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The extended V-Y flap for coverage of a mid-plantar defect
708 haemoglobin undergoes gelation, altering the malleability of the erythrocyte, which assumes an elongated sickle shape. These misshapen erythrocytes cause sludging within the microcirculation and cell haemolysis. The resulting tissue ischaemia is very painful and may lead to permanent damage. Patients with sickle cell trait are regarded as near normal with a normal life expectancy. However, under extreme circumstances they may sickle, for instance splenic infarcts have been known to occur in sickle cell trait individuals travelling in unpressurised aircraft at high altitudes. Both the homozygous and the heterozygous forms of sickle cell disease are generally regarded as contraindications to free tissue transfer as marked hypoxia of the flap develops during the flap off time. Although pedicled flap surgery is thought to be safe if HbS is maintained between 30% and 40% 2,3 few reports of free tissue transfer in the presence of HbS exist in the literature. Spence reported the successful transfer of gracilis to cover a recurrent ankle ulcer in a patient with sickle cell anaemia. 4 Preoperative exchange transfusions were used to reduce the level of HbS from 97% to 34%. Richards et al used a radial forearm flap to cover a malleolar ulcer in a patient with sickle cell anaemia whose HbS was reduced preoperatively from 74% to 24%. 5 Following initial good flow, the flap eventually failed with large amounts of thick viscous blood found in the veins of the flap. Weinzweig and Gonzalez reported the use of a free latissimus dorsi flap to cover a painful ankle ulcer. 6 Preoperatively the HbS was brought down to 30% and the flap off time was 50 min. At 9 h postoperatively the flap was explored due to a sudden decrease in perfusion. Both the arterial and venous anastomoses were found to be patent but there was patchy necrosis within the muscle leading to eventual loss of the majority of the flap. Despite two periods of ischaemia, the muscle flap used in our patient who had sickle cell trait experienced no microcirculatory compromise and there was complete skin-graft take with no flap loss. It must be noted, however, that the ischaemic times were kept as short as possible. In conclusion, we feel that free tissue transfer can sometimes
British Journal of Plastic Surgery be accomplished successfully in patients with sickle cell trait provided that ischaemic times can be minimised, though most plastic surgeons would only take the risk of performing a free flap in this type of patient when there were no other options or where it confers a huge benefit to the patient. Despite preoperative exchange transfusions, patients with sickle cell disease appear to have a poor outcome from free tissue transfer, with flaps failing from a combination of microcirculatory sludging and hypercoagulability. It is not possible to tell from the literature what effect flap ischaemia times have on this poor outcome. References
1. Hickman M, Modell B, Greengross P, et al. Mapping the prevalence of sickle cell and beta thalassaemia in England: estimating and validating ethnic-specificrates. Br J Haematol 1999; 104: 860-7. 2. Ashbell TS. Exchange transfusion for flap surgery in sickle cell anemia. Surg Forum 1972; 23:516-18 . . . . 3. Heckler FR, Dibbell DG, McCraw JB. Successful use of muscle flaps or myocutaneousflaps in patients with sickle cell disease. Plast Reconstr Surg 1977; 60: 902-8. 4. Spence ILl. The use of a free flap in homozygoussickle cell disease. Plast Reconstr Surg 1985; 76: 616-19. 5. Richards RS, Bowen CVA, Glynn MFX. Microsurgical free flap transfer in sickle cell disease. Ann Plast Surg 1992; 29:278-81. 6. WeinzweigN, Gonzalez M. Free tissue transfer is not an all-or-none phenomenon. Plast Reconstr Surg 1995; 96: 648-60.
The A u t h o r s Alastair J. Platt MA, BM, BCh, FRCS, Specialist Registrar in Plastic
Surgery Angus Robertsnn BSe, MB ChB, MRCS(Ed), Senior House Officer
in Plastic Surgery Andrew G. Batehelor FRCS, FRCS(Plast), Consultant Plastic Surgeon
Department of Plastic and Reconstructive Surgery, St Jarnes's University Hospital, Beckett Street, Leeds LS9 7TF, UK. Correspondenceto Mr A. J. Platt. Paper received 19 May 2000. Accepted 17 July 2000.
