0007 1?~6:90:0043
Brirlsh Journd o/Plasric Sqerv ( 1990). 43, 54 I-545 ((‘; 1990 The Trustees of British Association of Plastic Surgeons
0541:$10.00
Distally-based random fasciocutaneous flaps for multi-staged reconstruction of defects in the lower third of the leg, ankle and heel S. P. LAGVANKAR Department
of Burns and Plastic Surgery,
B.J. Medical
College and Civil Hospital,
Ahmedabad,
India
Summary-Distally-based random pattern fasciocutaneous flaps were used to reconstruct defects of the lower third of the leg, the ankle and the heel in eight patients. Though a multi-staged procedure, thissimplified fasciocutaneousflap design ensured safe transfer of tissue to defects in which it would otherwise have been very difficult to have obtained cover. This paper discusses the anatomical basis of the distally-based random pattern fasciocutaneous flaps and reviews the design, surgical technique, advantages, limitations and complications of these flaps.
Reconstruction in the lower third of the leg, ankle and heel is a difficult problem. Free tissue transfers can certainly cover defects in this region but not all centres have the facilities for microsurgery. Crossleg flaps are not an acceptable procedure for even co-operative patients as the technique involves immobilisation in an uncomfortable position. A number of distally-based fasciocutaneous flaps incorporating specific vessels have been described to cover defects in this region (Donski and Fogdestam, 1983; Amarante et al., 1986; Ferreira et al., 1986; Wee, 1986; Morrison and Shen, 1987; Rocha et ai., 1987). We have now developed a distally-based random fasciocutaneous flap for multi-staged reconstruction in this region. Basis, design and technique It has been documented by Haertsch (198 l), Barclay et al. (1982) and Carriquiry et al. (1985) that a large number of branches from the popliteal, anterior tibial. posterior tibia1 and peroneal vessels pierce the deep fascia of the leg, divide and anastomose with one another to form a rich vascular plexus just superficial to the fascia. Though the perforators divide in all directions, the general axis of the plexus is longitudinal. This suprafascial plexus supplies a number of branches to the overlying skin and subcutaneous tissue and forms the basis of fasciocutaneous flaps. From the successful use of the distally-based flaps, based on known vessels, two important 541
findings emerge. First, there are perforators in the leg as low as 5 cm above the tips of the malleoli, which supply the skin of the leg above. Second, the venous drainage of the flaps is sufficient to sustain them. It is also a well-known fact that there is a relative paucity of vessels in the lower third of the leg. The design of distally-based random fasciocutaneous flaps for reconstruction in this region is very simple but it involves a three-staged procedure. The base of the flap is always kept at the junction of the middle and lower third of the leg. The widthto-length ratio is maintained at 1 : 3. It is mandatory not to exceed this ratio or the vascularity of the flap is likely to be compromised. It is desirable to keep this 1: 3 ratio as a ratio less than that reduces the length of the flap and thereby reduces its reach. The flap extends proximally up to the knee joint line and can be planned on either side of the tibia. In the first of the three stages a marginal delay is done. This involves marking the flap, after careful planning-in-reverse, incising the flap margin down to the deep fascia and closing the wound. In the second stage, a week later, the flap is transferred to the defect. When it is to be transferred to the lower third of the leg, the flap is folded upon itself. but when it is transposed to the heel region it is turned over and rotated 180” along its long axis to allow inset into the defect. No attempt should be made to tube the flap as it leads to tension and ultimately results in vascular compromise. The donor defect and the exposed undersurface of the flap are
542
BRITISH JOURNAL
covered primarily by split thickness skin grafts. In the third stage the pedicle is divided 3 weeks after transfer, the carrier segment is returned and the final inset is made at the defect site. Clinical observations In the last 2 years, eight distally-based random fasciocutaneous flaps were used in eight patients for reconstruction in the lower third of the leg, the ankle and the heel. All these patients were males, whose ages ranged from 10 to 45 years; seven were aged between 20 and 45 years. All the patients except one had developed defects following roadside vehicular accidents. One patient (Table 1, Case 6) (Figs l-3) developed a defect in the lower third of the leg following electrical burns. Two patients were operated on as emergency cases and hence prior delay was not done. The other patients were operated on electively