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.     

Fasciocutaneous island flap based on the medial plantar artery: clinical applications for leg, ankle, and forefoot

Soft-tissue deficits over the plantar forefoot, plantar heel, tendo calcaneus, and lower leg are often impossible to cover with a simple skin graft. The previously developed medial plantar fasciocutaneous island flap has been adapted to cover soft-tissue defects over these areas. This fasciocutaneous flap based on the medial plantar neurovascular bundle is capable of providing sensate and structurally similar local tissue. Application of this fasciocutaneous island flap is demonstrated in 12 clinical cases. Successful soft-tissue cover was achieved on the plantar calcaneus (four patients), tendo calcaneus (four patients), lower leg (two patients), and plantar forefoot (two patients). Follow-up ranged from 6 months to 5 years. All flaps were viable at follow-up. Protective sensation was present in 11 of 12 flaps evaluated at 6 months. In addition, all 11 patients were able to ambulate in normal footwear. The medial plantar island flap seems to be more durable than a skin graft, and the donor site on the non-weight-bearing instep is well tolerated. This study demonstrates that the medial plantar fasciocutaneous island flap should be considered as another valuable tool in reconstructive efforts directed at the plantar forefoot, plantar heel, posterior ankle, and lower leg.     

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.     

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).     

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.     

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.     

The lateral intercostal neurovascular free flap

The lateral intercostal flap is a new neurovascular flap that may be used as a free or island flap. It is based on the lateral cutaneous branch of a single posterior intercostal neurovascular bundle. The donor area of the flap is the anterolateral skin of the abdomen. The flap is large, thin, and has a long pedicle that contains the lateral cutaneous nerve. The donor pedicles of the flap are multiple, and its venous drainage is adequate. The detection and design of this flap were based on information gained from the dissection of 95 intercostal spaces in 40 fresh cadavers. The flap was then applied 12 times in 11 patients. Ten flaps were successful, one flap was partially lost, and one was completely lost. The flap was used as a noninnervated flap to resurface six defects in the neck and one facial defect, and it was used as an innervated flap to cover two hand defects and two heel defects.     

The extensor digitorum brevis muscle island flap for soft-tissue loss around the ankle

The extensor digitorum brevis muscle flap, which has already been suggested as a local flap for the foot, has been applied by us in 2 cases with excellent results. This flap, as with other muscle flaps, provides an excellent bed for the skin graft. Furthermore, because of its width, it allows for covering an area of skin loss 5 X 7 cm in size in areas that are difficult to cover by other reconstructive means. The arch of rotation of this flap allows for coverage of the lateromedial and posterior surfaces of the ankle with no functional loss at the donor site. The relative ease of elevating this flap presents a reasonable justification for its wider application as a single local procedure for skin problems around the ankle.     

Distally based lateral supramalleolar adipofascial flap for reconstruction of the dorsum of the foot and ankle

Soft-tissue reconstruction of the dorsum of the foot and ankle has long been a challenge for reconstructive surgeons. Limitations in the available local tissue and donor-site morbidity restrict the options. In an effort to solve these difficult problems, the authors have begun to use a distally based lateral supramalleolar adipofascial flap. This report presents the authors' early experience with seven patients treated with this flap. The patients' ages ranged from 5 to 26 years; four of the patients were male and three were female. The cause of the soft-tissue defects involved acute trauma and chronic scar contracture. The flap and the adjoining raw area were covered with a full-thickness skin graft, and the donor site at the lateral aspect of the leg was closed primarily without grafting. A skin graft was taken from the groin area, which was closed primarily. Compared with the other flaps, this adipofascial flap was thinner and produced less bulkiness to the recipient site and minor aesthetic sequelae to the donor site. It is believed that this flap is versatile and effective and is a good addition to the available techniques used by reconstructive surgeons for coverage of the dorsum of the foot and ankle.     

Treatment of late ulceration in free muscle flaps to the foot

One of the preferred methods for the repair of large defects of the foot has been the use of free muscle flaps covered with skin grafts. Although this method has served well, some patients will experience ulceration in the weight-bearing surface. Three cases are reported in which small ulcerations developed in the heel after reconstruction of traumatic defects with muscle free flaps. All three patients were treated with a neurovascular island flap from the side of the great toe. All three patients are active young males, and all three patients have subsequently maintained intact skin for an average of 6.8 years (range, 5.1 to 9.1 years).     

