RECONSTRUCTION OF THE LATERAL MALLEOLUS AND CALCANEUS REGION USING FREE THORACODORSAL ARTERY PERFORATOR FLAPS SANG WHA KIM, M.D.,1 DONG HYUN YOUN, M.D.,2 KYU TAE HWANG, M.D., Ph.D.,3 IL HOON SUNG, M.D., Ph.D.,3 JEONG TAE KIM, M.D., Ph.D.,2 and YOUN HWAN KIM, M.D., Ph.D.2*
Reconstruction of the lateral malleolus or calcaneus region is challenging because of poor vascularity, minimal presence of soft tissue, and difficulties with flap positioning during and after the operation. In many cases, local flaps are limited in terms of size, durability, and vascularity. Free tissue transfer can be useful for complicated wounds. We report here on the results of the reconstruction in this region using free thoracodorsal artery perforator flaps. Between October 2010 and October 2013, 16 cases of lateral malleolus or calcaneus defects were reconstructed using free thoracodorsal artery perforator flaps. The defects varied from 2 3 5 cm2 to 12 3 16 cm2, and the flaps from 3 3 5 cm2 to 10 3 15 cm2. Two cases were reconstructed using chimeric-pattern flaps. Only the superficial adipose layers were harvested for all the flaps, without further thinning or debulking process. Five cases with complications occurred, including three cases of partial necrosis of the flap and two cases of venous congestion caused by thrombosis and compression of the venous pedicle, and one flap was totally lost. The mean follow-up duration was 11.8 months. All the patients were able to wear shoes. All but one were able to walk. The thoracodorsal artery perforator flap can be made super-thin, allowing patients to wear shoes, and it can be harvested in a chimeric-pattern for complex defects. Therefore, it may represent a viable alternative choice for the reconstruction of the lateral C 2015 Wiley Periodicals, Inc. Microsurgery 00:000–000, 2015. malleolus and calcaneus region. V
The use of loco-regional and pedicle flaps based on perforators originating from the peroneal artery,1 lateral calsural artery,5–8 and lateral caneal artery,2–4 9,10 supramalleolar artery, and on the peroneus brevis muscle11–14 for the reconstruction of soft tissue defects of the foot and ankle has been documented in the literature. Many surgeons use these flaps in reliable reconstructive procedures for soft tissue injuries in the heel and lateral malleolus regions. However, the use of local or pedicle flaps is limited if the defect is large or complicated by severe traumatic damage, infection, or exposure of the tendons or bones. In addition to size and composition limitations, local or pedicle flaps may leave large scars on the exposed lower leg and require skin grafting for unclosed donor sites.1–3,9,10 Defects of the lateral malleolus and calcaneus region are often associated with bony fractures. In such cases, wide debridement of the injury zone must be performed, and this requires skin and soft tissue coverage exceeding the size of the defect. Moreover, for the internal fixation of plates and screws, 1 Department of Plastic and Reconstructive Surgery, The Catholic University of Korea, Seoul, Korea 2 Department of Plastic and Reconstructive Surgery, College of Medicine, Hanyang University, Seoul, Korea 3 Department of Orthopedic Surgery, College of Medicine, Hanyang University, Seoul, Korea *Correspondence to: Youn Hwan Kim, M.D., Department of Plastic and Reconstructive Surgery, School of Medicine, Hanyang University, 17 Haengdang-Dong, 133-792 Seongdong-Gu, Seoul, Korea. E-mail: [email protected] Sang Wha Kim is currently at Department of Plastic and Reconstructive Surgery, Seoul National University Hospital, Seoul, Korea. Received 14 April 2014; Revision accepted 19 January 2015; Accepted 22 January 2015 Published online 00 Month 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22389
Ó 2015 Wiley Periodicals, Inc.
large areas of skin and soft tissue are required to prevent device exposure.15–22 Free tissue transfer can be used in a wider spectrum of cases than loco-regional flaps, which makes it useful for the treatment of complicated wounds. There are few publications describing reconstruction of the lateral malleolus region and calcaneus defects using free flaps, such as the anterolateral thigh flap,16 medial sural artery perforator flap,17,18,23 and superficial circumflex iliac artery perforator flap.24,25 The free thoracodorsal artery perforator flap has been used for the various reconstruction from head and neck region to extremities.26–31 However, there are no reports utilizing the free thoracodorsal artery perforator flap for the reconstruction of lateral malleolus and calcaneus region. We report here the results of using free thoracodorsal artery perforator flaps to recreate the natural contouring in this region. PATIENTS AND METHODS
Between October 2010 and October 2013, 16 patients (3 women and 13 men; mean age 57-years old, ranging 18–73 years old) with soft tissue defects in the lateral malleolus region or the heel underwent reconstructive procedures using thoracodorsal artery perforator flaps. The cause of the defect was acute trauma in seven patients, infection in two patients, chronic ulceration after trauma in two patients, soft tissue necrosis after a burn injury in two patients, pressure sore in one patient with paraplegia, diabetic ulceration in one patient, and one chronic ulceration of unknown cause. The sizes of the defects ranged from 2 3 5 cm2 to 12 3 16 cm2. The characteristics of the patients are listed in Table 1.