and the tissue transfer was completed in three stages. The width-to-length ratio was 1: 3 in all but one case, in whom it was 1:4. The flap width varied from 5 to 8 cm. Results These are summarised in Table 1. The first patient (Case 1) came immediately after injury with an exposed tendo achillis. The defect was covered successfully in two stages by a distally-based random fasciocutaneous flap, without prior delay. The second patient (Case 2) had exposed tendons in front of the ankle. The defect was covered as in Case 1 without prior delay, but the width-to-length ratio of this flap was 1:4 (5 x 20 cm) in the hope that it might include one of the perforators described by Carriquiry et al. (1985). Unfortunately the terminal 6.5 cm of the flap necrosed. When it
OF PLASTIC SURGERY
was excised on the 5th postoperative day the tendons were covered by granulation tissue and were split thickness grafted. Following this bitter experience, we started delaying the flap and restricting the width-to-length ratio to 1: 3 and this policy yielded good results in all but one patient. A patient (Case 4) with an exposed medial malleolus developed septic arthritis of the ankle joint after the flap was delayed and it took 16 days after the delay for the sepsis to come under control. The flap was then transferred but there was necrosis of one corner, exposing part of the medial malleolus. As the flap was bigger than the defect, it was possible to cover the exposed bone by readjusting it after the detachment. Case 3 is illustrated in Figures 446. Discussion The two cases with flap necrosis clearly show the need to delay the flap. It is a common experience (Barclay et al., 1982; Tolhurst et af., 1983) that random fasciocutaneous flaps with a width-tolength ratio of 1:3 are safe even if they are transferred without delay. However, for reconstruction in the lower third of the leg the transfer of a distally-based flap involves slight kinking as well as rotation along its long axis. This puts an extra demand on the vascularity of the flap, making the delay mandatory, therefore this procedure cannot be undertaken when the defect needs to be covered immediately. This is a disadvantage but it ensures the safe transfer of tissues to an area which otherwise is very difficult to cover. It is a very simple method and does not involve difficult dissection. A number of distally-based fasciocutaneous flaps based on specific vessels have been described but
Table 1 CCLW
Age
oflesion
Type of wound
Defect size (cm) horizontal x vertical
Flap size lcmi width x length
Result
Exposed
tendo achillis
5x5
6x 18
Good
Exposed
tendons
3.5 x 4
5 x 20
Necrosis Good
no.
Sex
(years)
Site
1
M M
2s
Heel
2
40
Anterior
3
M
45
Heel
Exposed
implant
5x 11
8 x 24
4
M
10
Medial malleolus
Exposed
tibia
2x3
5 x 15
Partial necrosis
5
M
25
Heel
Unstable
scar
6x7
7 x 21
Good Good
ankle
6
M
20
Lower third
Exposed
tibia
3.5 x 6
7 x 21
7
M
28
Lower third
Exposed
tibia
4 x 4.5
6x 18
Good
8
M
30
Heel
Unstable
scar
4.5 x6
7x21
Good
543
Fig. 1
Fig. 2
Fig. 3 Figure l-~-(Casr 6, Table I). Preoperative view of 20-year-old patient with exposed tibia in the lower third of the leg following electrical burns. Figure 2-Delayed distally-based fasciocutaneous flap transferred to the defect. (A) Anterior. (B) medial and (C) posterior views. Figure S Postoperative views. (A) One month after the pedicle was returned. (B) Final inset of flap.
544
BRITISH JOURNAL
Fig. 4
OF PLASTIC SURGERY
Fig. 5
Fig. 6 Figure 4-(Case 3, Table 1). Preoperative view of 45year-old patient with a defect of the heel, with an exposed implant and a delayed flap. Figure SPostoperative view 2 days after the flap was transferred to the defect. Figure &(A. B, C) Postoperative views 6 weeks after the final inset.
as the leg length and the location of the specific vessels vary in different individuals, these flaps are difficult to standardise. Besides, these vessels may be absent or of small calibre. Hence they require preoperative confirmation of location and size, which may involve invasive investigations like angiography (Rocha et al., 1987). Unlike the distally-based fasciocutaneous flaps based on anterior tibia1 vessels, this flap does not sacrifice these vessels which are very important for lower limb circulation. The random flap is safe even if the injury involves the anterior tibial, posterior tibia1
or dorsalis pedis vessels, lower down. However, it has a wider flap base than the axial flaps and its movement is, therefore, relatively restricted. Our experience of this simple and safe multistaged procedure adds one more flap to the surgeon’s armamentarium for the reconstruction of difficult defects in the lower leg, ankle and heel. References Amarante, J., Costa, H., Reis, J. and Soares, R. (1986). A new distally based fasciocutaneous flap of the leg. British Journal of Plastic Surgery, 39,338.
