Forefoot reconstruction by reversed island flaps in diabetic patients

Soft-tissue coverage of the foot is often difficult, especially when the distal third of the foot (dorsal or plantar aspects) is involved. The clinical situation can be further complicated when diabetic patients are affected by painful and unstable wounds of this kind because of the familiar phenomenon of vasculopathy. The purpose of this study was to evaluate the possibility of using distally based foot flaps to cover forefoot defects in diabetic patients. Preoperative selection of patients was the key to this study; those who had other major disease, chronic infection, bone involvement, and/or insufficient foot vascularization were excluded from the study. The authors report a series of 12 diabetic patients in whom the reconstruction of medium-sized defects (ranging from 1.5 x 2.0 cm to 3.0 x 7.0 cm) of the forefoot was performed using distally based dorsalis pedis flaps or medial plantar flaps. The transferred flaps survived and adapted well to the defects, except for one flap in a patient who had a slight venous insufficiency at outset. Wearing their own footwear, patients could walk after 20 to 30 days. After the follow-up period (3 months to 3 years), no skin breakdown in the treated areas was observed. Temporary donor-site pain was reported by medial plantar flap patients, and partial skin graft loss at the donor site occurred in some of the dorsalis pedis patients. The authors suggest that in selected cases, medium-sized soft-tissue defects involving the dorsal aspects or the weight-bearing areas of the diabetic foot can be successfully covered with distally based island flaps.     

Our experience with combined procedures in aesthetic plastic surgery

The instep flap needs neither muscle nor a transposition base for survival or innervation. It can be transposed as an island fasciocutaneous flap either on the medial or lateral plantar neurovascular bundles or both, and it can be transferred also as a free flap from the opposite foot. Four cases demonstrating the use of the flap as an island and free flap are presented with follow-up ranging from 1 to 2 years. The absence of muscle in the flap provides greater stability of the heel reconstruction and results in a lesser secondary defect. Sensation in the flaps is diminished but adequate for long-term function, but hyperkeratotic reaction remains an unpredictable problem. The ability to transfer the flap as a free transfer widens the scope of the flap to reconstruct both heel and forefoot defects where local instep tissue or vascularity are inadequate for local reconstruction. The secondary defect, particularly when no muscle is included in the flap, has been minimal.     

The distally based lesser saphenous venofasciocutaneous flap for ankle and heel reconstruction

Finding an appropriate soft-tissue grafting material to close a wound located over the ankle and heel can be a difficult task. The distally based lesser saphenous venofasciocutaneous flap mobilized from the posterior aspect of the upper leg, used as an island pedicle skin flap, can be useful for this purpose. The vascular supply to the flap is derived from the retrograde perfusion of the accompanying arteries of the lesser saphenous vein. These arteries descend along both sides of the lesser saphenous vein to the distal third of the leg, either terminating or anastomosing with the septocutaneous perforators of the peroneal artery. Between February of 1999 and March of 2001, four variants of this flap were applied in 21 individuals, including 11 fasciocutaneous, five fascial, three sensory, and two fasciomyocutaneous flaps. Skin defects among all patients were combined with bone, joint, and/or tendon exposure. The authors found that the flap was reliable and technically simple to design and execute. This one-stage procedure not only preserves the major arteries and the sural nerve of the injured leg, but it also has proved valuable for covering a weight-bearing heel and filling a deep defect, because it potentially provides protective sensation and a well-vascularized muscle fragment. When conventional local flaps are inadequate, this flap should be considered for its reliability and low associated morbidity.     

Versatility of the medial plantar flap: our clinical experience

The medial plantar flap presents an ideal tissue reserve, particularly for the reconstruction of the plantar and palmar areas, which require a sensate and unique form of skin. In the past 5 years, the authors performed 16 free flaps, 10 locally pedicled flaps, and five cross-leg flaps on 31 patients for the reconstruction of palmar and plantar defects. All flaps transferred to the palmar area survived, providing good color match and sufficient bulkiness. The overall results were satisfactory in terms of function and sensation, and no complications related to flap survival in the plantar area were observed. All flaps used to cover defects in the heel and ankle region adapted well to their recipient areas, and all lower extremities remained functional. Because the medial plantar flap presents glabrous, sensate skin with proper bulkiness and permits the movement of underlying structures, the authors advocate its use and view this procedure as an excellent alternative in the reconstruction of palmar and plantar weight-bearing areas.     

