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Fasciocutaneous flaps for lower extremity wounds
Injury (1989) 20,273-276
Printed in Greaf Britain
273
Fasciocutaneous flaps for lower extremity wounds A. D. Mandrekas, B. C. Theodorou and E. Miliotis The Plastic Surgery Clinic, Naval and Veterans Hospital of Athens, Greece
Theuseof fascb4taneous
flaps to wver soft tissue&feds of the lowerleg
followingtrauma,is dscmsd in thisarticle,Our experiencewith 15 casts is preset&. There have been no complications We feel fhaf fmkmkneous flaps are a safe and reliable &hod for ,the managementof difimlt woundsof the lower kg
Introduction The technique for wound coverage of the lower leg has undergone many changes, with split skin grafts, tube pedicles, cross-leg flaps, fasciocutaneous flaps, muscle or musculocutaneous flaps and lately free flaps. Each of these methods has its application according to the extent and location of the injury. Fasciocukaneous flaps supply large amounts of stable skin and can be transferred with the rotation, transposition or cross-leg flap technique. The first successful cross-leg flap was described by Hamilton (1954); Ambroggio et al. (1982) reported 183 cross-leg flaps used over a 20-year period with no loss of the flap. Ponten (1981) should be credited with the recognition of the value of the fasciocutaneous flap. McGraw and Dibbell(1977) described the fascial plexus of vessels in the leg, and Haertsch (1981) pointed out that the surgical plane in the leg should be deep to the deep fascia because of the fascial plexus. The ‘super flap’ of Ponten (1981) has been used successfully, covering large defects with a length-to-width ratio of 3 to I. When necessary, even this ratio can be exceeded without the fear of flap necrosis (Tolhurst et al., 1983). We present our experience with IS flaps used over a 4-year period to cover several areas of the lower leg.
The most common indication for the use of flap coverage was a traumatic soft tissue defect, with or without underlying fracture (Table 0). Fasciocutaneous flaps were used from the posterior and lateral aspects of the leg, mostly over the gastrocnemius muscle. The flap can be designed with measurements as large as 18 x 8 cm. The dissection began distally with the incision down to the subfascial plane. The fascia with the overlying fat and skin was taken off the muscle taking care not to separate the fascia from the fat; it is wise to tack it to the skin with sutures. Small perforators from Ihe muscle were coagulated because haemostasis is mandatory. Dressings were not applied so that viability of the flap could be seen. The donor site was always covered with split-skin grafts. The immobilization time for rotation flaps was 5-7 days and for the cross-leg flaps the plaster-of-Paris was removed on the 4th postoperative day and the patient started active exercises. Most of the flaps were thinned with liposuction after 3 months with excellent results. In a total of 15 consecutive flaps raised on the lower leg, the only complication was the loss of 3 cm of the tip of a cross-leg flap; the wound healed after gratingjhe surviving underlying fascia.
Table I.
Fasciocutaneous flaps for lower leg wounds Location of defect
Type of flap Cross-leg Rotation Transposition
7 7 1
Foot Leg Proximal third of tibia Middle third of tibia Distal third of tibia Multiple zone Knee
Materials and methods (Figs.l-3) In this 4-year period we used I5 fasciocutaneous flaps in 15 patients for defects of the lower leg. The age of the patients ranged from 18 to 80 years. There were 12 males and 3 females. The defects included one of the knee, one of the upper third of the lower leg, four of the middle third, three of the lower third, two of the foot and four overlapped two zones (Table I). Seven fasciocutaneous flaps were used as rotation flaps, seven were used as cross-leg flaps and one as a transposition flap (Table I). 0 1989 Butterworth & Co (Publishers) Ltd 0020-1383/89/050273-04 $03.00
Table II. Indications
for use of fasciocutaneous
Type of injury Soft tissue defect without fracture Soft tissue defect associated with open fracture Chronic defect Exposed plate
2 13 1 4 3 4 1
flaps in our series N= 15
:, 3 3
Injury: the British Journal of Accident Surgery (1989) Vol. 20/No. s
274
b
d
e
Figure 1. u,b, A 22-year-old sailor (J.A.)who sustained an open fracture of his right tibia and fibula with extensive soft tissue loss. c,d,A free latissimus dorsi muscle flap failed (thrombosis of the artery) to cover the defect. e,j A cross-leg fasciocutaneous flap provided enough coverage for further orthopaedic management.
