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A new distally based fasciocutaneous flap of the leg
British Journal of Plastic Surgery (1986) 39.338-340 0 1986 The Trustees of British Association of Plastic Surgeons
A new distally based fasciocutaneous flap of the leg J. AMARANTE,
H. COSTA, J. REIS and R. SOARES
Plastic Surgery Department, Hospital de S. Jogo, Oporto, Portugal
Summary-A distally based flap on the medial side of the lower leg is described. In ten cadaver dissections two perforating arteries from the posterior tibia1 artery were a constant finding and a flap has been designed based on these. It has been used successfully in four patients.
on these studies we designed a flap which we decided to use in selected patients.
The principle of the fasciocutaneous flap was clearly described by Ponten in 198 1 and Barclay et al. (1982) discussed the use of such flaps in lower leg injuries. In 1983 Donski and Fogdestam described a distally based fasciocutaneous flap from the sural region based on perforating branches from the peroneal artery, which pierce the deep fascia of the posterior border of the lateral compartment in the lower third of the leg. This flap is useful to cover soft tissue defects in the lower leg, heel and ankle regions but it will not reach many medial defects. We have looked for a distally based fasciocutaneous flap based on the medial compartment of the lower third of the leg.
Operative technique After finding the posterior tibia1 artery at the medial malleolus (by palpation or Doppler), we draw its proximal course. On this line, 8cm above the malleolus, we mark the flap rotation point and then we draw the flap with a 4cm wide pedicle, extending no farther proximally than 10 cm below the knee (Fig. 2B and 4B). The surgical procedure starts with a proximal incision, from the skin to the muscle, including the deep fascia which is immediately sutured to the skin. Dissection proceeds distally, with ligation of the perforating arteries of the middle third of the leg but preserving the saphenous nerve and the long saphenous vein, until the level of the rotation point. At this stage the flap can generally be transposed. In one of our four patients, dissection had to be extended until the perforating artery and veins were visualised (Fig. 1C). This allowed a better point of rotation and the flap could then have been transposed to the medial and lateral side of the ankle, heel or the lower third of the leg. The donor area of the flap always has to be split skin grafted (Fig, 3C).
Anatomical dissections We have dissected 10 cadavers to look for anastomotic arteries from the posterior tibia1 artery. In the first six cadavers, we made a vertical incision in the lower third of the medial aspect of the leg, to expose and dissect the posterior tibia1 artery from below upwards. We always found two perforating cutaneous arteries and accompanying veins at about 4 cm and 6.5 cm above the medial malleolus (varying from 2.8 to 4.2 cm and from 5.2 to 7.5 cm respectively). In the other four cadavers we tried to delineate a distally based fasciocutaneous flap supplied. by these arteries. To accomplish this, we raised the fasciocutaneous unit of almost all the postero-medial aspect of the leg, from 8 cm below the knee to 1 cm above the medial malleolus. All the proximal perforators were ligated, leaving only the two arteries mentioned above. The posterior tibia1 artery was ligated above and below the two perforating arteries and then methylene blue was injected into it. About 70% of the skin of the raised area became stained with the dye. Based
Case reports Case I (male, 48 years old). On 10 April 1984 this patient was involved in a road traffic accident and suffered abdominal injuries and exposure of the Achilles tendon on the lower third of the right leg (Fig. 1A). After a failed attempt to close the defect with a split skin graft, on 4 May 1984 we used a medial distally based fasciocutaneous gap (Fig. 1B). Dissection of the pedicle was needed to permit easier flap rotation and the perforator was found at about 6cm above the medial malleolus (Fig. 1C). Uneventful healing followed (Fig. 1D). 338
A NEW DISTALLY
BASED
FASCIOCUTANEOUS
FLAP OF THE LEG
Fig. 2 Fig. 1 Figure I-Case 1 (A) Soft tissue defect over the Achilles tendon. (B) The flap raised. (C) The distal perforating artery demonstrated. (D) Two months postoperatively.
Case 2 (male, 26 years old) On 13 November 1984 this patient was sent to our department with a chronic osteomyelitic ulcer in the anterior aspect of the lower third of his left leg, after an open fracture of the tibia (Fig. 2A). One week later we operated on him, starting by curettage of the ulcer. The flap was drawn on the postero-medial aspect of the lower leg (Fig. 2B), raised (Fig. 2C) and immediately transposed to the defect. Healing was uneventful (Fig. 2D).
Case 3 (male, 26 years old) On 4 March a paraplegic patient was seen with a pressure sore on the medial malleolus of his left leg. As previous medical treatment had failed, we decided to use the flap (Fig. 3A). The pressure sore was excised and the flap was
Figure 2-Case
2 (A) Osteomyelitic ulcer in the anteripr aspect
of the lower third of the left leg. (B) Drawing of the flap. (C) Flap lifted on its fasciocutaneous pedicle. (D) Appearance of the flap 4 months postoperatively.
raised, transposed and the donor area split skin grafted (Fig. 3B and C). The flap healed uneventfully (Fig. 3D). Case 4 (male, 45 years old) On 11 June 1985 this patient was referred to our department with a chronic pretibial skin ulcer, related to osteomyelitis in the lower third of his left tibia (Fig. 4A). He had suffered a road accident ten months previously and had been submitted to several surgical procedures. The lateral side of his lower leg was split skin grafted and a cross-leg flap had failed to cover the exposed tibja. Three days later we performed a bone curettage and the defect was closed by a medial distally based fasciocutaneous flap (Fig. 4B and C). The patient has recovered without problems (Fig. 4D).
