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V–Y gastrocnemius muscle slide with turnover fascial flap for compound Achilles defects: A simple solution
Journal of Plastic, Reconstructive & Aesthetic Surgery (2010) 63, e406ee410
CASE REPORT
VeY gastrocnemius muscle slide with turnover fascial flap for compound Achilles defects: A simple solution N.K. Agrawal*, V. Bhattacharya Department of Plastic Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221005, Uttar Pradesh, India Received 30 April 2009; received in revised form 11 September 2009; accepted 20 September 2009
KEYWORDS Compound Achilles defects; Turnover fascial flaps; Non-axial fascial flap
Summary Background: Compound defects of the Achilles region pose a reconstructive challenge. Poor vascularity of the Achilles region predisposes to complications. Repair of the tendon with simultaneous soft-tissue cover gives the patient the best chance to recover. Materials and methods: Gastrocnemius musculotendinous VeY slide for Achilles tendon defect with non-axial turnover fascial flaps based on the proximal end of the defect with a split-skin graft on the fascial flap was used in two patients. The vascular bases of such flaps and the technical details has been discussed. Results: The functional and aesthetic results were highly satisfactory with minimal donor-site morbidity. The flap was thin enough to fit the contour of the Achilles region. The fascial flap with skin graft was durable and withstood footwear well. The flap also allowed tendon gliding beneath it, with near-complete movements at the ankle joint. Conclusion: Large flaps can sufficiently be raised with a wide base to cover small- to mediumsized defects. It is a good, rapid and cost-effective solution for a difficult clinical problem. ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Achilles tendon repair is often vulnerable to complications due to wound infection, necrosis and dehiscence of the tendon. Limited mobility and vascularity of the skin in this area and thin subcutaneous tissue predisposes it to complications. Secondary reconstruction becomes not only * Corresponding author. Tel.: þ919984665799; fax: þ915422368180. E-mail addresses: [email protected], agrawalnk@ yahoo.com (N.K. Agrawal).
difficult but also technically demanding. Therefore, it is essential to combine tendon repair with a well-vascularised cover. An ideal resurfacing should be stable, thin and well contoured, able to withstand friction caused by footwear and should allow good tendon gliding with full movements of the ankle joint and normal gait. Free flaps have been reported as an alternative, but they require microsurgical expertise and prolonged operating time. Loco-regional flaps are rapid and easy but the
1748-6815/$ - see front matter ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2009.09.017
VeY gastrocnemius muscle slide with turnover fascial flap for compound Achilles defects
e407
Figure 1 (a). Case I e30-year-old male with 4 days old compound defect of the Achilles tendon, (b). Achilles tendon lengthened by VeY gastrocnemius muscle slide, (c). Turnover fascial flap in place, donor site closed but not over the pedicle, (d). Follow up of nine months.
unpleasant bulky sight over the Achilles tendon poses a problem while wearing footwear. Hence, they may require secondary debulking. In addition, the flaps are associated with significant donor-site morbidity and poor cosmesis. We have reported two cases of primary tendoachilles repair and simultaneous cover with fascial turnover flap based on the proximal end of the defect with an overlying skin graft. The results obtained were excellent after a follow-up of 15 months.
Flap vascularity There is a rich anastomosing vascular network in the deep fascia, perfused by adjacent perforators from the major vascular trunks of the leg, with the subfascial system being dominant. This is also the basis of fasciocutaneous flaps and
adipofascial flaps. The survival of such flaps gives the impetus to using the fascia alone. Lees et al. described a distally based fascial flap raised on perforating vessels of the posterior tibial artery.1 Worseq et al. described vertically based deep fascia turnover flaps with paratibial or parafibular pedicle.2 Microscopic examination of the deep fascia in lower limbs of cadavers has revealed four clinically important sources of supply to the deep fascia. Non-axial fasciocutaneous perforators were found to be one of them, highlighting the potential use of non-axial fascial flaps.3
Patients and methods Two patients sustained compound injury of the Achilles tendon (Figures 1a and 2a). The unhealthy skin margins and
Figure 2 (a). Case II e 22 year old female with 12 days old compound defect of the Achilles tendon, (b). Fifteen months follow up showing the final apearance.
