mechanical stress. The reconstruction of such wounds is challenging due to the paucity of soft tissue resources in this region. Various procedures including orthobiologics, skin grafting (SG) with or without negative pressure wound therapy and local random flaps have been used with varying degrees of success to cover diabetic lower leg or foot ulcerations. Other methods include: local or regional muscle and fasciocutaneous flaps, free muscle and fasciocutaneous, or perforator flaps, which also have varying degrees of success.

Patients and methods

This article reviews 25 propeller perforator flaps (PPF) which were performed in 24 diabetic patients with acute and chronic wounds involving the foot and/or lower leg. These patients were admitted beween 2008 and 2011. Fifteen PPF were based on perforators from the peroneal artery, nine from the posterior tibial artery, and one from the anterior tibial artery.

Results

A primary healing rate (96%) was obtained in 18 (72%) cases. Revisional surgery and SG for skin necrosis was performed in six (24%) cases with one complete loss of the flap (4%) which led to a lower extremity amputation.

Conclusions

The purpose of this article is to review the use of PPF as an effective method for soft tissue coverage of the diabetic lower extremity and/or foot. In well-controlled diabetic patients that present with at least one permeable artery in the affected lower leg, the use of PPF may provide an alternative option for soft tissue reconstruction of acute and chronic diabetic wounds.

Propeller perforator flaps in distal lower leg: evolution and clinical applications

Simple or complex defects in the lower leg, and especially in its distal third, continue to be a challenging task for reconstructive surgeons. A variety of flaps were used in the attempt to achieve excellence in form and function. After a long evolution of the reconstructive methods, including random pattern flaps, axial pattern flaps, musculocutaneous flaps and fasciocutaneous flaps, the reappraisal of the works of Manchot and Salmon by Taylor and Palmer opened the era of perforator flaps. This era began in 1989, when Koshima and Soeda, and separately Kroll and Rosenfield described the first applications of such flaps. Perforator flaps, whether free or pedicled, gained a high popularity due to their main advantages: decreasing donor-site morbidity and improving aesthetic outcome. The use as local perforator flaps in lower leg was possible due to a better understanding of the cutaneous circulation, leg vascular anatomy, angiosome and perforasome concepts, as well as innovations in flaps design. This review will describe the evolution, anatomy, flap design, and technique of the main distally pedicled propeller perforator flaps used in the reconstruction of defects in the distal third of the lower leg and foot.

Complete subtalar release for older children who had recurrent clubfoot deformity

BACKGROUND

Neglected idiopathic clubfoot deformities, and severe recurrent deformity after previous surgery presents technical difficulties for correction and challenges for surgeons to achieve primary skin closure.

METHODS

Between 2000 and 2006, 18 children (30 feet), had complete subtalar release (CSTR) for failed previous surgery in 28 feet and severe neglected congenital talipes equinovarus (CTEV) in 2 feet followed by cross leg fasciocutaneous flaps for reconstruction of residual defect at the ankle and foot after full correction of the deformity. Mean patients followed up were 4.5 years (average 2-8 years). 23 feet were classified as Dimeglio III and 7 feet as Dimeglio IV.

RESULTS

All cases achieved a plantigrade foot, better walking ability (p<0.03), and parental satisfaction with the result (p<0.001). Ankle joint doriflexion increased from mean (-21.33 degrees ) preoperatively to (12.5 degrees ) postoperatively. All cases showed postoperative improvement in their radiographic findings. The mean preoperative talocalcaneal angle increased from (15.7 degrees to 30.03 degrees ). The talo-first metararsal angle improved from a preoperative mean of -16 degrees mean of 5.53 degrees postoperatively. At the final follow-up cosmetically acceptable plantigrade foot was achieved in all feet. Four legs (14.28%) developed hypertrophic scars at the donar flap site. One patient developed 1.5cm marginal necrosis of the flap, which did heal after debridement by secondary intention. None of the feet had recurrence at the final follow up. Despite the enormous improvement clinically and radiologically, their was no statistical significant difference between preoperative and postoperative radiological angles (p<0.069). The number of previous surgical interventions had no influence on the outcome. All the previously treated feet had inadequate release of important tethered soft tissue.

CONCLUSION

This is indicative of the enormous value of complete subtalar release combined with cross leg fasciocutaneous flap without the need for bony intervention in previously operated failed feet or neglected deformities.