British Journal of Plastic Surgery (2000), 53 9 2000 The British Association of Plastic Surgeons doi: 10.1054/bjps.2000.3438
The extended V-Y flap for coverage of a mid-plantar defect L. Ero~lu, E. Gtineren, M. Keskin, O. A. Uysal and Y. Tomak*
Divisions of Plastic and Reconstructive Surgery, and *Orthopaedics, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey SUMMARY. A mid-plantar ulcer was successfully reconstructed with an extended V - Y flap incorporating part of the flexor digitorum brevis muscle to achieve more volume and increase the safety of the flap. This flap can be used as a reliable alternative to other techniques to repair a moderately sized defect of the plantar midfoot. 9 2000 The British Association of Plastic Surgeons Keywords: extended V - Y flap, plantar defect.
When reconstructing the unique weight-bearing surface of the plantar skin, it is important to achieve sensate
tissue coverage and to minimise donor-site morbidity. Advancing forefoot skin in a V - Y fashion may cover
The extended V-Y flap for coverage of a mid-plantar defect
709
Figure 1--Deep plantar ulcer in the lateral mid-plantar region.
Figure 3---Advancement and transposition of the flap into the defect.
Figure 2---The defect after excision and design of the extended V-Y flap.
Figure4--The healed ulcer 4 months after the operation.
small defects of the mid-plantar region. In this study, we report the successful reconstruction of a defect located in the weight-bearing surface of the midfoot with an extended V - Y flap, which is able to cover larger defects than a standard V - Y flap.
Case report A 38-year-old woman presented with chronic ulceration on the plantar midfoot, which had been present for 2 years and had been refractory to a previous effort at primary closure 1 year ago. Previously she had a history of a fall onto her feet 10 years
710 before. Her feet and legs became oedematous when she stood up for a long time. She had a deep-seated ulcer about 2.7 cm in diameter located in the lateral mid-plantar region and another ulcer 1 cm in diameter on the plantar forefoot (Fig. 1). Radiographs revealed an old fracture of the fifth metatarsal diaphysis. At operation under tourniquet the ulcer was excised down to bone. The fibrous tissue in the fifth metatarsal fracture zone was debrided and the bone was shaved. A frozen-section study was performed and indicated possible malignancy, so the wound was left open until the paraffin sections were examined and reported to show chronic granulation tissue. At the second operation an extended V-Y flap was designed to cover the 4-cm defect (Fig. 2). The flap was incised deep to the plantar fascia. The fourth and fifth tendons of the flexor digitorum brevis were divided and the muscle was split and included in the flap to add more volume. The flap was advanced and inset (Fig. 3). Since the ulcer in the distal forefoot was not on the weight-bearing surface it was excised and covered with a splitthickness skin graft and the wound healed uneventfully (Fig. 4). Weight beating was strictly prohibited for 5 weeks. The patient was beating full weight on the flap without complication when seen 6 months postoperatively. Plantar sensation on the flap was assessed by light touch and found to be present. There was no hypertrophic scarring and minimal hyperkeratosis in the plantar scar lines. Discussion Reconstruction of the plantar midfoot is best achieved with plantar skin. A small defect o f the plantar midfoot can be closed with a neurovascular island flap, a r a n d o m pattern plantar skin flap or a V - Y a d v a n c e m e n t f l a p ) ,2 In defects larger than 4 - 5 c m in diameter, free tissue transfer or distant flaps m a y be u s e d J -6 The different quality of the skin, the need for multiple operations, prolonged treatment time and poor sensation are drawbacks o f distant flaps. The a d v a n c e m e n t of small V - Y flaps is limited by the attachment o f the plantar skin and the plantar fascia with fibrous septa. For larger defects, two opposing V - Y flaps m a y be used but the advancement is c o m m o n l y insufficient. For the plantar forefoot, flexor digitorum brevis and adductor digiti m i n i m i m u s c u l o c u t a n e o u s V - Y a d v a n c e m e n t flaps have been described. 7'8 The extended V - Y flap described by Pribaz et al has been used in the reconstruction of facial, ischial and trunk defects. 9-1z The extended V - Y flap relies on both a d v a n c e m e n t and transposition principles and borrows tissue from two planes. 9 We used an extended V - Y flap to reconstruct an ulcer 4 c m in diameter, located on the weight-bearing surface of the plantar midfoot. Part of the flexor digitorum brevis muscle was included in the flap to achieve more v o l u m e