e408
N.K. Agrawal, V. Bhattacharya
Table 1
Results of distally based turnover fascial flaps
Age Sex Tendon gap (years)
Size of soft Dimensions Length: Method of tissue defect of the flap width tendon repair ratio
30
M
4 cm (Achilles tendon 9 4.5 cm avulsed from the calcaneal insertion)
22
F
3 cm
5 6.5 cm
12 5 cm
2.4:1
8 7 cm
1.1:1
To the calcaneum by drilling a hole and fixing by stainless steel To the distal cut end of the tendon
Movements at Sensations the ankle joint Doriflexion 0 e Plantar flexion N Z 40-0-45 O Z 40-0-45
Touch and pain present
N Z 40-0-50 O Z 35-0-50
Touch and pain present
N Z Normal, O Z Operated.
a portion of the tendon were debrided. The dimensions of the soft-tissue defect and the tendon gap were assessed (Table 1). Margins of the skin defect were undermined by 5 mm. A lazy ‘S’ skin incision was made extending proximally from the middle of proximal margin of the defect. It was deepened through the subcutaneous tissue to expose the glistening deep fascia. Skin flaps superficial to the deep fascia were undermined on either side. A turnover fascial flap as wide as the defect was planned with a base width of 1 cm. The flap was 2.5 cm longer than the defect. This length of 2.5 cm was measured due to the following reasons: (a) 1 cm to cross over the undissected base, (b) 1 cm for smooth hinging of the flap and (c) 5 mm to be tucked underneath the undermined defect margins (Figure 3). It was meticulously dissected from the perimysium over the calf muscles. This exposed the underlying musculotendinous area. A 0.5-cm inverted ‘V’ incision was made on the middle of the belly of the gastrocnemius muscle to incise the perimysium and a few of the superficial fibres of the muscle. This resulted in an easy advancement of the Achilles tendon, which bridged the tendon gap. The tendon was then repaired. The inverted ‘V’
on the belly of gastrocnemius was closed as ‘Y’ (Figure 1b). Since the base of the fascial flap lies on the Achilles tendon, it also slides with an advancement of the tendon. The length of the required flap is thus reduced. This is a distinct technical advantage. The margins of the flap were tucked under the undermined margins of the soft-tissue defect (Figure 1c). The donor site was closed as far as the flap pedicle but not over it. A thin split-thickness skin graft was applied over the flap. A below-knee anterior slab with ankle in plantar flexion was applied for 3 weeks and physiotherapy was started thereafter. Gradual weight bearing was allowed after 3 weeks and full weight bearing 3 months onwards. After a follow-up of 15 months, the flap proved to be useful with the following features ereliability of the flap, quality of softtissue cover, durability of the flap, sensations, movements of the ankle joint and aesthetics of donor and recipient site.
Results Dimensions of the fascial flaps and length-to-width ratio have been outlined in Table 1. In both the cases, the flap survived completely with full take of the graft. Primary closure of the donor site was a major advantage and the appearance of the donor-site linear scar was highly satisfactory (Figures 1d and 2b). The thinness of the fascial flap was appreciated by the patients, as they did not have any problem in wearing footwear. The flap developed protective sensations in the form of touch and pain. Dorsiflexion and plantar flexion at the ankle joint were near normal (Figures 4aed). Hypoaesthesia was noted in the distribution of sural nerve in one patient, which improved over 3 months. Tipe toe standing was almost equal to the normal side (Figure 5).
Discussion
Figure 3 Schematic diagram showing the parts of the turnover fascial flap based on the proximal end of the defect.