Discussion The fasciocutaneous flap provides a large amount of skin to work with, is fairly simple to transfer to the other leg, and is
safe, thanks to its ample fascial network of superficial vessels (Barclay et al, 1982; Ingianni and Muhlbauer, 1982; Walton and Bunkis, 1984). The flap can be raised distally, based either laterally (Donski and Fogdestam, 1983) or medially
(Amarante et al., 1986) to filldefects of the lower third of the leg.
Although the large number of free flaps being done today reflect the new horizon for plastic surgery, when the technical background of free tissue transfer is not available or the injury to the vessels is very extensive, the alternative soft tissue coverage of the lower leg is a muscle or a
275
Mandrekas et al.: Fasciocutaneous flaps for lower extremity wounds
a
Figure 2. a, A 55-year-old man (N.S.) suffering from chronic osteitis of his right tibia was treated with a rotation fasciocutaneous flap, which covered the front area of his tibia (b).
a Figure 3. A Jo-year-old Lieutenant of the Greek Navy (C.C.) sustained a crush injury of his left foot with fracture of the 1st and 2nd metatarsal bones. The bones were plated, but the covering skin of the dorsum of the foot necrosed. A cross-leg fasciocutaneous flap was used successfully to cover the defect (a) and the bulky flap was thinned 3 months later with liposuction
fasciocutaneous flap, either from the same or the other leg. The harvesting of the regional muscle not only creates additional surgical trauma in the vicinity of previous injury but also sacrifices. the use of one of the remaining healthy muscles, and the resultant contour deformity is objectionable both in donor and recipient sites (Mathews and Nahai, 1982). A complication rate as high as 34 per cent has been reported with the use of muscle and musculocutaneous flaps in lower limb reconstruction (Neale et al., 1983). Especially for the lower third, the use of the cross-leg fasciocutaneous flap remains a more reliable technique for coverage than the use of local muscle flaps. The abnormal position is not a d&c&y for the younger patients but is not
(b).
recommended for older people where it can cause stiffness of the lower limb joints. The thin random flap generally provides a superior result in terms of form and function than the bulky local musculocutaneous flap. The distally based muscle transposition is not reliable because of variability in the location of the minor pedicles, and Nahai, 1982). Free and high rate of failure (Mathews flaps are the best alternative, especially free fascia flaps, but even in experienced hands the rate of failure is 8-9 per cent (Zook et al., 1986). For small defects, Maruyama (1985) suggested the use of the bilobed fasciocutaneous flap in order to avoid the need for a secondary skin graft to the donor area of the fiap.