An anatomic study of the intermuscular septum of the lower leg; branches from the posterior tibial artery and potential for reconstruction of the lower leg and the heel

The anatomy of the intermuscular septum (IMS) of the lower leg has been studied in 10 legs of 10 cadavers. The IMS was well developed in the distal half of the lower leg and its vascular supply from the posterior tibial artery was frequently seen at 60mm proximal from the tip of the medial malleolus. We advocate that these anatomical features contribute to clinical applications of the IMS flap. It may be useful for reconstruction of the lower leg and heel as safer options with less morbidity.

Examination of the Skin Perforators of the Posterior Tibial Artery on the Leg and the Ankle Region and Their Clinical Use

BACKGROUND

There are many treatment alternatives for reconstruction of leg and foot defects. One of these treatment alternatives includes local flaps. A detailed understanding of the blood flow of the leg region is essential for producing new alternatives for the reconstruction of defects of this region.

METHODS

The leg and foot region blood flow was examined on 11 fresh cadavers, and perforators of this region were examined in three zones. Perforator numbers and their diameters were defined at this region. It was determined in cadaver studies that especially zones I and II were more suitable for the planned flaps based on perforators of the posterior tibial artery. In a clinical study that accompanies this anatomical study, eight patients underwent reconstruction by flaps based on the perforators of the posterior tibial artery.

RESULTS

Patients were followed for 3 to 14 months. In three patients, venous drainage problems had developed, and in one of them, partial flap loss had developed. This partially necrosed region was left to heal by secondary intention. Venous drainage problems resolved in 5 to 7 days in the two remaining patients. No other complications were seen.

CONCLUSION

Regarding the results of the clinical study, the authors observed that this flap can provide the desired soft-tissue support for defects that expose the bones, tendons, and neural and vascular bundles.

Posterior Tibial Artery Flap in Poliomyelitis Patients with Lower Extremity Paralysis

BACKGROUND

Poliomyelitis is a disease that can render affected individuals incapacitated to a variable degree. A normal lifespan is expected and therefore the patients deserve every effort at curative cancer resection and reconstruction. Those with lower extremity paralysis rely heavily on their upper limbs and torso for ambulation; therefore, their compromised limbs may be a better donor site for flaps.

METHODS

All poliomyelitis patients with lower extremity paralysis over a 20-month period who underwent head and neck reconstruction were selected for a retrospective review. Perioperative complications were noted and outpatient follow-up was performed.

RESULTS

Three patients underwent reconstruction of defects using the posterior tibial artery flap. Two patients required reconstruction of a buccal defect and one patient required soft palate reconstruction. All patients healed without complications and none required reexploration. At a mean follow-up of 10 months, there was no incidence of donor limb vascular compromise, cold intolerance, or long-term paresthesias.

CONCLUSIONS

The posterior tibial artery free flap has been used successfully in the past; however, its popularity has been limited because of sacrifice of the posterior tibial artery. Nevertheless, in patients with lower extremity paralysis, this flap may fulfill the requirements of a thin, pliable flap with minimal hair that has a long pedicle and a reliable blood supply. Most importantly, the use of this flap obviates the need to use flaps that fulfill the same requirement, such as forearm flaps, that would be taken from patients' functioning limbs.

Perforator Flaps from the Lateral Lower Leg for Intraoral Reconstruction

Perforator flaps are based on cutaneous, small-diameter vessels that originate from a main pedicle and perforate fascia or muscle to reach the skin. Although these flaps have recently become popular for soft-tissue reconstructions in nearly all regions of the body, the systematic application of perforator flaps with short, small-caliber pedicles for intraoral reconstruction has not been reported. Experience with the use of 10 consecutive perforator flaps from the lateral lower leg for intraoral defect coverage is reported. In 10 cases, a 4- to 6-cm-long septocutaneous or myocutaneous perforating vessel from the peroneal artery, with a diameter of 1 to 2 mm, could be identified in the proximal one-half of the lateral lower leg. The thin, pliable skin paddles, measuring up to 6 x 8 cm, were used for defect coverage after resection of squamous cell carcinomas of the floor of the mouth (five cases), soft palate (one case), tongue (two cases), or buccal mucosa (two cases). Anastomoses were performed to the lingual artery and concomitant vein. Except for one case, all perforator flaps healed without complications and the functional results were satisfying. At the donor site, which was always closed directly, an approximately 15-cm-long scar resulted, without functional impairments. The peroneal artery was regularly preserved. Perforator flaps from the lateral lower leg might have many applications for intraoral soft-tissue reconstruction, especially because of their minimal donor-site morbidity.