Compound defects of the Achilles tendon have always been a problem for the reconstructive surgeon. This has resulted in evaluation of different flaps in the search for the optimum technique. Vascularised fascia lata,4 free tensor fascia lata flap5 and deep fascia with lateral arm flap6 have been the microsurgical options. However, reconstruction by fascia lata does not return complete power to the tendon. In addition, the surgery is time consuming; the flaps are bulky and cause significant donor-site morbidity. Bipedicled VeY gastrocnemius myocutaneous flap,7 island medial plantar flap8 and reverse sural flap9 have been described as loco-
VeY gastrocnemius muscle slide with turnover fascial flap for compound Achilles defects
e409
Figure 4 (a,b). Case I e good dorsiflexion and plantar flexion of the left foot compared with the right foot. (c,d). Case II e good dorsiflexion and plantar flexion of the right foot compared with the left foot.
regional options but they give an unpleasant bulky sight, posing problems with footwear. They form a dog-ear with poor donor-site cosmesis. A second surgery in the form of debulking is usually required for both free and pedicled flaps. Fong et al. (1997) successfully used distally based fascial flaps on perforators of posterior tibial and peroneal artery for covering the soft-tissue defects over the Achilles tendon.10 However, the anatomical location of these flaps would not allow exposure of the gastrocnemius musculotendinous area for simultaneous tendon repair. There has been sparse literature regarding non-axial turnover fascial flaps. These flaps have been shown to be anatomically feasible in cadaver dissections.3 In this study, we have used them in two cases with a maximum defect of 9 4.5 cm. The fascial flaps were raised with an undissected base as wide as the defect and were
1 cm in length from the proximal margin of the defect. The largest flap measured 12 5 cm and the length:width ratio of 2.4:1 suitably covered the defect. The major technical advantage of such a flap was simultaneous exposure of the gastrocnemius muscle, which was slid in a VeY fashion to bridge the Achilles tendon defect. It also provided the desired function of the tendon gliding underneath. The depth of the inverted ‘V’ incision depends on the required advancement of the Achilles tendon, which, in turn, depends on the tendon gap. In our patients, we have incised the perimysium and the superficial muscle fibres on the belly of the gastrocnemius muscle up to a depth of 0.5 cm and have achieved an advancement of the Achilles tendon by 4 cm. However, in cases with larger tendon gaps, the muscle fibres may be incised to a greater depth, keeping in mind not to jeopardise the vascularity of the muscle. A fascial flap has a distinct advantage over other contemporary flaps as it appropriately fits the contour of the Achilles region, is technically easy, rapid and has sufficient vascularity to support a skin graft. It resists frictional forces caused by footwear and permits near complete movements of the foot. Moreover, the donor site can be closed primarily with only a linear scar showing. Both the patients had gratifying functional and aesthetic results after a follow-up of 15 months. Thus, with this technique, large flaps can sufficiently be raised with a wide base to cover small- toemedium-sized defects providing a reasonably simple solution for a difficult clinical entity.
Conflict of interest statement Figure 5 Case 1 standing on his toes, also showing slight hypoaesthesia over the distribution of sural nerve.
The authors do not have any financial and personal relationships with other people or organisations that could inappropriately influence their work.
e410
N.K. Agrawal, V. Bhattacharya University, Varanasi, for making the line diagram showing the parts of a turnover fascial flap.
References
Role of funding source There is no role of study sponsors, in the study design, in the collection, analysis and interpretation of data; in the writing of the manuscript; and in the decision to submit the manuscript for publication.