BRITISH JOURNAL OF PLASTIC SURGERY
Fig. 4 Figure 4--Case 4 (A) Pretibial ulcer and faiIed cross-leg flap. (B) Drawing of the flap. (C) Flap transposed. (D) Postoperative appearance at 15 days.
Acknowledgements Fig. 3 Figure 3-Case 3 (A) Pressure sore over the medial malleolus of the left leg. (B) The defect and the flap outlined. (C) Postoperative view of the transposed flap. (D) Two months after operation.
Discussion This medial flap (with a narrow pedicle which permits a large arc of rotation) is very versatile and can cover all the soft tissue defects of the heel and around the ankle, including those in the medial side, that could not be reached by lateral distally based flaps. The two perforating arteries, each one with its two veins, have been present in every case we have searched for them. In all four of our clinical cases the flaps healed uneventfully.
The authors wish to thank Professor Dr Pinto da Costa and Professor Dr Paula Barbosa for generously providing the anatomical specimens used in this study.
References Barclay, T. L., Cardosa, E., Sharpe, D. T. and Crocket, D. J. (1982). Repair of lower leg injuries with fasciocutaneous flaps. British Journal ofPla& Surgery, 35, 121. Donski. P. K. and Fondestam. I. (1983). Distallv based fasciocutaneous flap fromthe sural region.‘Scandin&ian Journal of Plastic and Reconstructive Surgery, 17, 19 1.
Ponten, B. (1981). The fasciocutaneous flap: its use in soft tissue defects of the lower leg. British Journal of Plastic Surgery, 34, 215.
The Authors Jo& Amarnate, MD, Consultant Plastic Surgeon. Horiacio Costa, MD, Resident Plastic Surgeon. Jorge Reis, MD, Resident Plastic Surgeon. Ribeirinko Sonres, MD, Resident Plastic Surgeon. Plastic Surgery Department, Hospital de S. JoHo, Medical School, Oporto, Portugal. Requests for reprints to: Jose Amarante, Service de Cirurgia Plastica, Hospital de S. JoHo, 4200 Porto, Portugal.
A new distally based fasciocutaneous flap of the leg J. AMARANTE,
H. COSTA, J. REIS and R. SOARES
Plastic Surgery Department, Hospital de S. Jogo, Oporto, Portugal
Summary-A distally based flap on the medial side of the lower leg is described. In ten cadaver dissections two perforating arteries from the posterior tibia1 artery were a constant finding and a flap has been designed based on these. It has been used successfully in four patients.
on these studies we designed a flap which we decided to use in selected patients.
The principle of the fasciocutaneous flap was clearly described by Ponten in 198 1 and Barclay et al. (1982) discussed the use of such flaps in lower leg injuries. In 1983 Donski and Fogdestam described a distally based fasciocutaneous flap from the sural region based on perforating branches from the peroneal artery, which pierce the deep fascia of the posterior border of the lateral compartment in the lower third of the leg. This flap is useful to cover soft tissue defects in the lower leg, heel and ankle regions but it will not reach many medial defects. We have looked for a distally based fasciocutaneous flap based on the medial compartment of the lower third of the leg.
Operative technique After finding the posterior tibia1 artery at the medial malleolus (by palpation or Doppler), we draw its proximal course. On this line, 8cm above the malleolus, we mark the flap rotation point and then we draw the flap with a 4cm wide pedicle, extending no farther proximally than 10 cm below the knee (Fig. 2B and 4B). The surgical procedure starts with a proximal incision, from the skin to the muscle, including the deep fascia which is immediately sutured to the skin. Dissection proceeds distally, with ligation of the perforating arteries of the middle third of the leg but preserving the saphenous nerve and the long saphenous vein, until the level of the rotation point. At this stage the flap can generally be transposed. In one of our four patients, dissection had to be extended until the perforating artery and veins were visualised (Fig. 1C). This allowed a better point of rotation and the flap could then have been transposed to the medial and lateral side of the ankle, heel or the lower third of the leg. The donor area of the flap always has to be split skin grafted (Fig, 3C).