Comparative study of two series of distally based fasciocutaneous flaps for coverage of the lower one-fourth of the leg, the ankle, and the foot

Skin defects over the lower one-fourth of the leg and over the foot are difficult to cover. Two types of pedicled fasciocutaneous flaps used to cover such defects were studied: the lateral supramalleolar flap and the distally based sural neurocutaneous flap. The series consisted of 27 and 36 cases, respectively. The lateral supramalleolar flap was used 27 times: for skin defects over the ankle (4), foot (16), and leg (7). The distally based sural neurocutaneous flap was used 42 times: over the foot (24), ankle (13), and leg (5). Fourteen of these patients were 65 years of age or older, and local vascularity was diminished in 16 cases. The flaps were evaluated clinically twice: in the immediate postoperative period for survival or for partial or total flap necrosis, and again to determine the presence of pain at the donor or recipient sites and the cosmetic appearance. Thirty-nine patients (62 percent) were reviewed subsequently, with a mean follow-up of 5 years for the supramalleolar flap and 2 years for the sural neurocutaneous flap. The results were evaluated for the presence or absence of pain, the appearance of the flap, the disability due to the insensate nature of the flap, and the presence or absence of secondary ulceration. Painful neuromata were noted in three cases with the sural neurocutaneous flap, whereas complete necrosis of the supramalleolar artery flap occurred in three patients. The distally based sural neurocutaneous island flap is very reliable, even in debilitated patients. Though the lateral supramalleolar artery flap offers the possibility of covering the same areas as the sural neurocutaneous flap, it is much less reliable in the presence of diminished local vascularity (18.5 percent failure rate as compared with 4.8 percent for the sural neurocutaneous flap). Because the procedure can cover extensive defects and is easy to perform, the distally based sural neurocutaneous flap was the method of choice for covering skin defects over the foot, heel, ankle, and the lower one-fourth of the leg. The lateral supramalleolar artery flap is indicated only when the sural neurocutaneous flap is contraindicated.     

A reverse ulnar hypothenar flap for finger reconstruction

A reverse-flow island flap from the hypothenar eminence of the hand was applied in 11 patients to treat palmar skin defects, amputation injuries, or flexion contractures of the little finger. There were three female and eight male patients, and their ages at the time of surgery averaged 46 years. A 3 x 1.5 to 5 X 2 cm fasciocutaneous flap from the ulnar aspect of the hypothenar eminence, which was located over the abductor digiti minimi muscle, was designed and transferred in a retrograde fashion to cover the skin and soft-tissue defects of the little finger. The flap was based on the ulnar palmar digital artery of the little finger and in three patients was sensated by the dorsal branch of the ulnar nerve or by branches of the ulnar palmar digital nerve of the little finger. Follow-up periods averaged 42 months. The postoperative course was uneventful for all patients, and all of the flaps survived without complications. The donor site was closed primarily in all cases, and no patient complained of significant donor-site problems. Satisfactory sensory reinnervation was achieved in patients who underwent sensory flap transfer, as indicated by 5 mm of moving two-point discrimination. A reverse island flap from the hypothenar eminence is easily elevated, contains durable fasciocutaneous structures, and has a good color and texture match to the finger pulp. This flap is a good alternative for reconstruction of palmar skin and soft-tissue defects of the little finger.     

Reconstruction of heel and sole defects by free flaps

One latissimus dorsi musculocutaneous flap and five radial forearm flaps were used in reconstruction of weight-bearing parts of the heel and sole, the follow-up period being 7 to 38 months. Additional injuries such as forefoot amputations or amputations of the other leg were present in four patients. There was no flap loss. The latissimus dorsi flap proved to be too bulky and showed recurrent ulcerations, several reoperations were necessary, and definite healing has not occurred. The five forearm flaps gave good results, with a walking range from 2 hours to unimpeded walking. Complications included fissuring at the edges of one large flap and a local infection which was successfully treated. Cutaneous sensation returned in all but one flap, where it was reduced preoperatively due to a meningomyelocele. The results indicate that the fasciocutaneous radial forearm flap should be taken into consideration for reconstruction of weight-bearing areas of the heel and sole. Shortcomings of this flap include an unsightly donor defect and possible hair growth on the flap.     

The ulnar recurrent fasciocutaneous island flap: reverse medial arm flap

A new island fasciocutaneous flap raised on the inner medial surface of the upper arm has been used for reconstruction of soft-tissue defects of the elbow. The blood supply to this flap comes from the fasciocutaneous perforators of the ulnar recurrent vessels. This unique vascular arrangement allows for safe transference of the upper medial skin to the elbow region. This flap has been used to cover nine defects in eight patients, and results have been good. Except for one case of sensory disturbance, there were no complications or loss of overlying skin. It is a relatively quick and simple procedure involving only one stage that adequately corrects the skin defect around the elbow region and does not require prolonged splinting.     