DISTALLY-BASED
RANDOM
FASCIOCUTANEOUS
FLAPS
Barclay, T. L., Cardoso, E., Sharpe, D. T. and Crockett, D. J. (1982). Repax of lower leg injuries with Fasciocutaneous Raps. British Jwrnul yf PiusticSurgery. 35, 121. Carriquiry, C., Costa, M. A. and Vasconez, L. 0. (1985). An anatomlc study of the septocutaneous vessels of the leg. Phzstic and Rrcomtructiw Surgery. 16. 354. Donski, P. K. and Fogdestam, 1. (1983). Distally-based fasciocutaneous flap from the sural region. Scandinakzn Journui o/ Plosttc and Reconstructive Surgery, 17. 191, Ferreira, M. C., Gabbianelli, G., Alonso, N. and Fontana, C. (1986). The distal pedicle fascia flap of the leg. LScandinaciun Journal of Plastic and Reconstructiw Surgery, 20, 133. Haertsch, P. (1981). The blood supply to the skin of the leg: a post-mortem investigation. British Journut’of Plastic Surgery. 34,470. Morrison, W. A. and Shen, T. Y. (1987). Anterior tibia1 artery flap: anatomy and case report. British Journul of P&tic Surgery. 40,230. Rocha, J. F. R., Gilbert, A., Masquelet, A., Yousif, N. J., Sanger, J. R. and Matloub, H. S. (1987). The anterior tibia1 artery flap: anatomic study and clinical application. Plastic und Rrcomtructiw Surgery. 19. 396.
545 Tolhurst, D. E., Haeseker, B. and Zeeman, R. J. (1983). The development of the fasciocutaneous flap and Its clinical applications. Plastic and Reconstructice Surgery. 71. 591 Wee, J. T. K. (1986). Reconstruction of the lower leg and foot with the reverse-pedicled anterior tibia1 flap : preliminary report of a new fasciocutaneous flap. .& Journal of Pkrytic Surgrrv, 39. 327.
The Author Shrikant, P. Lagvankar, MS. MCh, DNB, AssIstant Professor of Plastx Surgery. Department of Burns and Plastic Surgery. B.J. Medical College and Civil Hospital. Ahmedabad, India. Requests for reprints Government Colony, 380 052. India.
to: Dr Shrikant P. Lagvankar. D-4/70 Drive-in Road. Vastrapur. Ahmedabad
Paper received 7 November Accepted 5 March 1990.
1989.
Brirlsh Journd o/Plasric Sqerv ( 1990). 43, 54 I-545 ((‘; 1990 The Trustees of British Association of Plastic Surgeons
0541:$10.00
Distally-based random fasciocutaneous flaps for multi-staged reconstruction of defects in the lower third of the leg, ankle and heel S. P. LAGVANKAR Department
of Burns and Plastic Surgery,
B.J. Medical
College and Civil Hospital,
Ahmedabad,
India
Summary-Distally-based random pattern fasciocutaneous flaps were used to reconstruct defects of the lower third of the leg, the ankle and the heel in eight patients. Though a multi-staged procedure, thissimplified fasciocutaneousflap design ensured safe transfer of tissue to defects in which it would otherwise have been very difficult to have obtained cover. This paper discusses the anatomical basis of the distally-based random pattern fasciocutaneous flaps and reviews the design, surgical technique, advantages, limitations and complications of these flaps.