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 free thoracoumbilical flap for resurfacing large soft-tissue defects of the lower extremity

Both cadavers and living patients were studied regarding a method to resolve large skin defects with bone exposure in the leg, with long-distance thrombosis of the anterior tibial vessels or posterior tibial vessels resulting from traumatic lesions. Forty-six casting mold specimens of cadaveric legs were investigated. There were rich communication branches among the anterior tibial artery, posterior tibial artery, and fibular artery in the foot and ankle, which complemented each other well. Twenty-six patients with large skin defects with bone exposure in the proximal or middle segment of the leg were admitted to the authors' hospital. Among those patients, 19 demonstrated long-distance thrombosis of the anterior tibial vessels or posterior tibial vessels resulting from traumatic lesions. During treatment, a thoracoumbilical flap based on the inferior epigastric vessels was anastomosed to the distal stump of the anterior tibial vessels or the posterior tibial vessels, with reversed flow. All defects were successfully repaired, with good color and texture matches of the flaps. This method can be used for patients with normal anterior tibial vessels or posterior tibial vessels, normal distal stumps of the injured blood vessels, and good reversed flow. The method has the advantages of dissecting blood vessels in the recipient area during the débridement, not affecting the blood circulation of the injured leg, not sacrificing blood vessels of the opposite leg, and not fixing the patient in a forced posture. The muscles are less bulky in the distal one-third of the leg, and the blood vessels are shallow and can be dissected and anastomosed easily. When the flap is used for reconstruction in the proximal two-thirds of the leg, the blood vessel pedicle of the free flap is at a straight angle, without kinking.     

The reversed fasciosubcutaneous flap in the leg

A reversed fasciosubcutaneous tissue flap in the leg is described. This distally based flap is vascularized by the perforating cutaneous branches of the peroneal and tibialis posterior arteries. It must carry all its subcutaneous tissue. A study on the vascularization of the subcutaneous tissue reveals the predominance of the vascular network in this layer with regard to the dermal or fascial plane. The dermal vascular network at the donor site is sufficient to let the skin survive without its underlying subcutaneous vascular support. The flap can reach the malleolar and heel region. The advantages of this technique are (1) easy dissection, (2) preservation of the major vascular pedicles of the lower limb, (3) skin preservation at the donor site, thus preserving the shape of the limb, and (4) versatility (it is supple and can adapt to every surface, and it can be grafted on the deep or the superficial side). The addition of this technique to the armamentarium of the reconstructive surgeon has proved to be very useful in repairing soft-tissue defects in the lower limb. Often it can replace the classical fasciocutaneous flap or even a free flap.     

The lateral supramalleolar flap

An anatomic study (40 fresh dissected specimens) and clinical experience (14 patients) have shown the reliability of a skin flap designed on the lower third of the lateral aspect of the leg. It is supplied by a cutaneous branch from the perforating branch of the peroneal artery. This perforating branch continues distally deep to the fascia along the anterior ankle and into the foot. This can be used as a reversed pedicle, giving the flap an arc of rotation that allows coverage of the dorsal, lateral, and plantar aspects of the foot, the posterior heel, and the lower medial portion of the leg.     

The sandwich temporoparietal free fascial flap for tendon gliding.

Microsurgical transfer of the superficial and deep temporal fascia based on the superficial temporal vessels has been documented. This article analyzes the functional recovery when each layer of this facial flap is placed on either side of reconstructed or repaired tendons, to recreate a gliding environment. This fascial flap also provided a thin, pliable vascular cover in selected defects of the extremities.Six patients (four male and two female) with tendon loss and skin scarring of the hand (three dorsum, one palmar, and one distal forearm) and posttraumatic scarring of the ankle with tendoachilles shortening (one patient) underwent this procedure. No flap loss was witnessed. Good overall functional recovery and tendon excursion were observed. Complication of partial graft loss was observed in two patients.     

Reconstructing the breast mound employing a secondary island omental skin flap

We have shown in an initial animal study that omentum will adequately vascularize a skin flap and allow transfer of this tissue composite for use in surgical reconstruction of the breast. Based on this experimental procedure, a technique employing a two-stage operation has been developed and used in 21 female patients in reconstruction of the breast after radical mastectomy. In the first stage, the omentum, attached to one gastroepiploic artery and vein, is exteriorized to the subcutaneous tissue of the lower abdominal wall. In the second stage, the distal omentum, now vascularizing the overlying skin and soft tissue, is moved as a secondary island flap to the anterior chest wall to complete the breast reconstruction. In all but 1 of our 21 patients who have been followed for 1 to 8 years, reconstruction of large defects, including the chest wall, breast mound, and infraclavicular axillary fold depression, was performed without use of a prosthesis. In one patient, there was complete necrosis of the flap due to vascular impairment; there were three instances of delayed healing and a significant but partial loss of the flap in one patient. All complications were encountered in the first 10 patients of the series during the time the technique was being refined.     

