INTRODUCTION
Soft-tissue defects around the foot and ankle have generally presented a difficult task to plastic surgeons.1-3 Coverage of the medial malleolus, medial foot dorsum has been particularly troublesome. Many type of local flaps have been described,2,4-6 but all with their own complications. A distally based adipofascial flap based on the perforator of the posterior tibia artery (PTA) was described by Lin et al.,7 but, they showed the use of the flap in relatively small defects with a short follow-up
period. Here, we report the use of this flap in large defects with a longer follow-up.
MATERIALS AND METHODS
Patients
Nine patients with soft tissue defects on the medial foot and ankle area from March 2009 to May 2014 underwent the procedure. Average age was 54-year-old (range, 8~82 years).
Male patients were 5 and women were 4. The causes of the
Diatally-Based Medial Crural Adipofascial Flap for Coverage of Medial Foot and Ankle
Min Bom Kim, Young Ho Lee*, Ho Sung Choi, Dong Hwan Kim, Jung Hyun Lee, Goo Hyun Baek
Department of Orthopaedic Surgery, Seoul National University Hospital, Seoul, Korea
CC This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright © 2015 by the Korean Society for Microsurgery. All Rights Reserved.
Received November 3, 2015 Revised November 23, 2015 Accepted November 24, 2015
*Correspondence to: Young Ho Lee Department of Orthopaedic Surgery, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea
Tel: +82-2-2072-4186 Fax: +82-2-764-2718 E-mail: [email protected]
Financial support: None.
Conflict of interest: None.
Purpose: We report on the clinical result after coverage of a soft tissue defect on the medial foot and ankle with an adipofascial flap based on the perforator from the posterior tibia artery.
Materials and Methods: Nine patients with soft tissue defects on the medial foot and ankle area from March 2009 to May 2014 underwent the procedure. Average age was 54 years old (range, 8~82 years). There were five male patients and four female patients.
The causes of the defect were trauma (4), tumor (3), and infection (2). The pivot point of transposition of this flap is the lower perforator originating from the posterior tibia artery.
The fatty tissue side of this flap could be used to resurface the defect. The donor site was closed primarily with the preserved skin, and a small caliber drain tube was used. The split- thickness skin graft was grafted to the flap and the wound. If the wound was still infected, this skin graft could be performed at a later date.
Results: All flaps survived and normal soft tissue coverage was obtained for the medial foot and ankle of all patients after the skin graft. Normal footwear was possible for all cases because of thin coverage. There was an extension contracture on the medial ray of the foot, which was resolved by contracture release and skin graft.
Conclusion: For the medial foot and ankle soft tissue defect, the medial crural adipofascial flap based on a perforator branch of the posterior tibia artery could be a good option to cover it.
Key Words: Soft tissue defect, Medial foot and ankle, Adipofascial flap, Posterior tibia artery, Perforator artery
ARMS
Archieves of Reconstructive Microsurgery http://dx.doi.org/10.15596/ARMS.2015.24.2.56defect were trauma (4), tumor (3), and infection (2). The defect size was 24 cm2 (range, 15~36 cm2) in average. The mechanism of trauma was high-energy injury caused by car-tire friction injury and traffic accidents. The infection was caused by post-surgical wound dehiscence. All wounds were located in the area of the medial malleolus and medial foot dorsum with exposure of the bone, tendon, or internal fixator device. All cases were collected and reviewed via EMR retrospectively.
Surgical procedure
Under general anesthesia, flaps were raised with tourniquet control. The PTA perforators were identified preoperatively with a hand-held Doppler, and marked to help plan the base of the flap (Fig. 1). With supine position, skin was prepared and ordinary surgical draping was performed. The flap design was marked with zigzag skin incision. The lowest perforator was selected among the PTA perforators. The length and width of the flap were decided by the length and width of the defect, for tension-free covering of the flap.