The medialis pedis flap: a new fasciocutaneous flap

An anatomic study (30 fresh specimens dissected) and clinical experience (5 patients) have shown the reliability of a fasciocutaneous flap raised from the medial side of the foot. The artery that supplies the flap is issued from the medial plantar artery. The arch of rotation allows one to cover some specific areas, such as the medial malleolus, posterior aspect of the heel, and distal insertion of Achilles tendon.     

The medial adiposofascial flap of the leg: anatomical basis and clinical applications

Despite recent advances in microsurgical techniques, coverage of lower leg defects by locoregional flaps remains indicated in selected cases. The interest in these types of flaps has improved because recent clinical work advocates that fascial and fasciocutaneous flaps can be well indicated for bone coverage. The anatomical study of the medial adiposofascial flap is presented in this article. The flap is based on the rich vascular network supplied by the saphenous artery and the posterior tibial artery perforators. This flap can be harvested on the anteromedial aspect of the leg and can be mobilized to cover defects located between the patella and the heel. This multiple blood supply makes it possible to harvest this flap in various ways, so various defects can be covered. To confirm and prove the versatility and clinical value of this flap, the authors have studied a series of 22 cases in which this flap was used for coverage of lower leg defects. For these defects, especially when situated in the lower third or around the heel and ankle, coverage by a free flap is most often the only proposed solution. However, the authors have obtained excellent results in the majority of these cases, avoiding a free flap procedure. Moreover, in this way, the option of using a free flap remains possible if needed. There is minimal donor-site morbidity and a high functional and aesthetic outcome, making this flap a first-choice flap in selected cases of lower leg defects.     

Anterolateral thigh flap in the treatment of postburn flexion contractures of the knee

The use of the anterolateral thigh fasciocutaneous flap in the reconstruction of soft-tissue defects around the knee among burn patients is described. The anterolateral thigh fasciocutaneous flap was used for eight patients (all male; mean age, 45 years; age range, 32 to 60 years). Flexion contracture was observed for seven patients with unhealed wounds and one patient with a healed burn wound. The anterolateral thigh flap was used as a free flap for six patients and as a distally based island flap for two patients. The flaps ranged from 8 to 17 cm in width and from 12 to 30 cm in length. Seven flaps were based on a musculocutaneous perforator, and two of them were thinned before transfer to the defect. A true septocutaneous perforator was observed in only one case. The mean follow-up period was 12.5 months (range, 3 to 23 months). Only one flap exhibited distal superficial necrosis, which did not compromise the final result. All patients returned to ambulatory status in 15 to 22 days. Extensor splints were applied to prevent mobilization of the skin graft at the flap donor site for only 7 days. The anterolateral thigh flap has many advantages for the reconstruction of postburn flexion contracture of the knee, as follows: (1) very large thin flaps can be elevated, (2) the two-team approach is possible, (3) color and texture matches are good, (4) the donor-site scar can be easily hidden, and (5) the technique allows early mobilization and patients can return to normal daily activity in a short time. Free or distally based anterolateral thigh flaps are a good choice, both aesthetically and functionally, for the reconstruction of soft-tissue defects of the knee region.     

Free flap to the arteria peronea magna for lower limb salvage

A 36-year-old woman sustained an amputation of her right leg at the thigh level and a degloving injury of her left foot and ankle region in an accident during a suicide attempt. Primarily, her left foot was covered with a split skin graft, resulting in a soft-tissue defect at the medial malleolus and at the calcaneus bone. Reconstruction was planned with a free latissimus dorsi muscle flap. Preoperative examinations revealed an arteria peronea magna with a hyperplastic peroneal artery solely providing arterial blood supply to the foot. The arteria peronea magna divided into two branches proximal to the upper ankle joint, replacing the dorsal pedis artery and the medial plantar artery. Tibial posterior and tibial anterior arteries were hypoplastic-aplastic. Microvascular end-to-end anastomoses of the flap vessels to the medial branch ("medial plantar artery") of the arteria peronea magna and its concomitant vein at the medial malleolar bone level were successfully performed. The postoperative course was uneventful. Four weeks postoperatively, the patient started walking assisted by a prosthesis on her right thigh stump. This experience demonstrates that even in a case of arteria peronea magna, free flap surgery for lower limb salvage is a reliable and worthwhile method.     

Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps

The free anterolateral thigh flap is becoming one of the most preferred options for soft-tissue reconstruction. Between June of 1996 and August of 2000, 672 anterolateral thigh flaps were used in 660 patients at Chang Gung Memorial Hospital. Four hundred eighty-four anterolateral thigh flaps were used for head and neck region recontruction in 475 patients, 58 flaps were used for upper extremity reconstruction in 58 patients, 121 flaps were used for lower extremity reconstruction in 119 patients, and nine flaps were used for trunk reconstruction in nine patients. Of the 672 flaps used in total, a majority (439) were musculocutaneous perforator flaps. Sixty-five were septocutaneous vessel flaps. Of these 504 flaps, 350 were fasciocutaneous and 154 were cutaneous flaps. Of the remaining 168 flaps, 95 were musculocutaneous flaps, 63 were chimeric flaps, and the remaining ten were composite musculocutaneous perforator flaps with the tensor fasciae latae. Total flap failure occurred in 12 patients (1.79 percent of the flaps) and partial failure occurred in 17 patients (2.53 percent of the flaps). Of the 12 flaps that failed completely, five were reconstructed with second anterolateral thigh flaps, four with pedicled flaps, one with a free radial forearm flap, one with skin grafting, and one with primary closure. Of the 17 flaps that failed partially, three were reconstructed with anterolateral thigh flaps, one with a free radial forearm flap, five with pedicled flaps, and eight with primary suture, skin grafting, and conservative methods.In this large series, a consistent anatomy of the main pedicle of the anterolateral thigh flap was observed. In cutaneous and fasciocutaneous flaps, the skin vessels (musculocutaneous perforators or septocutaneous vessels) were found and followed until they reached the main pedicle, regardless of the anatomic position. There were only six cases in this series in which no skin vessels were identified during the harvesting of cutaneous or fasciocutaneous anterolateral thigh flaps. In 87.1 percent of the cutaneous or fasciocutaneous flaps, the skin vessels were found to be musculocutaneous perforators; in 12.9 percent, they were found as septocutaneous vessels. The anterolateral thigh flap is a reliable flap that supplies a large area of skin. This flap can be harvested irrespective of whether the skin vessels are septocutaneous or musculocutaneous. It is a versatile soft-tissue flap in which thickness and volume can be adjusted for the extent of the defect, and it can replace most soft-tissue free flaps in most clinical situations.     

Osteocutaneous posterior interosseous flap for reconstruction of the metacarpal bone and soft-tissue defects in the hand

A vascularized bone segment of the ulna together with a posterior interosseous fasciocutaneous flap is harvested, including a cuff of the extensor pollicis longus muscle. The authors treated five male patients with metacarpal bone and soft-tissue defects of the hand using a distally based island osteocutaneous posterior interosseous flap. Their ages at the time of surgery ranged from 15 to 37 years (mean, 24 years). The bone defects were in the first metacarpal in three cases, the fourth metacarpal in one, and the fifth metacarpal in one. The length of the donated ulna ranged from 3 to 7 cm (mean, 5 cm). The follow-up period ranged from 5 to 92 months (mean, 39 months). All flaps survived completely. The posterior interosseous flap provides thin skin of good texture, together with vascularized bone, for a one-stage reconstruction of the metacarpal bone and soft-tissue defects in the hand.     

Limb salvage for soft-tissue malignancies of the foot: an evaluation of free-tissue transfer.

Free flaps may safely allow meaningful ambulation, durable limb preservation, and better quality of life in patients undergoing resections of soft-tissue cancers of the foot. To prove this, the records of a series of patients at The University of Texas M. D. Anderson Cancer Center (n = 67) who underwent limb salvage following tumor-related resection (n = 71 procedures) from 1989 to 1999 were retrospectively reviewed. Eighteen patients who were not candidates for local flaps or skin grafts received a total of 20 free flaps to preserve their limbs. Most defects (mean size, 78 cm2; range, 20 to 150 cm2) were on a weight-bearing surface of the foot (nine on a weight-bearing heel, three on a plantar foot); the remainder were on a non-weight-bearing surface (six on dorsum, two on a non-weight-bearing heel). Melanoma was diagnosed in nine cases (50 percent); soft-tissue sarcoma, in seven (39 percent); and squamous cell carcinoma, in two (11 percent). Fasciocutaneous and skin-grafted muscle flaps were used on both weight-bearing and non-weight-bearing surfaces. Free-tissue transfer was successful in 17 of 20 cases (85 percent); the three flap losses occurred in two patients. Minor complications (i.e., small hematoma, partial skin graft loss, and delayed wound healing) occurred in five patients. In all cases of successful free-tissue transfer, patients began partial weight bearing at a mean of 7.4 weeks (range, 2 to 12 weeks), and all ultimately achieved full weight bearing. Sixty-seven percent still required special footwear. In one patient, an ulceration on the weight-bearing portion of the flap resolved after a footwear adjustment. Only one patient was lost to follow-up (mean, 23 months). In the 17 remaining patients, limb salvage succeeded in 15 (88 percent). Of these, nine (60 percent) were alive without evidence of disease, three (20 percent) were alive with disease, and three (20 percent) had died of disease. Local recurrence developed in two patients but was successfully treated by excision and closure. No late amputations were required for local control. Thus, it seems that free flaps help facilitate limb salvage and that they may preserve meaningful limb function in patients who undergo resection of soft-tissue malignancies of the foot.     