Distally based double paddle fasciocutaneous island flap following lower limb trauma

We report a modification of the distally based islanded fasciocutaneous flap that is suited to cover two separate defects following lower limb trauma.

The venoneuroadipofascial pedicled distally based sural island myofasciocutaneous flap: case reports

Complex soft-tissue defects of the lower third of the leg, the heel and the ankle still present a challenge for the reconstructive surgeon. In addition to skin replacement, many of these defects require muscle bulk, which promotes the healing of open bone fractures, effectively fills osteomyelitic cavities and deep three-dimensional defects, and helps to reconstruct the Achilles tendon. In an anatomical study, we developed a new flap based on the 'neuromuscular concept'. This flap consists of a paddle of gastrocnemius muscle and a skin paddle based distally on the sural venoneuroadipofascial pedicle supplied by the lower peroneal perforators. Three cases are presented to illustrate the versatile use of this flap.

History of hand surgery in Hong Kong

The development of hand surgery in Hong Kong can be largely divided into three phases: the early years, the 1960s and 70s, and the present. In the immediate post-World War II years, incidence of infectious diseases was high; there were many patients with tuberculosis, poliomyelitis, leprosy and osteomyelitis. In the 1960s and 70s, the light industry revolution brought along many patients with serious hand injuries caused by machines. Dr Yen-Shui Tsao was the first local surgeon trained in hand surgery. Prof. SP Chow and Prof. PC Leung were the two pioneers who developed this subspecialty and microsurgery during that period.

At present, with the change in economic environment, the disease pattern has also changed. Despite our heavy clinical involvement, we have been very active in academic researches. The Hong Kong Society for Surgery of Hand was formed in 1986. For the past 15 years, the society organized Workshops and Annual Congresses attended by overseas speakers, including surgeons from China. It also provided scholarships for Fellows of the Asia-Pacific countries. In addition, the society provided the participants with the chance to exchange ideas and forge friendships. Hong Kong has thus been and will continue to be the meeting point of the East and the West.

Large transverse fasciocutaneous leg flap: whole leg flap

Large defects of leg and sole often need massive tissue transfer. As an alternative to microvascular transfer, we have developed a fasciocutaneous flap in which almost the whole of the skin of the opposite leg is transferred based just on the septocutaneous perforators of the posterior tibial artery. The flap has been used as a cross-leg fasciocutaneous flap with potential for use as a free flap by taking a segment of the posterior tibial artery. Our experience with 11 cases is presented. Two patients suffered marginal necrosis while donor site problems were seen in another two patients. We have found this flap to be safe, technically easy and with minimal donor-site morbidity.

Free posterior tibial perforator flap: anatomy and a report of 6 cases

Anatomy of cutaneous perforators of the posterior tibial artery were studied in 20 limbs of 10 cadavers. The majority of the perforators (n = 74, 61%) were located in the middle two quarters of the leg, at an average of 18.6 cm (s.d. 4.5 cm; range 10.5-26 cm) from the medial malleolus, or around 54% (s.d 16%) of the length of the leg. There were usually 3 or 4 perforators in this region, with an average caliber of 1.5 mm (s.d. 0.2 mm; range 1-2 m.m.) and an average length from the posterior tibial artery to the skin of 4.0 cm (s.d. 1.3 cm; range 2.5-6 c.m.). A free fasciocutaneous skin flap based on one of these perforators (the posterior tibial perforator flap, PTP flap) was successfully transplanted in 6 cases. This modified technique of the posterior tibial flap enables the surgeon to retain the posterior tibial artery when the skin of the medial aspect of the leg is chosen to be used as skin flap donor.