Acknowledgement We thank Mr. Aurobindo Kundu, Incharge, Art and Photo Section, Institute of Medical Sciences, Banaras Hindu
1. Lees V, Townsend PLG. Use of a pedicled fascial flap based on septocutaneous perforators of the posterior tibial artery for repair of distal lower limb defects. British Journal of Plastic Surgery 1992;45:141e5. 2. Worseq AP, Kuzbari R, Jahl G, et al. The vertically based deep fascia turnover flap of the leg: anatomic studies and clinical applications. Plast Reconstr Surg 1997 Dec;100: 1746e61. 3. Batchelor JS, McGuinness A. A reappraisal of axial and nonaxial lower leg fascial flaps: an anatomic study in human cadavers. Plast Reconstr Surg 1996 Apr;97:993e1000. 4. Kuo YR, Kuo MH, Chou WC, et al. One-stage reconstruction of soft tissue and Achilles tendon defects using a composite free anterolateral thigh flap with vascularized fascia lata: clinical experience and functional assessment. Ann Plast Surg 2003 Feb;50:149e55. 5. Dabernig J, Shilov B, Schumacher O, et al. Functional reconstruction of Achilles tendon defects combined with overlaying skin defects using a free tensor fasciae latae flap. J Plast Reconstr Aesthet Surg 2006;59:142e7. 6. Berthe JV, Toussaint D, Coessens BC. One-stage reconstruction of an infected skin and Achilles tendon defect with a composite distally planned lateral arm flap. Plast Reconstr Surg 1998 Oct; 102:1618e22. 7. Xu YQ, Zhu YL, Ysng J, et al. Bi-pedicled V-Y gastrocnemius myocutaneous flap for repairing Achilles tendon and overlying skin defect: the anatomic basis and clinical application. Chin J Traumatol 2007 Apr;10:77e81. 8. Taniguchi Y, Tamaki T. Reconstruction of the Achilles tendon and overlying skin defect with a medial plantar flap and tensor fasciae latae graft. J Reconstr Microsurg 2000 Aug;16: 423e5. 9. Bullocks JM, Hickey RM, Basu CB, et al. Single-stage reconstruction of Achilles tendon injuries and distal lower extremity soft tissue defects with the reverse sural fasciocutaneous flap. J Plast Reconstr Aesthet Surg 2008;61: 566e72. 10. Fong EP, Papini RPG, McKiernan MV, et al. Reconstruction of an Achilles tendon skin defect using a local fascial flap. European Journal of Plastic Surgery 1997 September;20.
CASE REPORT
VeY gastrocnemius muscle slide with turnover fascial flap for compound Achilles defects: A simple solution N.K. Agrawal*, V. Bhattacharya Department of Plastic Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221005, Uttar Pradesh, India Received 30 April 2009; received in revised form 11 September 2009; accepted 20 September 2009
KEYWORDS Compound Achilles defects; Turnover fascial flaps; Non-axial fascial flap
Summary Background: Compound defects of the Achilles region pose a reconstructive challenge. Poor vascularity of the Achilles region predisposes to complications. Repair of the tendon with simultaneous soft-tissue cover gives the patient the best chance to recover. Materials and methods: Gastrocnemius musculotendinous VeY slide for Achilles tendon defect with non-axial turnover fascial flaps based on the proximal end of the defect with a split-skin graft on the fascial flap was used in two patients. The vascular bases of such flaps and the technical details has been discussed. Results: The functional and aesthetic results were highly satisfactory with minimal donor-site morbidity. The flap was thin enough to fit the contour of the Achilles region. The fascial flap with skin graft was durable and withstood footwear well. The flap also allowed tendon gliding beneath it, with near-complete movements at the ankle joint. Conclusion: Large flaps can sufficiently be raised with a wide base to cover small- to mediumsized defects. It is a good, rapid and cost-effective solution for a difficult clinical problem. ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Achilles tendon repair is often vulnerable to complications due to wound infection, necrosis and dehiscence of the tendon. Limited mobility and vascularity of the skin in this area and thin subcutaneous tissue predisposes it to complications. Secondary reconstruction becomes not only * Corresponding author. Tel.: þ919984665799; fax: þ915422368180. E-mail addresses: [email protected], agrawalnk@ yahoo.com (N.K. Agrawal).