Triple coverage of ischial ulcers with adipofascial turnover and fasciocutaneous flaps

Despite a wide variety of flap options, ischial ulcers remain the most difficult pressure ulcers to treat. This article describes the authors' successful surgical procedure for coverage of ischial ulcers using adipofascial turnover flaps combined with a local fasciocutaneous flap. After debridement, the adipofascial flaps are harvested both cephalad and caudal to the defect. The flaps are then turned over to cover the exposed bone in a manner so as to overlap the two flaps. A local fasciocutaneous flap (Limberg flap) is applied to the raw surface of the turnover flaps. Twenty-two patients with ischial ulcers were treated using this surgical procedure. Overall, 86.4 percent of the flaps (19 of 22) healed primarily. Triple coverage with the combination of double adipofascial turnover flaps and a local fasciocutaneous flap allows for an easily performed and minimally invasive procedure, preservation of future flap options, and a soft-tissue supply sufficient for covering the prominence and bony prominence and filling dead space. This technique provides successful soft-tissue reconstruction for minor to moderate-size ischial pressure ulcers.     

Free transfer of expanded parascapular, latissimus dorsi, and expander "capsule" flap for coverage of large lower-extremity soft-tissue defect

The coverage of large soft-tissue defects usually requires a large flap transfer, especially in a combination and expanded form. However, some large soft-tissue defects still cannot be covered by such flaps. In this article, we present a case of a civil war injury in a patient from Afghanistan who had severe trauma to the right knee, lower thigh, and upper leg and a marked soft-tissue defect. This large soft-tissue defect was covered with a large combined free flap of the expanded parascapular and latissimus dorsi muscle, including a large retrograde hinge flap of the tissue expander capsule and a complementary skin graft. The defect was covered completely, and the final result was excellent.     

Extremity reconstruction using the free deltoid flap

The deltoid fasciocutaneous flap is a thin, reliable flap that is easily dissected from the posterolateral arm. It has large-caliber vessels and is capable of sensory reinnervation to portions of the flap above the deltoid/triceps groove through the lateral brachial cutaneous nerve. There is little sensory return to the large vascular territory, which can be extended inferiorly below the deltoid triceps groove. The donor site can be closed primarily or skin grafted and when large may be objectionable to some patients. The flap is an excellent choice for extremity soft-tissue reconstruction on the plantar or palmar surfaces. Protective sensibility has returned to all reinnervated flaps. We present our experience in 10 patients with extremity problems.     

Reconstruction of soft-tissue defect of the posterior heel with a lateral calcaneal artery island flap

We obtained most favorable results in 11 patients with a lateral calcaneal artery island flap. It is a simple, stable, sensate, and yet safe and versatile flap to repair defects around the ankle and heel. We have also used this flap to cover defects around the medial malleolus without any delay (extended lateral calcaneal artery island flap).     

Clinical applications of free soleus and peroneal perforator flaps

Clinical applications of two free lateral leg perforator flaps are described: a free soleus perforator flap that is based on the musculocutaneous perforator vessels from one of the three main arteries in the proximal lateral lower leg, and a free peroneal perforator flap that is based on the septocutaneous or direct skin perforator vessels from the peroneal artery in the distal and middle thirds of the lateral lower leg. The authors applied free soleus perforator flaps to 18 patients and free peroneal perforator flaps to five patients with soft-tissue defects. The recipient site was the great toe in 14 patients, the hand and fingers in five patients, the leg in two patients, and the upper arm and the jaw in one patient each. The largest soleus perforator flap was 15 x 9 cm, and the largest peroneal perforator flap was 9 x 4 cm. Vascular pedicle lengths ranged from 6.5 to 10 cm in soleus perforator flaps and from 4 to 6 cm in peroneal perforator flaps. All flaps, except for the flap in one patient in the peroneal perforator flap series, survived completely. Advantages of these flaps are that there is no need to sacrifice any main artery in the lower leg, and there is minimal morbidity at the donor site. For patients with a small to medium soft-tissue defect, these free perforator flaps are useful.