Anatomical study of the perforating vessels of the lower leg

Difficulty of soft tissue defects of the lower leg demands the development of new methods to treat such defects. The aim of this study is the examination of perforators and the various ways of blood supply to the skin in the lower leg. Provided with certain regularity, we would be able to cure soft-tissue defects also in the difficult zone of the distal segment and on the dorsum of the foot not harming vessels and not affecting mobility of muscles. Subcutaneous island-flaps supplied by perforating vessels could replace free flaps. By saving the crural fascia of 10 lower legs we flayed layers of skin and fat, marked the perforating vessels with pins, and photographed and documented them. Specimens were divided into a proximal, an intermediate and a distal segment, each of them subdivided into a medial, lateral and dorsal section. The perforators, which can be classified as septocutaneous and musculocutaneous vessels, followed a reproducible pattern all over the lower leg. All vessels were sufficient in number as well as in size. Additionally these perforators can easily be identified by colour-coded sonography. The knowledge that perforators in the lower leg occur regularly enables the development of a new operative approach in therapy of soft-tissue defects in this region with the advantage, that the vessels used can be selected preoperatively.

A five year review of islanded distally based fasciocutaneous flaps on the lower limb

The use of the distally based islanded fasciocutaneous flap is described in 61 patients with lower limb defects and its application in coverage of compound fractures of the tibia is highlighted. A total of 66 flaps were raised from the posteromedial border of the leg, based on a single perforator off the posterior tibial artery. Flap coverage extended to include defects of the lower one third of the leg (n = 47) as well as the ankle, heel and foot (n = 4). Bony stabilisation was performed with a tibial intramedullary locking nail in 30 out of 53 fractures; mean time to bony union was 5.9 months. Mean operating time was 1.7 hours and mean hospital stay was 25 days (range 8-98 days). Mean follow-up time was 13 months (maximum 5 years). Twenty-five flaps were used to cover Gustilo IIIb fractures primarily, with a 20% complication rate in this group. The flaps were used preferentially in males and in older females. The overall flap failure rate was 7.6%, with a further 10.6% of flaps suffering from tip necrosis and haematoma formation. Contributory factors to suboptimal healing included the presence of peripheral vascular disease and heavy smoking.

The distally based posterior tibial myofasciocutaneous island flap in foot reconstruction

We report 3 cases of foot reconstruction with a distally based posterior tibial island flap incorporating both muscle and a fasciocutaneous part. The medial half of the soleus muscle which is included in the flap is well vascularised and can be used to fill cavities, for example after debridement of chronically infected wounds.

Distal vascular pedicle-hemisoleus to tibial length ratio as a main predictive index in preoperative flap planning

The management of severe compound tibial fractures is aimed at obtaining osseous consolidation, proper cutaneous and muscular cover, absence of infection and restoration of limb function. A knowledge of the cutaneous and muscular vascularisation allows the surgeons to use many flaps in a rational and predictable manner. One of the most commonly used flaps is the soleus muscular flap. This may be used as a proximally or distally based muscular flap and the use of a hemisoleus flap has also been described. A morphometric analysis of the relation between tibial length and soleus vascular pattern provides a simple and reliable method for planning this flap preoperatively. The study was performed on fresh and preserved cadavers.

Clinical application of the distally based medial adipofascial flap for soft tissue defects on the lower half of the leg

OBJECTIVE

Reconstruction of soft tissue defects on the lower half of the leg.

DESIGN

The distally based medial adipofascial flap nourished by the lower perforator originating from the posterior tibial artery was harvested, and the pivot point of flap transposition is 9 to 12 cm above the tip of the medial malleolus.

MATERIALS AND METHODS

Twelve cases of open tibial fracture associated with soft tissue defects on the lower half of the leg were reconstructed with this flap. The cases consisted of ten males and two females, and their ages ranged from 16 to 71 (averaging 41 years).

MEASUREMENTS AND MAIN RESULTS

Size of the flap varied from 4 x 7 cm to 5 x 18 cm. Eleven flaps had good perfusion and survived completely. Tip necrosis of the flap occurred in one case. In the early postoperative period, take of the meshed split-thickness skin graft on the flap was not complete. All wounds, however, were resurfaced completely without the need of a second grafting. Discharging sinuses occurred in one case, which was managed by removal of infected bony fragments. All the donor sites were closed primarily, and desquamation of wound edges occurred occasionally.

CONCLUSIONS

The distally based medial adipofascial flap was a reliable and effect local flap for the reconstruction of soft tissue defects on the lower half of the leg.

Reconstruction of limb defects with the free posterior tibial artery fasciocutaneous flap

There are few reports on the use of free posterior tibial artery free flaps. We present four cases of reconstruction of a limb defect with a free posterior tibial artery fasciocutaneous flap.