difficult but also technically demanding. Therefore, it is essential to combine tendon repair with a well-vascularised cover. An ideal resurfacing should be stable, thin and well contoured, able to withstand friction caused by footwear and should allow good tendon gliding with full movements of the ankle joint and normal gait. Free flaps have been reported as an alternative, but they require microsurgical expertise and prolonged operating time. Loco-regional flaps are rapid and easy but the
1748-6815/$ - see front matter ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2009.09.017
VeY gastrocnemius muscle slide with turnover fascial flap for compound Achilles defects
e407
Figure 1 (a). Case I e30-year-old male with 4 days old compound defect of the Achilles tendon, (b). Achilles tendon lengthened by VeY gastrocnemius muscle slide, (c). Turnover fascial flap in place, donor site closed but not over the pedicle, (d). Follow up of nine months.
unpleasant bulky sight over the Achilles tendon poses a problem while wearing footwear. Hence, they may require secondary debulking. In addition, the flaps are associated with significant donor-site morbidity and poor cosmesis. We have reported two cases of primary tendoachilles repair and simultaneous cover with fascial turnover flap based on the proximal end of the defect with an overlying skin graft. The results obtained were excellent after a follow-up of 15 months.
Flap vascularity There is a rich anastomosing vascular network in the deep fascia, perfused by adjacent perforators from the major vascular trunks of the leg, with the subfascial system being dominant. This is also the basis of fasciocutaneous flaps and
adipofascial flaps. The survival of such flaps gives the impetus to using the fascia alone. Lees et al. described a distally based fascial flap raised on perforating vessels of the posterior tibial artery.1 Worseq et al. described vertically based deep fascia turnover flaps with paratibial or parafibular pedicle.2 Microscopic examination of the deep fascia in lower limbs of cadavers has revealed four clinically important sources of supply to the deep fascia. Non-axial fasciocutaneous perforators were found to be one of them, highlighting the potential use of non-axial fascial flaps.3
Patients and methods Two patients sustained compound injury of the Achilles tendon (Figures 1a and 2a). The unhealthy skin margins and
Figure 2 (a). Case II e 22 year old female with 12 days old compound defect of the Achilles tendon, (b). Fifteen months follow up showing the final apearance.
e408
N.K. Agrawal, V. Bhattacharya
Table 1
Results of distally based turnover fascial flaps
Age Sex Tendon gap (years)
Size of soft Dimensions Length: Method of tissue defect of the flap width tendon repair ratio
30
M
4 cm (Achilles tendon 9 4.5 cm avulsed from the calcaneal insertion)
22
F
3 cm
5 6.5 cm
12 5 cm
2.4:1
8 7 cm
1.1:1
To the calcaneum by drilling a hole and fixing by stainless steel To the distal cut end of the tendon
Movements at Sensations the ankle joint Doriflexion 0 e Plantar flexion N Z 40-0-45 O Z 40-0-45
Touch and pain present
N Z 40-0-50 O Z 35-0-50
Touch and pain present
N Z Normal, O Z Operated.