British Journal of Plastic Surgery and to increase the safety of the flap. The donor site was easily closed primarily. Sensation was maintained on the reconstructed area. We believe that the extended V - Y flap m a y be used for coverage of even larger defects by dividing the adductor digiti m i n i m i muscle from its origin. References 1. Hidalgo DA, Shaw WW. Reconstruction of foot injuries. Clin Plast Surg 1986; 13: 663-80. 2. Colen BC. The diabetic foot. In Cohen M, ed. Mastery of Plastic and Reconstructive Surgery. Vol 3. Boston." Little, Brown and Company, 1994: 1847. 3. Morris AM, Buchan AC. The place of the cross-leg flap in reconstructive surgery of the lower leg and foot: a review of 165 cases. Br J Plast Surg 1978; 31: 138-42. 4. Taylor GA, Hopson WLG. The cross-foot flap. Plast Reconstr Surg 1975; 55: 677-81. 5. May JW Jr, Halls MJ, Simon SR. Free microvascular muscle flaps with skin graft reconstruction of extensive defects of the foot: a clinical and gait analysis study. Plast Reconstr Surg 1985; 75: 627-41. 6. Wood MB, Irons GB, Cooney WP III. Foot reconstruction by free flap transfer. Foot Ankle 1983; 4: 2-7. 7. Mathes SJ, Nahai E Flexor digitomm brevis flap. In Mathes SJ, Nahai F, eds. Reconstructive Surgery: principles, anatomy, and technique. Vol. 2. New York: Churchill Livingstone, 1997: 1557-69. 8. Mathes SJ, Nahai E Abductor digiti miniini flap. In Mathes SJ, Nahai E eds. Reconstructive Surgery:principles, anatomy, and technique. Vol. 2. New York: Churchill Livingstone, 1997: 1515-26. 9. Pribaz JJ, Chester CH, Barrall DT. The extended V-Y flap. Plast Reconstr Surg 1992; 90: 275-80. 10. Terashi H, Kurata S, Hashimoto' H, et al. Extended V-Y flap: patient reports and reconsideration. Ann Plast Surg 1997; 38: 147-50. 11. Brynildsen PJ. The extended V-Y flap. Plast Reconsu" Surg 1993; 9l: 965. 12. Pribaz JJ. The extended V-Y flap - reply. Plast Reconstr Surg 1993; 91: 965-6. The A u t h o r s Liitfi Ero~iu MD, Ethem Gilneren MD, Mustafa Keskin MD, Osman Ata Uysal MD, Division of Plastic and Reconstructive Surgery Yllmaz Tomak MD, Division of Orthopaedics Faculty of Medicine, Ondokuz Mayis University, Samsnn, Turkey. Correspondence to Dr Ltitfi Ero~lu. Paper received 22 February 2000. Accepted 18 July 2000, after revision.
British Journal of Plastic Surgery be accomplished successfully in patients with sickle cell trait provided that ischaemic times can be minimised, though most plastic surgeons would only take the risk of performing a free flap in this type of patient when there were no other options or where it confers a huge benefit to the patient. Despite preoperative exchange transfusions, patients with sickle cell disease appear to have a poor outcome from free tissue transfer, with flaps failing from a combination of microcirculatory sludging and hypercoagulability. It is not possible to tell from the literature what effect flap ischaemia times have on this poor outcome. References
1. Hickman M, Modell B, Greengross P, et al. Mapping the prevalence of sickle cell and beta thalassaemia in England: estimating and validating ethnic-specificrates. Br J Haematol 1999; 104: 860-7. 2. Ashbell TS. Exchange transfusion for flap surgery in sickle cell anemia. Surg Forum 1972; 23:516-18 . . . . 3. Heckler FR, Dibbell DG, McCraw JB. Successful use of muscle flaps or myocutaneousflaps in patients with sickle cell disease. Plast Reconstr Surg 1977; 60: 902-8. 4. Spence ILl. The use of a free flap in homozygoussickle cell disease. Plast Reconstr Surg 1985; 76: 616-19. 5. Richards RS, Bowen CVA, Glynn MFX. Microsurgical free flap transfer in sickle cell disease. Ann Plast Surg 1992; 29:278-81. 6. WeinzweigN, Gonzalez M. Free tissue transfer is not an all-or-none phenomenon. Plast Reconstr Surg 1995; 96: 648-60.