73
73
46
28
67
53
73
73
65
73
45
71
18
26
73
50
M
F
M
M
F
M
F
M
M
M
M
M
M
M
M
M
Open fracture
Open fracture Open f racture Infection
Open fracture Infection
None
Open fracture Chronic ulceration Burn
Chronic ulceration
Open fracture Open fracture Unknown
DM
Sore
Cause of defect
Lateral malleolus Lateral malleolus Lateral malleolus Lateral malleolus Lateral malleolus
Lateral malleolus Heel
Lateral malleolus Lateral malleolus Heel
Lateral malleolus Lateral malleolus Heel
Lateral malleolus Heel
Heel
Location of defect
Epidural hemorrhage
RA Angina
None
None
HTN DM
HTN DM Heart failure COPD HTN DM Angina Infarction None
HTN congestive heart failure None
HTN Liver cirrhosis None
None
None
HTN DM RA
DM Infarction
Underlying disease
10x14
3x4
2x5 3x4
7x8
6x8
10x12
9x12
8x10
6x9
12x15
4x7
7x8
12x16
6x8
5x6
3x4
Size of the defect (cm)
8x13
4x4
3x63x 4
6x10
6x10
10x10
10x12
8x10
8x10
10x15
5x7
8 x10
10x15
6x9
5x7
3x5
Size of the flap (cm)
TDp
chimeric TDp TDp
TDp
TDp
TDp
TDp
chimeric TDp1SA TDp
TDp
TDp
TDp
TDp
TDp
TDp
TDp
Type
ATA,AV
ATA,AV
PTA,AV
ATA,AV
PTA,AV
PTA,AV
PTA,AV
ATA,AV
ATA,AV
PTA,AV
PTA,AV
ATA,AV
ATA,AV
PTA,AV
ATA,AV
PTA,AV
Recipient vessels
HTN: Hypertension. DM: Diabetes. RA: Rheumatoid arthritis. COPD: chronic obstructive pulmonary disease. TDp: thoracodorsal artery perforator flap. SA: serratus anterior flap. ATA: anterior tibial artery. PTA: posterior tibial artery. AV: accompanying vein. a Case 1 patient could wear shoes with assistance, however he could not walk due to cerebral infarction after operation.
Age (years)
Sex
135
165
190
265
155
210
165
200
210
315
215
180
245
220
315
230
Operation time (min)
Table 1. Summary of Patient Characteristics
Primary closure Primary closure Primary closure Primary closure Primary closure Primary closure Primary closure Primary closure Primary closure Primary closure
Primary closure Primary closure Primary closure Primary closure Primary closure Primary closure
Donor site
Partial necrosis
None
None
None
Venous congestion None
None
None
Venous congestion Total loss Partial necrosis None
None
Partial necrosis None
None
None
Complication
4
2
6
4
3
2
11
6
13
14
15
17
8
24
31
29
Follow up (months)
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Wearing shoes
With Walk aid
Yes
Yes
Yes
Yes
With walking aid Yes
Yes
With walking aid Yes
Yes
Yes
Yes
Yes
Yes
Noa
Ambulation
Lateral Malleolus and Calcaneus Region Reconstruction
Surgical Technique
Before the operations, all patients underwent computed tomographic angiography to confirm their vascular status. If the wound required serial debridement, a negative-pressure dressing was applied for 2–3 weeks between debridement procedures, until the wound was clear and prepared for coverage. To harvest free thoracodorsal artery perforator flaps, patients were placed in a supine position with the arm abducted and elevated. An incision was made along the midline between the border of the pectoralis major and latissimus dorsi (LD) muscles. To avoid missing very small perforators, traction and counter-traction were applied. If no perforators piercing the LD muscle were found, septocutaneous or direct cutaneous perforators were often located instead. The branch of the thoracodorsal artery perforator pedicle that entered the perforators to the skin paddles was dissected. If muscle component was required, the other branches of the thoracodorsal artery, such as transverse branches feeding the latissimus dorsi muscle, could be harvested with latissimus dorsi muscle flaps. In addition, a serratus anterior muscle flap could be harvested with the same vascular pedicle, which drained into the subscapular arterial system via the thoracodorsal vessels. After identifying suitable vessels for the flap, an outline appropriate for the defect size was made. The flap was then harvested in the caudocephalic direction. We ensured that the pedicle length was at least 15 cm, which was sufficient for any locations of the recipient vessels. If a thin flap was required, the flap included only the superficial adipose layers, and the deep adipose layers were removed. Micro-anastomosis was performed after insetting the flap into the defect. The anterior tibial or posterior tibial artery was identified as the recipient vessel. The anastomosis was completed using 9-0 sutures, and primary closure of the entire donor site was completed. RESULTS
The dimensions of the flaps from 3 3 5 cm2 to 10 3 15 cm2. Chimeric-pattern flaps were used in two cases, one with two skin paddles using two separate thoracodorsal artery perforators and the other using a thoracodorsal artery perforator flap and a serratus anterior flap. The recipient vessel was the anterior tibial artery in eight cases and the posterior tibial artery in the remaining eight cases. Only the superficial adipose layers were harvested for all the flaps, and no further tinning or debulking was performed. The mean operation time was 213 min (ranging 135–315 min). All the donor sites were closed primarily. There were five cases with complications, including two cases of venous congestion and three cases of partial