Reconstruction in the lower third of the leg, ankle and heel is a difficult problem. Free tissue transfers can certainly cover defects in this region but not all centres have the facilities for microsurgery. Crossleg flaps are not an acceptable procedure for even co-operative patients as the technique involves immobilisation in an uncomfortable position. A number of distally-based fasciocutaneous flaps incorporating specific vessels have been described to cover defects in this region (Donski and Fogdestam, 1983; Amarante et al., 1986; Ferreira et al., 1986; Wee, 1986; Morrison and Shen, 1987; Rocha et ai., 1987). We have now developed a distally-based random fasciocutaneous flap for multi-staged reconstruction in this region. Basis, design and technique It has been documented by Haertsch (198 l), Barclay et al. (1982) and Carriquiry et al. (1985) that a large number of branches from the popliteal, anterior tibial. posterior tibia1 and peroneal vessels pierce the deep fascia of the leg, divide and anastomose with one another to form a rich vascular plexus just superficial to the fascia. Though the perforators divide in all directions, the general axis of the plexus is longitudinal. This suprafascial plexus supplies a number of branches to the overlying skin and subcutaneous tissue and forms the basis of fasciocutaneous flaps. From the successful use of the distally-based flaps, based on known vessels, two important 541
findings emerge. First, there are perforators in the leg as low as 5 cm above the tips of the malleoli, which supply the skin of the leg above. Second, the venous drainage of the flaps is sufficient to sustain them. It is also a well-known fact that there is a relative paucity of vessels in the lower third of the leg. The design of distally-based random fasciocutaneous flaps for reconstruction in this region is very simple but it involves a three-staged procedure. The base of the flap is always kept at the junction of the middle and lower third of the leg. The widthto-length ratio is maintained at 1 : 3. It is mandatory not to exceed this ratio or the vascularity of the flap is likely to be compromised. It is desirable to keep this 1: 3 ratio as a ratio less than that reduces the length of the flap and thereby reduces its reach. The flap extends proximally up to the knee joint line and can be planned on either side of the tibia. In the first of the three stages a marginal delay is done. This involves marking the flap, after careful planning-in-reverse, incising the flap margin down to the deep fascia and closing the wound. In the second stage, a week later, the flap is transferred to the defect. When it is to be transferred to the lower third of the leg, the flap is folded upon itself. but when it is transposed to the heel region it is turned over and rotated 180” along its long axis to allow inset into the defect. No attempt should be made to tube the flap as it leads to tension and ultimately results in vascular compromise. The donor defect and the exposed undersurface of the flap are
542
BRITISH JOURNAL
covered primarily by split thickness skin grafts. In the third stage the pedicle is divided 3 weeks after transfer, the carrier segment is returned and the final inset is made at the defect site. Clinical observations In the last 2 years, eight distally-based random fasciocutaneous flaps were used in eight patients for reconstruction in the lower third of the leg, the ankle and the heel. All these patients were males, whose ages ranged from 10 to 45 years; seven were aged between 20 and 45 years. All the patients except one had developed defects following roadside vehicular accidents. One patient (Table 1, Case 6) (Figs l-3) developed a defect in the lower third of the leg following electrical burns. Two patients were operated on as emergency cases and hence prior delay was not done. The other patients were operated on electively and the tissue transfer was completed in three stages. The width-to-length ratio was 1: 3 in all but one case, in whom it was 1:4. The flap width varied from 5 to 8 cm. Results These are summarised in Table 1. The first patient (Case 1) came immediately after injury with an exposed tendo achillis. The defect was covered successfully in two stages by a distally-based random fasciocutaneous flap, without prior delay. The second patient (Case 2) had exposed tendons in front of the ankle. The defect was covered as in Case 1 without prior delay, but the width-to-length ratio of this flap was 1:4 (5 x 20 cm) in the hope that it might include one of the perforators described by Carriquiry et al. (1985). Unfortunately the terminal 6.5 cm of the flap necrosed. When it
OF PLASTIC SURGERY
was excised on the 5th postoperative day the tendons were covered by granulation tissue and were split thickness grafted. Following this bitter experience, we started delaying the flap and restricting the width-to-length ratio to 1: 3 and this policy yielded good results in all but one patient. A patient (Case 4) with an exposed medial malleolus developed septic arthritis of the ankle joint after the flap was delayed and it took 16 days after the delay for the sepsis to come under control. The flap was then transferred but there was necrosis of one corner, exposing part of the medial malleolus. As the flap was bigger than the defect, it was possible to cover the exposed bone by readjusting it after the detachment. Case 3 is illustrated in Figures 446. Discussion The two cases with flap necrosis clearly show the need to delay the flap. It is a common experience (Barclay et al., 1982; Tolhurst et af., 1983) that random fasciocutaneous flaps with a width-tolength ratio of 1:3 are safe even if they are transferred without delay. However, for reconstruction in the lower third of the leg the transfer of a distally-based flap involves slight kinking as well as rotation along its long axis. This puts an extra demand on the vascularity of the flap, making the delay mandatory, therefore this procedure cannot be undertaken when the defect needs to be covered immediately. This is a disadvantage but it ensures the safe transfer of tissues to an area which otherwise is very difficult to cover. It is a very simple method and does not involve difficult dissection. A number of distally-based fasciocutaneous flaps based on specific vessels have been described but
Table 1 CCLW
Age
oflesion
Type of wound
Defect size (cm) horizontal x vertical
Flap size lcmi width x length
Result
Exposed
tendo achillis
5x5
6x 18
Good
Exposed
tendons
3.5 x 4
5 x 20
Necrosis Good
no.