276
Injury: the British Journal of Accident Surgery (1989) Vol. 2WNo. 5
References Amarante J., Costa H., Reis J. et al. (1986) A new distally based fasciocutaneous flap for the leg. Br. J P/usf.Swg. 39,338. Ambroggio G., Oberto E. and Teich-Alasia S. (1982) Twenty years’ experience using the cross-leg flap technique. Ann. Plast. Surg. 9,152. Barclay T. L., Cardoso E., Sharpe D. T. et al. (1982) Repair of lower leg injuries with fasciocutaneous flaps. Br. J. Phf. Surg. 35,127. Donski P. K. and Fogdestam I. (1983) Distally based fasciocutaneous flap from the sural region. Stand. J. Plasf. Rem&r. Surg. 17,191. Haertsch P. A. (1981) The blood supply to skin of the leg: A post mortem investigation. Br. J. Phsf. Surg 34,470. Hamilton F. H. (1954) E&$r.sty orAr+&fy fo theTwdmenfofOld Ulcers.Also A New Mode of Tredwmf forDelayed
Printed in Greaf Britain
273
Fasciocutaneous flaps for lower extremity wounds A. D. Mandrekas, B. C. Theodorou and E. Miliotis The Plastic Surgery Clinic, Naval and Veterans Hospital of Athens, Greece
Theuseof fascb4taneous
flaps to wver soft tissue&feds of the lowerleg
followingtrauma,is dscmsd in thisarticle,Our experiencewith 15 casts is preset&. There have been no complications We feel fhaf fmkmkneous flaps are a safe and reliable &hod for ,the managementof difimlt woundsof the lower kg
Introduction The technique for wound coverage of the lower leg has undergone many changes, with split skin grafts, tube pedicles, cross-leg flaps, fasciocutaneous flaps, muscle or musculocutaneous flaps and lately free flaps. Each of these methods has its application according to the extent and location of the injury. Fasciocukaneous flaps supply large amounts of stable skin and can be transferred with the rotation, transposition or cross-leg flap technique. The first successful cross-leg flap was described by Hamilton (1954); Ambroggio et al. (1982) reported 183 cross-leg flaps used over a 20-year period with no loss of the flap. Ponten (1981) should be credited with the recognition of the value of the fasciocutaneous flap. McGraw and Dibbell(1977) described the fascial plexus of vessels in the leg, and Haertsch (1981) pointed out that the surgical plane in the leg should be deep to the deep fascia because of the fascial plexus. The ‘super flap’ of Ponten (1981) has been used successfully, covering large defects with a length-to-width ratio of 3 to I. When necessary, even this ratio can be exceeded without the fear of flap necrosis (Tolhurst et al., 1983). We present our experience with IS flaps used over a 4-year period to cover several areas of the lower leg.
The most common indication for the use of flap coverage was a traumatic soft tissue defect, with or without underlying fracture (Table 0). Fasciocutaneous flaps were used from the posterior and lateral aspects of the leg, mostly over the gastrocnemius muscle. The flap can be designed with measurements as large as 18 x 8 cm. The dissection began distally with the incision down to the subfascial plane. The fascia with the overlying fat and skin was taken off the muscle taking care not to separate the fascia from the fat; it is wise to tack it to the skin with sutures. Small perforators from Ihe muscle were coagulated because haemostasis is mandatory. Dressings were not applied so that viability of the flap could be seen. The donor site was always covered with split-skin grafts. The immobilization time for rotation flaps was 5-7 days and for the cross-leg flaps the plaster-of-Paris was removed on the 4th postoperative day and the patient started active exercises. Most of the flaps were thinned with liposuction after 3 months with excellent results. In a total of 15 consecutive flaps raised on the lower leg, the only complication was the loss of 3 cm of the tip of a cross-leg flap; the wound healed after gratingjhe surviving underlying fascia.
Table I.
Fasciocutaneous flaps for lower leg wounds Location of defect
Type of flap Cross-leg Rotation Transposition
7 7 1
Foot Leg Proximal third of tibia Middle third of tibia Distal third of tibia Multiple zone Knee
Materials and methods (Figs.l-3) In this 4-year period we used I5 fasciocutaneous flaps in 15 patients for defects of the lower leg. The age of the patients ranged from 18 to 80 years. There were 12 males and 3 females. The defects included one of the knee, one of the upper third of the lower leg, four of the middle third, three of the lower third, two of the foot and four overlapped two zones (Table I). Seven fasciocutaneous flaps were used as rotation flaps, seven were used as cross-leg flaps and one as a transposition flap (Table I). 0 1989 Butterworth & Co (Publishers) Ltd 0020-1383/89/050273-04 $03.00
Table II. Indications
for use of fasciocutaneous
Type of injury Soft tissue defect without fracture Soft tissue defect associated with open fracture Chronic defect Exposed plate
2 13 1 4 3 4 1
flaps in our series N= 15
:, 3 3
Injury: the British Journal of Accident Surgery (1989) Vol. 20/No. s
274
b
d
e
Figure 1. u,b, A 22-year-old sailor (J.A.)who sustained an open fracture of his right tibia and fibula with extensive soft tissue loss. c,d,A free latissimus dorsi muscle flap failed (thrombosis of the artery) to cover the defect. e,j A cross-leg fasciocutaneous flap provided enough coverage for further orthopaedic management.