The A u t h o r s Alastair J. Platt MA, BM, BCh, FRCS, Specialist Registrar in Plastic
Surgery Angus Robertsnn BSe, MB ChB, MRCS(Ed), Senior House Officer
in Plastic Surgery Andrew G. Batehelor FRCS, FRCS(Plast), Consultant Plastic Surgeon
Department of Plastic and Reconstructive Surgery, St Jarnes's University Hospital, Beckett Street, Leeds LS9 7TF, UK. Correspondenceto Mr A. J. Platt. Paper received 19 May 2000. Accepted 17 July 2000.
British Journal of Plastic Surgery (2000), 53 9 2000 The British Association of Plastic Surgeons doi: 10.1054/bjps.2000.3438
The extended V-Y flap for coverage of a mid-plantar defect L. Ero~lu, E. Gtineren, M. Keskin, O. A. Uysal and Y. Tomak*
Divisions of Plastic and Reconstructive Surgery, and *Orthopaedics, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey SUMMARY. A mid-plantar ulcer was successfully reconstructed with an extended V - Y flap incorporating part of the flexor digitorum brevis muscle to achieve more volume and increase the safety of the flap. This flap can be used as a reliable alternative to other techniques to repair a moderately sized defect of the plantar midfoot. 9 2000 The British Association of Plastic Surgeons Keywords: extended V - Y flap, plantar defect.
When reconstructing the unique weight-bearing surface of the plantar skin, it is important to achieve sensate
tissue coverage and to minimise donor-site morbidity. Advancing forefoot skin in a V - Y fashion may cover
The extended V-Y flap for coverage of a mid-plantar defect
709
Figure 1--Deep plantar ulcer in the lateral mid-plantar region.
Figure 3---Advancement and transposition of the flap into the defect.
Figure 2---The defect after excision and design of the extended V-Y flap.
Figure4--The healed ulcer 4 months after the operation.
small defects of the mid-plantar region. In this study, we report the successful reconstruction of a defect located in the weight-bearing surface of the midfoot with an extended V - Y flap, which is able to cover larger defects than a standard V - Y flap.
Case report A 38-year-old woman presented with chronic ulceration on the plantar midfoot, which had been present for 2 years and had been refractory to a previous effort at primary closure 1 year ago. Previously she had a history of a fall onto her feet 10 years
710 before. Her feet and legs became oedematous when she stood up for a long time. She had a deep-seated ulcer about 2.7 cm in diameter located in the lateral mid-plantar region and another ulcer 1 cm in diameter on the plantar forefoot (Fig. 1). Radiographs revealed an old fracture of the fifth metatarsal diaphysis. At operation under tourniquet the ulcer was excised down to bone. The fibrous tissue in the fifth metatarsal fracture zone was debrided and the bone was shaved. A frozen-section study was performed and indicated possible malignancy, so the wound was left open until the paraffin sections were examined and reported to show chronic granulation tissue. At the second operation an extended V-Y flap was designed to cover the 4-cm defect (Fig. 2). The flap was incised deep to the plantar fascia. The fourth and fifth tendons of the flexor digitorum brevis were divided and the muscle was split and included in the flap to add more volume. The flap was advanced and inset (Fig. 3). Since the ulcer in the distal forefoot was not on the weight-bearing surface it was excised and covered with a splitthickness skin graft and the wound healed uneventfully (Fig. 4). Weight beating was strictly prohibited for 5 weeks. The patient was beating full weight on the flap without complication when seen 6 months postoperatively. Plantar sensation on the flap was assessed by light touch and found to be present. There was no hypertrophic scarring