a portion of the tendon were debrided. The dimensions of the soft-tissue defect and the tendon gap were assessed (Table 1). Margins of the skin defect were undermined by 5 mm. A lazy ‘S’ skin incision was made extending proximally from the middle of proximal margin of the defect. It was deepened through the subcutaneous tissue to expose the glistening deep fascia. Skin flaps superficial to the deep fascia were undermined on either side. A turnover fascial flap as wide as the defect was planned with a base width of 1 cm. The flap was 2.5 cm longer than the defect. This length of 2.5 cm was measured due to the following reasons: (a) 1 cm to cross over the undissected base, (b) 1 cm for smooth hinging of the flap and (c) 5 mm to be tucked underneath the undermined defect margins (Figure 3). It was meticulously dissected from the perimysium over the calf muscles. This exposed the underlying musculotendinous area. A 0.5-cm inverted ‘V’ incision was made on the middle of the belly of the gastrocnemius muscle to incise the perimysium and a few of the superficial fibres of the muscle. This resulted in an easy advancement of the Achilles tendon, which bridged the tendon gap. The tendon was then repaired. The inverted ‘V’
on the belly of gastrocnemius was closed as ‘Y’ (Figure 1b). Since the base of the fascial flap lies on the Achilles tendon, it also slides with an advancement of the tendon. The length of the required flap is thus reduced. This is a distinct technical advantage. The margins of the flap were tucked under the undermined margins of the soft-tissue defect (Figure 1c). The donor site was closed as far as the flap pedicle but not over it. A thin split-thickness skin graft was applied over the flap. A below-knee anterior slab with ankle in plantar flexion was applied for 3 weeks and physiotherapy was started thereafter. Gradual weight bearing was allowed after 3 weeks and full weight bearing 3 months onwards. After a follow-up of 15 months, the flap proved to be useful with the following features ereliability of the flap, quality of softtissue cover, durability of the flap, sensations, movements of the ankle joint and aesthetics of donor and recipient site.
Results Dimensions of the fascial flaps and length-to-width ratio have been outlined in Table 1. In both the cases, the flap survived completely with full take of the graft. Primary closure of the donor site was a major advantage and the appearance of the donor-site linear scar was highly satisfactory (Figures 1d and 2b). The thinness of the fascial flap was appreciated by the patients, as they did not have any problem in wearing footwear. The flap developed protective sensations in the form of touch and pain. Dorsiflexion and plantar flexion at the ankle joint were near normal (Figures 4aed). Hypoaesthesia was noted in the distribution of sural nerve in one patient, which improved over 3 months. Tipe toe standing was almost equal to the normal side (Figure 5).
Discussion
Figure 3 Schematic diagram showing the parts of the turnover fascial flap based on the proximal end of the defect.
Compound defects of the Achilles tendon have always been a problem for the reconstructive surgeon. This has resulted in evaluation of different flaps in the search for the optimum technique. Vascularised fascia lata,4 free tensor fascia lata flap5 and deep fascia with lateral arm flap6 have been the microsurgical options. However, reconstruction by fascia lata does not return complete power to the tendon. In addition, the surgery is time consuming; the flaps are bulky and cause significant donor-site morbidity. Bipedicled VeY gastrocnemius myocutaneous flap,7 island medial plantar flap8 and reverse sural flap9 have been described as loco-
VeY gastrocnemius muscle slide with turnover fascial flap for compound Achilles defects
e409
Figure 4 (a,b). Case I e good dorsiflexion and plantar flexion of the left foot compared with the right foot. (c,d). Case II e good dorsiflexion and plantar flexion of the right foot compared with the left foot.
regional options but they give an unpleasant bulky sight, posing problems with footwear. They form a dog-ear with poor donor-site cosmesis. A second surgery in the form of debulking is usually required for both free and pedicled flaps. Fong et al. (1997) successfully used distally based fascial flaps on perforators of posterior tibial and peroneal artery for covering the soft-tissue defects over the Achilles tendon.10 However, the anatomical location of these flaps would not allow exposure of the gastrocnemius musculotendinous area for simultaneous tendon repair. There has been sparse literature regarding non-axial turnover fascial flaps. These flaps have been shown to be anatomically feasible in cadaver dissections.3 In this study, we have used them in two cases with a maximum defect of 9 4.5 cm. The fascial flaps were raised with an undissected base as wide as the defect and were
1 cm in length from the proximal margin of the defect. The largest flap measured 12 5 cm and the length:width ratio of 2.4:1 suitably covered the defect. The major technical advantage of such a flap was simultaneous exposure of the gastrocnemius muscle, which was slid in a VeY fashion to bridge the Achilles tendon defect. It also provided the desired function of the tendon gliding underneath. The depth of the inverted ‘V’ incision depends on the required advancement of the Achilles tendon, which, in turn, depends on the tendon gap. In our patients, we have incised the perimysium and the superficial muscle fibres on the belly of the gastrocnemius muscle up to a depth of 0.5 cm and have achieved an advancement of the Achilles tendon by 4 cm. However, in cases with larger tendon gaps, the muscle fibres may be incised to a greater depth, keeping in mind not to jeopardise the vascularity of the muscle. A fascial flap has a distinct advantage over other contemporary flaps as it appropriately fits the contour of the Achilles region, is technically easy, rapid and has sufficient vascularity to support a skin graft. It resists frictional forces caused by footwear and permits near complete movements of the foot. Moreover, the donor site can be closed primarily with only a linear scar showing. Both the patients had gratifying functional and aesthetic results after a follow-up of 15 months. Thus, with this technique, large flaps can sufficiently be raised with a wide base to cover small- toemedium-sized defects providing a reasonably simple solution for a difficult clinical entity.
