Reconstruction of defects around the ankle region has always been challenging for plastic surgeons. Distally based lateral and medial leg adipofascial flaps are among the flaps of choice for coverage of this difficult region. Presented here is the authors' clinical experience with these flaps, particularly emphasizing the complicated attempts in diabetic patients.
Seven skin defects around the ankle were reconstructed with lateral and medial leg adipofascial flaps. The lowermost perforators of the peroneal or posterior tibial artery were identified preoperatively, and a straight incision through skin only was made proximal to this perforator. With the skin flaps reflected, the adipofascial flap was than raised in the subfascial plane. The perforators to be retained in the base were located and the flap was then turned over to cover the defect, followed by application of a split-thickness skin graft over the flap. The donor site was closed primarily.
The ages of the patients ranged from 25 to 80 years, and the size of the flaps ranged from 3 x 5 cm to 7 x 10 cm. Four defects were reconstructed with lateral leg adipofascial flaps, and medial leg adipofascial flaps were used in three. Two flaps healed uneventfully. Partial or total graft loss and partial flap necrosis were observed in five patients, four of whom were diabetic.
Leg adipofascial flaps offer a valuable option for repair of defects around the ankle in many cases. However, adipofascial flaps should be used with caution in old, diabetic patients and, when performed, the probability of a second or third procedure should be considered.
"Diabetic ulcers on feet, once established, rarely heal spontaneously and often require flaps to achieve stable coverage. Universal clinical experience has shown that flaps in diabetic patients combined with diabetes-associated microvascular dysfunction, have a high morbidity, and the trend has been to avoid local flaps that require sacrifice of a major artery, or free flaps, in reconstruction of such ulcers  . "
[Show abstract][Hide abstract] ABSTRACT: Delayed sural flap based on the vascular axis of the sural nerve has been advocated for coverage of diabetic foot ulcers. In this study we compared the survival of neurovenous and standard inferior epigastric island flaps in diabetic and non-diabetic rats. VEGF concentrations and electrolyte balance of the flaps were also investigated during elevation and on the fifth day to explore the possible mechanisms that influence ischaemia of the flap during the hyperglycaemic state. There were no statistical differences in area surviving between diabetic and control rats for either flap. The VEGF concentrations were also similar in the two flaps in the two groups during elevation. On the fifth day, VEGF concentrations had decreased significantly in all of the flaps. Electrolyte balance paralleled VEGF concentrations. We conclude that flaps based on the vascular axis of a superficial nerve deserve further experimental and clinical attention as potential options for reconstruction of ulcers on diabetic feet.
Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery 02/2007; 41(1):22-5. DOI:10.1080/02844310601062556 · 0.94 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Utilization of the metatarsal bones and interosseous muscles in foot reconstruction should be based on the vascular anatomy of the metatarsal bones and interosseous muscles. We studied the vascular anatomy of the metatarsal bones and the interosseous muscles to design a split metacarpal musculoosseous flap and dorsal interosseous muscle flap. Twenty-two feet from eleven cadavers that had been embalmed in formalin were studied. Dissection was done using a dissection microscope (x3.5), delineating meticulously the arcuate artery, dorsal metatarsal arteries and the small branches arising from the metatarsal arteries. The dorsal metatarsal arteries do not course at the midline of the interosseous muscles. The first dorsal metatarsal artery proceeds close to the first metatarsal bone in the first metatarsal space. While proceeding to the distal, it shoots out a branch that individually feeds the lateral head of the first dorsal metatarsal muscle and medial face of the second metatarsus, thereby feeding muscle and bone. Except for this branch, the first dorsal metatarsal gives off segmental and periosteal branches that individually feed the medial heads of the first dorsal metatarsal muscle and first metatarsal bone. The second, third and fourth metatarsal arteries proceed close to the third, fourth and fifth metatarsal bones in the metatarsal spaces. In these courses, the arteries give out segmental branches to both faces of the interosseous muscles and periosteal branches to the medial face of metatarsal bones. For defects or disease of the ankle bones, the metatarsal bones can be split at the medial border distally, and a split metatarsal musculoosseous flap, based proximally on the dorsal metatarsal artery, can be done. Distal intermetatarsal anastomoses between the dorsal and plantar vascular networks enables a split metatarsal musculoosseous flap based distally, including the dorsal metatarsal artery for bony defects of the proximal phalanx.
Journal of Plastic Reconstructive & Aesthetic Surgery 07/2008; 62(9):1227-32. DOI:10.1016/j.bjps.2007.12.083 · 1.42 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Secondary reconstruction of lower extremity defects using local tissues is demanding and fraught with potential complications. Reconstructive efforts may be challenged by pre-existing scarring, paucity of recipient vessels, and patient co-morbidities limiting tolerance for prolonged and extensive surgery. We present a case of an 81-year-old male with a recurrent malignant melanoma invading the proximal and middle third of the tibia, who previously underwent reconstruction with the medial gastrocnemius muscle and a skin graft. After wide local re-excision and tibia fixation, a 12 cm x 28 cm reverse anterolateral thigh flap was used for soft tissue coverage. Because of the relatively large size of the flap based upon retrograde flow, we elected to supercharge the flap to augment its blood supply. Supercharging of the flap pedicle was accomplished by anastamosing the lateral circumflex femoral vessels to the anterior tibial vessels. The donor site wasclosed primarily. The flap survived entirely and successfully endured subsequent radiation therapy. Supercharging enhances reliability of the reverse anterolateral thigh flap, and thus, permits harvest of large tissue bulk for coverage of up to proximal two-thirds of the tibia.This is the first report describing successful supercharging of a large reverse anterolateral thigh flap which resulted in entire flap survival.
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