A skin incision was made in the midline of the marked flap design down to the adipose tissue. The skin edges were dissected in the sub-dermal plane leaving an adequate layer of adipose tissue attached to the developing skin flaps. This dissection was performed to just beyond the edge of the marked zone. With the skin flaps reflected, the adipofascial flap was then raised. Dissection started from incision of the fascia in a U shape. Dissection proceeded distally towards the base of the flap in the subfascial plane. Perforators that were not to be included in the flap were identified and cauterized with bipolar diathermy (Fig. 2A). The dissection continued to the base of the flap and the perforators to be retained were identified. The fascial incision was not extended all the way to the proximal margin of the defect. The flap was then turned over to cover the defect and the flap base so that the adipose tissue lay deep and the fascia became superficial (Fig. 2B). It is important to ensure that the flap can be inset without tension on the proximal
A B
Fig. 2. (A) Photo shows a reliable perforator from the posterior tibia artery after raising the adipofascial flap. (B) The flap covers the whole defect without tension and skin flaps of the donor site are reflected.
Fig. 1. Soft tissue defect on the anterior ankle with exposure of the tendons and bone. This always needs to be covered with adequate flap.
We tried to raise an adipofascial flap based a posterior tibia artery perforator branch.
perforator. The flap was sutured into position and the donor site was closed with a skin suture; suction drains were left in situ (Fig. 3).
An oily gauze dressing was applied to prevent the flap dry and the ankle was immobilized in a resting splint (Fig. 4). The patient remained on bed rest with no routine flap monitoring.
The flap was inspected 48 to 72 hours postoperatively, and the dressing lightened and the drains removed. The adipofascial flaps were covered with skin graft harvested from groin or thigh area after confirmation of wound maturation. Delayed skin graft was performed until the bed granulation became mature to enhance the skin graft survival. Patients were followed-up in the outpatient clinic to check the clinical outcome.
RESULTS
The results are summarized in Table 1. The defect size means the size after surgical debridement of the wound. All flaps were survived and normal soft tissue coverage was obtained for the medial foot and ankle of all patients after the skin graft. Patients recovered normal ambulation status without walking aids.
Wearing normal footwear was possible for all cases because of thin coverage around the medial foot and ankle. There was an extension contracture on the medial ray of the foot in the young female, which was resolved by contracture release and skin graft.
There were 4 cases which had partial skin necrosis in the skin flap of the flap donor site (Fig. 5). The wounds of the partial skin necrosis were resolved spontaneously without any efforts.
It turned to be a slight hypertrophic scar within the tolerable
Fig. 3. The donor site is sutured primarily after insetting the adipofascial flap. Suction drainage was planted.
Table 1. Summary of the patient and surgical outcomes
Case No. Gender/age (yr) Mechanism of injury Defect site Defect size (cm2) Flap outcome Timing of SG Complications
1 M/46 Tumor Med. malleolus 24 Survival Delayed Partial necrosis of donor site skin
2 F/72 Trauma Med. foot dorsum 26 Survival Delayed
3 F/8 Trauma Med. foot and ankle 36 Survival Delayed Extension contracture
4 M/82 Infection Med. malleolus 15 Survival Delayed Partial necrosis of donor site skin
5 F/69 Tumor Med. foot 16 Survival Delayed
6 M/53 Infection Ant. ankle 30 Survival Delayed Partial necrosis of donor site skin
7 M/73 Trauma Med. malleolus 32 Survival Delayed
8 F/63 Tumor Med. foot and ankle 16 Survival Delayed Partial necrosis of donor site skin
9 M/20 Trauma Med. malleolus 20 Survival Delayed
SG: skin graft, M: male, F: female, med.: medial.
Fig. 4. The adipofascial flap is dressed with antibiotics ointment- impregmented gauze to prevent to be dry.
appearance (Fig. 6).