Primary reconstruction of complex midfacial defects with combined lip-switch procedures and free flaps.

Free flaps are generally the preferred method for reconstructing large defects of the midface, orbit, and maxilla that include the lip and oral commissure; commissuroplasty is traditionally performed at a second stage. Functional results of the oral sphincter using this reconstructive approach are, however, limited. This article presents a new approach to the reconstruction of massive defects of the lip and midface using a free flap in combination with a lip-switch flap. This was used in 10 patients. One-third to one-half of the upper lip was excised in seven patients, one-third of the lower lip was excised in one patient, and both the upper and lower lips were excised (one-third each) in two patients. All patients had maxillectomies, with or without mandibulectomies, in addition to full-thickness resections of the cheek. A switch flap from the opposite lip was used for reconstruction of the oral commissure and oral sphincter, and a rectus abdominis myocutaneous flap with two or three skin islands was used for reconstruction of the through-and-through defect in the midface. Free flap survival was 100 percent. All patients had good-to-excellent oral competence, and they were discharged without feeding tubes. A majority (80 percent) of the patients had an adequate oral stoma and could eat a soft diet. All patients have a satisfactory postoperative result. Immediate reconstruction of defects using a lip-switch procedure creates an oral sphincter that has excellent function, with good mobility and competence. This is a simple procedure that adds minimal operative time to the free-flap reconstruction and provides the patient with a functional stoma and acceptable appearance. The free flap can be used to reconstruct the soft tissue of the intraoral lining and external skin deficits, but it should not be used to reconstruct the lip.     

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.     

The internal oblique muscle flap: an anatomic and clinical study

A new muscle flap based on the ascending branch of the deep circumflex iliac artery is described. Twenty internal oblique muscle flaps have been dissected and studied in 10 fresh cadavers. This muscle flap has been used successfully as a free-tissue transfer in seven lower extremity defects. There was one loss of flap due to venous thrombosis. Other complications included a local wound abscess (one case), partial loss of skin graft (two cases), and arterial thrombosis (one case). There has been no donor-site morbidity. The donor scars are well concealed and no hernias have been observed, the longest follow-up being 9 months. The additional advantages of this flap include its thin, flat shape, excellent vascularity, and ease of application to areas about the ankle, with good aesthetic results. The disadvantages are (1) bloody and tedious dissection and (2) potential for abdominal weakness or hernia in the long run. This muscle flap appears to be excellent as a free flap for coverage of small- to moderate-sized defects of the distal lower extremity and as a pedicle flap for coverage of soft-tissue defects of the groin and anterior perineum.     

Free fibula osteoseptocutaneous-pedicled pectoralis major myocutaneous flap combination in reconstruction of extensive composite mandibular defects

Lateral composite mandibular defects resulting from excision of advanced oral carcinoma often require mandible, intra-oral lining, external face, and soft-tissue bulk reconstruction. Ignorance of importance soft-tissue deficit in those patients may cause significant morbidity and functional loss. Such defects, therefore, can be reconstructed best with a double free flap technique. However, this procedure may not be feasible for every patient or surgeon. An alternative procedure is a free fibula osteoseptocutaneous flap combined with a pedicled pectoralis major myocutaneous flap. This combination was used in reconstruction of extensive composite mandibular defects in 14 patients with T3/T4 oral squamous cell carcinoma. All patients were men, and the average age was 54.3 years. The septocutaneous paddle of the fibula flap was used for the mucosal lining of the defects while the bony part established the rigid mandibular continuity. The pectoralis major flap then covered the external skin defect in the face and cheek, and the dead spaces left by the extirpated masticator muscles, buccal fat, and parotid gland. One free fibula flap failed totally, and one pectoralis major flap developed marginal necrosis. At the time of final evaluation, nine patients (64.3 percent) were alive, surviving an average of 25.7 months. All patients eventually regained their oral continence and an acceptable cosmetic appearance. In conclusion, the fibula osteoseptocutaneous flap plus regional myocutaneous flap choice is a successful and technically less demanding alternative to the double free flap procedures in reconstruction of extensive lateral mandibular defects.