Anatomical dissections We have dissected 10 cadavers to look for anastomotic arteries from the posterior tibia1 artery. In the first six cadavers, we made a vertical incision in the lower third of the medial aspect of the leg, to expose and dissect the posterior tibia1 artery from below upwards. We always found two perforating cutaneous arteries and accompanying veins at about 4 cm and 6.5 cm above the medial malleolus (varying from 2.8 to 4.2 cm and from 5.2 to 7.5 cm respectively). In the other four cadavers we tried to delineate a distally based fasciocutaneous flap supplied. by these arteries. To accomplish this, we raised the fasciocutaneous unit of almost all the postero-medial aspect of the leg, from 8 cm below the knee to 1 cm above the medial malleolus. All the proximal perforators were ligated, leaving only the two arteries mentioned above. The posterior tibia1 artery was ligated above and below the two perforating arteries and then methylene blue was injected into it. About 70% of the skin of the raised area became stained with the dye. Based
Case reports Case I (male, 48 years old). On 10 April 1984 this patient was involved in a road traffic accident and suffered abdominal injuries and exposure of the Achilles tendon on the lower third of the right leg (Fig. 1A). After a failed attempt to close the defect with a split skin graft, on 4 May 1984 we used a medial distally based fasciocutaneous gap (Fig. 1B). Dissection of the pedicle was needed to permit easier flap rotation and the perforator was found at about 6cm above the medial malleolus (Fig. 1C). Uneventful healing followed (Fig. 1D). 338
A NEW DISTALLY
BASED
FASCIOCUTANEOUS
FLAP OF THE LEG
Fig. 2 Fig. 1 Figure I-Case 1 (A) Soft tissue defect over the Achilles tendon. (B) The flap raised. (C) The distal perforating artery demonstrated. (D) Two months postoperatively.
Case 2 (male, 26 years old) On 13 November 1984 this patient was sent to our department with a chronic osteomyelitic ulcer in the anterior aspect of the lower third of his left leg, after an open fracture of the tibia (Fig. 2A). One week later we operated on him, starting by curettage of the ulcer. The flap was drawn on the postero-medial aspect of the lower leg (Fig. 2B), raised (Fig. 2C) and immediately transposed to the defect. Healing was uneventful (Fig. 2D).
Case 3 (male, 26 years old) On 4 March a paraplegic patient was seen with a pressure sore on the medial malleolus of his left leg. As previous medical treatment had failed, we decided to use the flap (Fig. 3A). The pressure sore was excised and the flap was
Figure 2-Case
2 (A) Osteomyelitic ulcer in the anteripr aspect
of the lower third of the left leg. (B) Drawing of the flap. (C) Flap lifted on its fasciocutaneous pedicle. (D) Appearance of the flap 4 months postoperatively.
raised, transposed and the donor area split skin grafted (Fig. 3B and C). The flap healed uneventfully (Fig. 3D). Case 4 (male, 45 years old) On 11 June 1985 this patient was referred to our department with a chronic pretibial skin ulcer, related to osteomyelitis in the lower third of his left tibia (Fig. 4A). He had suffered a road accident ten months previously and had been submitted to several surgical procedures. The lateral side of his lower leg was split skin grafted and a cross-leg flap had failed to cover the exposed tibja. Three days later we performed a bone curettage and the defect was closed by a medial distally based fasciocutaneous flap (Fig. 4B and C). The patient has recovered without problems (Fig. 4D).
BRITISH JOURNAL OF PLASTIC SURGERY
Fig. 4 Figure 4--Case 4 (A) Pretibial ulcer and faiIed cross-leg flap. (B) Drawing of the flap. (C) Flap transposed. (D) Postoperative appearance at 15 days.
Acknowledgements Fig. 3 Figure 3-Case 3 (A) Pressure sore over the medial malleolus of the left leg. (B) The defect and the flap outlined. (C) Postoperative view of the transposed flap. (D) Two months after operation.
Discussion This medial flap (with a narrow pedicle which permits a large arc of rotation) is very versatile and can cover all the soft tissue defects of the heel and around the ankle, including those in the medial side, that could not be reached by lateral distally based flaps. The two perforating arteries, each one with its two veins, have been present in every case we have searched for them. In all four of our clinical cases the flaps healed uneventfully.
The authors wish to thank Professor Dr Pinto da Costa and Professor Dr Paula Barbosa for generously providing the anatomical specimens used in this study.
References Barclay, T. L., Cardosa, E., Sharpe, D. T. and Crocket, D. J. (1982). Repair of lower leg injuries with fasciocutaneous flaps. British Journal ofPla& Surgery, 35, 121. Donski. P. K. and Fondestam. I. (1983). Distallv based fasciocutaneous flap fromthe sural region.‘Scandin&ian Journal of Plastic and Reconstructive Surgery, 17, 19 1.
Ponten, B. (1981). The fasciocutaneous flap: its use in soft tissue defects of the lower leg. British Journal of Plastic Surgery, 34, 215.
The Authors Jo& Amarnate, MD, Consultant Plastic Surgeon. Horiacio Costa, MD, Resident Plastic Surgeon. Jorge Reis, MD, Resident Plastic Surgeon. Ribeirinko Sonres, MD, Resident Plastic Surgeon. Plastic Surgery Department, Hospital de S. JoHo, Medical School, Oporto, Portugal. Requests for reprints to: Jose Amarante, Service de Cirurgia Plastica, Hospital de S. JoHo, 4200 Porto, Portugal.