Case illustrations
A 53-year-old male with soft tissue defect on the anterior ankle area after distal tibia trauma (Fig. 1; case 6) was referred to our hospital. An adipofascial flap with turned down pattern was raised immediately to cover the defect (Fig. 2). At 72 hours postoperatively the dressings were taken down, the graft looked healthy and the drains were removed. The skin flap of the donor site showed partial necrosis at tip of zigzag shape, but we managed it with conservative method (Fig. 5). At 3 months
postoperatively there was a well-healed donor site and the graft was mature and stable. He could wear normal footwear with thin flap coverage and he was satisfied with it (Fig. 6).
DISCUSSION
The merits of adipofascial flaps have been described by many authors. In recent years, authors have done much to popularize their work and have been some of the main advocates of its use in the lower limb.4,7,8 As a pedicled flap, there is no distant donor-site morbidity. The skin flaps from the donor site can be closed primarily. There have been no papers of wound dehiscence or total skin necrosis at the donor site; there is minimal sensory loss and a cosmetically acceptable scar.9
The adipofascial flap itself has many advantages over local fasciocutaneous or free flaps. The dissection is relatively easy and quick, remaining in the superficial planes of the leg only, thereby minimizing the risk of injury to major structures.8,10-12 The flap is malleable, readily recovering the natural contour of the leg.8,9 The fat tissue on the turned-over flap does not adhere to deep moving parts, so muscles and tendons move freely,9,12 and the fascial tissue accepts a skin graft.12 It has also been known that thinness of the flap maintains good deep protective coarse sensation, compared to other more bulky insensate flaps.4 The flap is used to cover exposed tendon, bone and internal device8,12-14 and has been reported to manage infection;15 it has also been used in cases of postoperative
A B
Fig. 6. (A) The ankle shows nearly normal appearance with minimal donor site morbidity. Skin flap area with partial necrosis healed with hypertrophic scar. (B) The anterior view of the ankle shows tolerable thickness of the flap coverage allowing the normal footwear.
Fig. 5. The adipoafascial flap survived with good granulation bed. The skin flap of the donor site shows partial necrosis, but we managed it conservatively.
wound problem, trauma and burns.1,14
Many authors insist that this flap yields a good cosmetic appearance at both the donor and recipient sites.4,8,9,11-13,16 This makes it very attractive for use in the lower leg. It is possible to identify the larger perforators by Doppler imaging, and this may help preoperative designing of the flap size. Subfascial plane dissection was performed, as suggested by Barclay et al.17 and Haertsch,3 preserving the prefascial plexus, which is usually the dominant plexus supplying the deep fascia.3,10
Both dermal and fascial plexi gain their blood supplies from perforators that are direct branches from one of the three main arteries in the lower leg.18 The procedure for the adipofascial flap is to divide the tissue between these plexi, leaving the dermal and subdermal plexi to supply the cutaneous flaps, which can be closed primarily, and the fascial plexi to feed for the fascia and adipose tissue of the flap. In a study of human lower limbs of cadavers, Batchelor and Moss10 described three peri-fascial vascular plexi. These were the sub-, intra- and pre-fascial plexi, which lie deep to, within and superficial to the deep fascia, respectively. All anastomose at the arteriolar level, but only the prefascial and subfascial plexi receive direct branches from the perforators, with dominant pre- fascial plexus.4,10,13,15,19,20 All three major vessels in the lower leg give off perforators. These reach the superficial tissues either by perforating the connective tissues between muscles (fasciocutaneous or septocutaneous perforators) or by directly perforating the muscle bellies (myocutaneous perforators).10,17 Medial flaps have been designed around the perforators of the posterior tibial artery. The five to seven perforator branches are located along a line joining the tibial tuberosity and the medial malleolus.21
For enhancement of the flap vascularity, and therefore to maximize its reliability, one should perhaps identify at least one, and preferably two, perforators in the base of the flap preoperatively, and dissect in the subfascial plane. The fasciocutaneous perforators are likely to be the dominant vascular supply to the flap, but blood flow is also received from surrounding fascial plexi4 through the base, and therefore, although this is an axially patterned flap, Lai et al.’s11 concept of base area may remain important in maintaining flow above the critical value.