Conflict of interest statement Figure 5 Case 1 standing on his toes, also showing slight hypoaesthesia over the distribution of sural nerve.
The authors do not have any financial and personal relationships with other people or organisations that could inappropriately influence their work.
e410
N.K. Agrawal, V. Bhattacharya University, Varanasi, for making the line diagram showing the parts of a turnover fascial flap.
References
Role of funding source There is no role of study sponsors, in the study design, in the collection, analysis and interpretation of data; in the writing of the manuscript; and in the decision to submit the manuscript for publication.
Acknowledgement We thank Mr. Aurobindo Kundu, Incharge, Art and Photo Section, Institute of Medical Sciences, Banaras Hindu
1. Lees V, Townsend PLG. Use of a pedicled fascial flap based on septocutaneous perforators of the posterior tibial artery for repair of distal lower limb defects. British Journal of Plastic Surgery 1992;45:141e5. 2. Worseq AP, Kuzbari R, Jahl G, et al. The vertically based deep fascia turnover flap of the leg: anatomic studies and clinical applications. Plast Reconstr Surg 1997 Dec;100: 1746e61. 3. Batchelor JS, McGuinness A. A reappraisal of axial and nonaxial lower leg fascial flaps: an anatomic study in human cadavers. Plast Reconstr Surg 1996 Apr;97:993e1000. 4. Kuo YR, Kuo MH, Chou WC, et al. One-stage reconstruction of soft tissue and Achilles tendon defects using a composite free anterolateral thigh flap with vascularized fascia lata: clinical experience and functional assessment. Ann Plast Surg 2003 Feb;50:149e55. 5. Dabernig J, Shilov B, Schumacher O, et al. Functional reconstruction of Achilles tendon defects combined with overlaying skin defects using a free tensor fasciae latae flap. J Plast Reconstr Aesthet Surg 2006;59:142e7. 6. Berthe JV, Toussaint D, Coessens BC. One-stage reconstruction of an infected skin and Achilles tendon defect with a composite distally planned lateral arm flap. Plast Reconstr Surg 1998 Oct; 102:1618e22. 7. Xu YQ, Zhu YL, Ysng J, et al. Bi-pedicled V-Y gastrocnemius myocutaneous flap for repairing Achilles tendon and overlying skin defect: the anatomic basis and clinical application. Chin J Traumatol 2007 Apr;10:77e81. 8. Taniguchi Y, Tamaki T. Reconstruction of the Achilles tendon and overlying skin defect with a medial plantar flap and tensor fasciae latae graft. J Reconstr Microsurg 2000 Aug;16: 423e5. 9. Bullocks JM, Hickey RM, Basu CB, et al. Single-stage reconstruction of Achilles tendon injuries and distal lower extremity soft tissue defects with the reverse sural fasciocutaneous flap. J Plast Reconstr Aesthet Surg 2008;61: 566e72. 10. Fong EP, Papini RPG, McKiernan MV, et al. Reconstruction of an Achilles tendon skin defect using a local fascial flap. European Journal of Plastic Surgery 1997 September;20.