Discussion The fasciocutaneous flap provides a large amount of skin to work with, is fairly simple to transfer to the other leg, and is
safe, thanks to its ample fascial network of superficial vessels (Barclay et al, 1982; Ingianni and Muhlbauer, 1982; Walton and Bunkis, 1984). The flap can be raised distally, based either laterally (Donski and Fogdestam, 1983) or medially
(Amarante et al., 1986) to filldefects of the lower third of the leg.
Although the large number of free flaps being done today reflect the new horizon for plastic surgery, when the technical background of free tissue transfer is not available or the injury to the vessels is very extensive, the alternative soft tissue coverage of the lower leg is a muscle or a
275
Mandrekas et al.: Fasciocutaneous flaps for lower extremity wounds
a
Figure 2. a, A 55-year-old man (N.S.) suffering from chronic osteitis of his right tibia was treated with a rotation fasciocutaneous flap, which covered the front area of his tibia (b).
a Figure 3. A Jo-year-old Lieutenant of the Greek Navy (C.C.) sustained a crush injury of his left foot with fracture of the 1st and 2nd metatarsal bones. The bones were plated, but the covering skin of the dorsum of the foot necrosed. A cross-leg fasciocutaneous flap was used successfully to cover the defect (a) and the bulky flap was thinned 3 months later with liposuction
fasciocutaneous flap, either from the same or the other leg. The harvesting of the regional muscle not only creates additional surgical trauma in the vicinity of previous injury but also sacrifices. the use of one of the remaining healthy muscles, and the resultant contour deformity is objectionable both in donor and recipient sites (Mathews and Nahai, 1982). A complication rate as high as 34 per cent has been reported with the use of muscle and musculocutaneous flaps in lower limb reconstruction (Neale et al., 1983). Especially for the lower third, the use of the cross-leg fasciocutaneous flap remains a more reliable technique for coverage than the use of local muscle flaps. The abnormal position is not a d&c&y for the younger patients but is not
(b).
recommended for older people where it can cause stiffness of the lower limb joints. The thin random flap generally provides a superior result in terms of form and function than the bulky local musculocutaneous flap. The distally based muscle transposition is not reliable because of variability in the location of the minor pedicles, and Nahai, 1982). Free and high rate of failure (Mathews flaps are the best alternative, especially free fascia flaps, but even in experienced hands the rate of failure is 8-9 per cent (Zook et al., 1986). For small defects, Maruyama (1985) suggested the use of the bilobed fasciocutaneous flap in order to avoid the need for a secondary skin graft to the donor area of the fiap.
276
Injury: the British Journal of Accident Surgery (1989) Vol. 2WNo. 5
References Amarante J., Costa H., Reis J. et al. (1986) A new distally based fasciocutaneous flap for the leg. Br. J P/usf.Swg. 39,338. Ambroggio G., Oberto E. and Teich-Alasia S. (1982) Twenty years’ experience using the cross-leg flap technique. Ann. Plast. Surg. 9,152. Barclay T. L., Cardoso E., Sharpe D. T. et al. (1982) Repair of lower leg injuries with fasciocutaneous flaps. Br. J. Phf. Surg. 35,127. Donski P. K. and Fogdestam I. (1983) Distally based fasciocutaneous flap from the sural region. Stand. J. Plasf. Rem&r. Surg. 17,191. Haertsch P. A. (1981) The blood supply to skin of the leg: A post mortem investigation. Br. J. Phsf. Surg 34,470. Hamilton F. H. (1954) E&$r.sty orAr+&fy fo theTwdmenfofOld Ulcers.Also A New Mode of Tredwmf forDelayed