We believe that this flap adds another choice to the surgeon’s armamentarium. It is consistent and can provide excellent
functional and cosmetic outcome, without significant donor- site morbidity. Raising the flap is easy and worth considering in difficult medial lower leg soft tissue defects in patients.
REFERENCES
1. Pontén B. The fasciocutaneous flap: its use in soft tissue defects of the lower leg. Br J Plast Surg 1981;34:215-20.
2. Morrison WA, Shen TY. Anterior tibial artery flap: anatomy and case report. Br J Plast Surg 1987;40:230-5.
3. Haertsch P. The surgical plane in the leg. Br J Plast Surg 1981;34:
464-9.
4. Lin SD, Lai CS, Chou CK, Tsai CW. The distally based posterior tibial arterial adipofascial flap. Br J Plast Surg 1992;45:284-7.
5. Donski PK, Fogdestam I. Distally based fasciocutaneous flap from the sural region. A preliminary report. Scand J Plast Reconstr Surg 1983;17:191-6.
6. Amarante J, Costa H, Reis J, Soares R. A new distally based fasciocutaneous flap of the leg. Br J Plast Surg 1986;39:338-40.
7. Lin SD, Chou CK, Lin TM, Wang HJ, Lai CS. The distally based lateral adipofascial flap. Br J Plast Surg 1998;51:96-102.
8. Lin SD, Lai CS, Chiu YT, Lin TM, Chou CK. Adipofascial flap of the lower leg based on the saphenous artery. Br J Plast Surg 1996;49:390-5.
9. Sarhadi NS, Quaba AA. Experience with the adipofascial turn- over flap. Br J Plast Surg 1993;46:307-13.
10. Batchelor JS, Moss AL. The relationship between fasciocutaneous perforators and their fascial branches: an anatomical study in human cadaver lower legs. Plast Reconstr Surg 1995;95:629-33.
11. Lai CS, Lin SD, Yang CC, Chou CK. Adipofascial turn-over flap for reconstruction of the dorsum of the foot. Br J Plast Surg 1991;44:170-4.
12. Lai CS, Lin SD, Chou CK, Tsai CW. Clinical application of adipofascial turn-over flaps for burn wounds. Burns 1993;19:73- 6.
13. Lin SD, Lai CS, Chou CK, Tsai CW, Tsai CC. Reconstruction of soft tissue defects of the lower leg with the distally based medial adipofascial flap. Br J Plast Surg 1994;47:132-7.
14. Lin SD, Lai CS, Tsai CC, Chou CK, Tsai CW. Clinical application of the distally based medial adipofascial flap for soft tissue defects on the lower half of the leg. J Trauma 1995;38:623-9.
15. Thatte RL, Laud N. The use of the fascia of the lower leg as a roll-over flap: its possible clinical applications in reconstructive surgery. Br J Plast Surg 1984;37:88-94.
16. Liu K, Li Z, Lin Y, Cao Y. The reverse-flow posterior tibial artery island flap: anatomic study and 72 clinical cases. Plast Reconstr Surg 1990;86:312-6.
17. Barclay TL, Cardoso E, Sharpe DT, Crockett DJ. Repair of lower leg injuries with fascio-cutaneous flaps. Br J Plast Surg 1982;35:
127-32.
18. Cormack GC, Lamberty BG. A classification of fascio-cutaneous
flaps according to their patterns of vascularisation. Br J Plast Surg 1984;37:80-7.
19. Schäfer K. Studies on angioarchitecture of the fascia (lower extremity). Z Anat Entwicklungsgesch 1972;139:21-54.
20. Pearl RM, Johnson D. The vascular supply to the skin: an
anatomical and physiological reappraisal: part I. Ann Plast Surg 1983;11:99-105.
21. Heymans O, Verhelle N, Peters S. The medial adiposofascial flap of the leg: anatomical basis and clinical applications. Plast Reconstr Surg 2005;115:793-801.