Sex
(years)
Site
1
M M
2s
Heel
2
40
Anterior
3
M
45
Heel
Exposed
implant
5x 11
8 x 24
4
M
10
Medial malleolus
Exposed
tibia
2x3
5 x 15
Partial necrosis
5
M
25
Heel
Unstable
scar
6x7
7 x 21
Good Good
ankle
6
M
20
Lower third
Exposed
tibia
3.5 x 6
7 x 21
7
M
28
Lower third
Exposed
tibia
4 x 4.5
6x 18
Good
8
M
30
Heel
Unstable
scar
4.5 x6
7x21
Good
543
Fig. 1
Fig. 2
Fig. 3 Figure l-~-(Casr 6, Table I). Preoperative view of 20-year-old patient with exposed tibia in the lower third of the leg following electrical burns. Figure 2-Delayed distally-based fasciocutaneous flap transferred to the defect. (A) Anterior. (B) medial and (C) posterior views. Figure S Postoperative views. (A) One month after the pedicle was returned. (B) Final inset of flap.
544
BRITISH JOURNAL
Fig. 4
OF PLASTIC SURGERY
Fig. 5
Fig. 6 Figure 4-(Case 3, Table 1). Preoperative view of 45year-old patient with a defect of the heel, with an exposed implant and a delayed flap. Figure SPostoperative view 2 days after the flap was transferred to the defect. Figure &(A. B, C) Postoperative views 6 weeks after the final inset.
as the leg length and the location of the specific vessels vary in different individuals, these flaps are difficult to standardise. Besides, these vessels may be absent or of small calibre. Hence they require preoperative confirmation of location and size, which may involve invasive investigations like angiography (Rocha et al., 1987). Unlike the distally-based fasciocutaneous flaps based on anterior tibia1 vessels, this flap does not sacrifice these vessels which are very important for lower limb circulation. The random flap is safe even if the injury involves the anterior tibial, posterior tibia1
or dorsalis pedis vessels, lower down. However, it has a wider flap base than the axial flaps and its movement is, therefore, relatively restricted. Our experience of this simple and safe multistaged procedure adds one more flap to the surgeon’s armamentarium for the reconstruction of difficult defects in the lower leg, ankle and heel. References Amarante, J., Costa, H., Reis, J. and Soares, R. (1986). A new distally based fasciocutaneous flap of the leg. British Journal of Plastic Surgery, 39,338.
DISTALLY-BASED
RANDOM
FASCIOCUTANEOUS
FLAPS
Barclay, T. L., Cardoso, E., Sharpe, D. T. and Crockett, D. J. (1982). Repax of lower leg injuries with Fasciocutaneous Raps. British Jwrnul yf PiusticSurgery. 35, 121. Carriquiry, C., Costa, M. A. and Vasconez, L. 0. (1985). An anatomlc study of the septocutaneous vessels of the leg. Phzstic and Rrcomtructiw Surgery. 16. 354. Donski, P. K. and Fogdestam, 1. (1983). Distally-based fasciocutaneous flap from the sural region. Scandinakzn Journui o/ Plosttc and Reconstructive Surgery, 17. 191, Ferreira, M. C., Gabbianelli, G., Alonso, N. and Fontana, C. (1986). The distal pedicle fascia flap of the leg. LScandinaciun Journal of Plastic and Reconstructiw Surgery, 20, 133. Haertsch, P. (1981). The blood supply to the skin of the leg: a post-mortem investigation. British Journut’of Plastic Surgery. 34,470. Morrison, W. A. and Shen, T. Y. (1987). Anterior tibia1 artery flap: anatomy and case report. British Journul of P&tic Surgery. 40,230. Rocha, J. F. R., Gilbert, A., Masquelet, A., Yousif, N. J., Sanger, J. R. and Matloub, H. S. (1987). The anterior tibia1 artery flap: anatomic study and clinical application. Plastic und Rrcomtructiw Surgery. 19. 396.
545 Tolhurst, D. E., Haeseker, B. and Zeeman, R. J. (1983). The development of the fasciocutaneous flap and Its clinical applications. Plastic and Reconstructice Surgery. 71. 591 Wee, J. T. K. (1986). Reconstruction of the lower leg and foot with the reverse-pedicled anterior tibia1 flap : preliminary report of a new fasciocutaneous flap. .& Journal of Pkrytic Surgrrv, 39. 327.
The Author Shrikant, P. Lagvankar, MS. MCh, DNB, AssIstant Professor of Plastx Surgery. Department of Burns and Plastic Surgery. B.J. Medical College and Civil Hospital. Ahmedabad, India. Requests for reprints Government Colony, 380 052. India.
to: Dr Shrikant P. Lagvankar. D-4/70 Drive-in Road. Vastrapur. Ahmedabad
Paper received 7 November Accepted 5 March 1990.
1989.