and minimal hyperkeratosis in the plantar scar lines. Discussion Reconstruction of the plantar midfoot is best achieved with plantar skin. A small defect o f the plantar midfoot can be closed with a neurovascular island flap, a r a n d o m pattern plantar skin flap or a V - Y a d v a n c e m e n t f l a p ) ,2 In defects larger than 4 - 5 c m in diameter, free tissue transfer or distant flaps m a y be u s e d J -6 The different quality of the skin, the need for multiple operations, prolonged treatment time and poor sensation are drawbacks o f distant flaps. The a d v a n c e m e n t of small V - Y flaps is limited by the attachment o f the plantar skin and the plantar fascia with fibrous septa. For larger defects, two opposing V - Y flaps m a y be used but the advancement is c o m m o n l y insufficient. For the plantar forefoot, flexor digitorum brevis and adductor digiti m i n i m i m u s c u l o c u t a n e o u s V - Y a d v a n c e m e n t flaps have been described. 7'8 The extended V - Y flap described by Pribaz et al has been used in the reconstruction of facial, ischial and trunk defects. 9-1z The extended V - Y flap relies on both a d v a n c e m e n t and transposition principles and borrows tissue from two planes. 9 We used an extended V - Y flap to reconstruct an ulcer 4 c m in diameter, located on the weight-bearing surface of the plantar midfoot. Part of the flexor digitorum brevis muscle was included in the flap to achieve more v o l u m e
British Journal of Plastic Surgery and to increase the safety of the flap. The donor site was easily closed primarily. Sensation was maintained on the reconstructed area. We believe that the extended V - Y flap m a y be used for coverage of even larger defects by dividing the adductor digiti m i n i m i muscle from its origin. References 1. Hidalgo DA, Shaw WW. Reconstruction of foot injuries. Clin Plast Surg 1986; 13: 663-80. 2. Colen BC. The diabetic foot. In Cohen M, ed. Mastery of Plastic and Reconstructive Surgery. Vol 3. Boston." Little, Brown and Company, 1994: 1847. 3. Morris AM, Buchan AC. The place of the cross-leg flap in reconstructive surgery of the lower leg and foot: a review of 165 cases. Br J Plast Surg 1978; 31: 138-42. 4. Taylor GA, Hopson WLG. The cross-foot flap. Plast Reconstr Surg 1975; 55: 677-81. 5. May JW Jr, Halls MJ, Simon SR. Free microvascular muscle flaps with skin graft reconstruction of extensive defects of the foot: a clinical and gait analysis study. Plast Reconstr Surg 1985; 75: 627-41. 6. Wood MB, Irons GB, Cooney WP III. Foot reconstruction by free flap transfer. Foot Ankle 1983; 4: 2-7. 7. Mathes SJ, Nahai E Flexor digitomm brevis flap. In Mathes SJ, Nahai F, eds. Reconstructive Surgery: principles, anatomy, and technique. Vol. 2. New York: Churchill Livingstone, 1997: 1557-69. 8. Mathes SJ, Nahai E Abductor digiti miniini flap. In Mathes SJ, Nahai E eds. Reconstructive Surgery:principles, anatomy, and technique. Vol. 2. New York: Churchill Livingstone, 1997: 1515-26. 9. Pribaz JJ, Chester CH, Barrall DT. The extended V-Y flap. Plast Reconstr Surg 1992; 90: 275-80. 10. Terashi H, Kurata S, Hashimoto' H, et al. Extended V-Y flap: patient reports and reconsideration. Ann Plast Surg 1997; 38: 147-50. 11. Brynildsen PJ. The extended V-Y flap. Plast Reconsu" Surg 1993; 9l: 965. 12. Pribaz JJ. The extended V-Y flap - reply. Plast Reconstr Surg 1993; 91: 965-6. The A u t h o r s Liitfi Ero~iu MD, Ethem Gilneren MD, Mustafa Keskin MD, Osman Ata Uysal MD, Division of Plastic and Reconstructive Surgery Yllmaz Tomak MD, Division of Orthopaedics Faculty of Medicine, Ondokuz Mayis University, Samsnn, Turkey. Correspondence to Dr Ltitfi Ero~lu. Paper received 22 February 2000. Accepted 18 July 2000, after revision.