3
necrosis of the flap. In one case of venous congestion, a vein was blocked by a thrombus, and a greater saphenous vein graft was used for salvaging. The flap survived without further complications. In the other case of venous congestion, the flap was totally lost because of the compression of the vein. The salvage procedure was too late and the venous congestion already proceeded to the capillary level. Therefore the falp was replaced by a serratus anterior muscle flap with a split-thickness skin graft. In the three cases of partial loss of the flap, necrotic tissue was removed and the regions was covered with a split-thickness skin graft. No complications were related to the use of chimeric-pattern flaps or to the thinning procedure. The mean follow-up duration was 11.8 months (ranging 2–31 months). All the patients were satisfied with the functional and aesthetic results. During the follow-up period, all the patients were able to wear shoes, and no debulking procedures were required. One patient was able to wear shoes but could not walk because of cerebral infarction. However, all the other patients were able to walk, and only three patients among them required walking aids. CASE REPORTS Case 1
A 73-year-old man presented with a 5 3 4 cm2 overgranulated wound with hyperkeratosis of the lateral malleolus of the left ankle (Fig. 1a). There was no underlying disease. The wound originated from a trauma with a nail that had occurred 10 years before, and a small defect had persisted. The region had been injured again 5 months before the presentation, and the size of the wound had increased as a result. In the initial operation, the entire hyperkeratotic mass was removed, leaving an 8 3 10 cm2 deep defect that included the joint space (Fig. 1b). A negative-pressure wound dressing system was applied for 8 days. A chimeric-type flap consisting of an 8 x 10 cm thoracodorsal artery perforator flap and a 3 3 3 cm2 serratus anterior muscle flap was then harvested (Fig. 1c). The serratus anterior muscle was packed into the joint space defect, and the thoracodorsal artery perforator flap was resurfaced over the serratus anterior muscle. The flap was anastomosed to the anterior tibial artery. Primary closure of the donor site was performed. The flap survived; the patient started to walk 2 weeks later and was discharged after 20 days (Fig. 1d). On the 13-months follow-up, the patient was able to wear shoes and walk without aid. Case 2
A 26-year-old man had suffered an open fracture of the calcaneus, which had been treated at a local hospital Microsurgery DOI 10.1002/micr
4
Kim et al.
Figure 1. (a) An over-granulated wound with hyperkeratosis of the lateral malleolus of the left ankle. (b) After debridement, an 8 3 10 cm2 deep defect remained and the joint space was exposed. (c) A chimeric-type flap including the thoracodorsal artery perforator flap and the serratus anterior muscle was harvested. (d) The serratus anterior muscle was packed into the defect, and the thoracodorsal artery perforator flap was resurfaced over the muscle.
by open reduction and internal fixation with a titanium plate and screws. An open wound penetrating the calcaneus had been present in the medial and lateral aspects of the hind foot. The fixation site and medial wound had not healed, and the fixed plate had been exposed. When the patient came to our hospital after 3 months, there was a 3 3 3 cm2 skin defect in the lateral aspect of the hind foot with exposure of the plate and the presence of methicillin-resistant Staphylococcus epidermidis infection (Fig. 2a). A 2 3 2 cm2 skin defect with a large dead space was present in the medial aspect of the hind foot (Fig. 2b). To cover both defects, a thoracodorsal artery perforator chimeric flap, comprising 3 3 4 cm2 and 3 3 6 cm2 skin flaps, was harvested (Figs. 2c–2e). The arterial and venous pedicles were anastomosed to the posterior tibial artery and accompanying vein. The flap was survived without any complications. After 6 months of follow-up, the patient was able to wear shoes and walk without further intervention (Fig. 2f). Microsurgery DOI 10.1002/micr
DISCUSSION
The lateral malleolus and calcaneus region is critical for ambulation,21 with many important structures, such as the Achilles tendon, ankle joint, and distal tibia and fibula, providing functional stability.9 However, this region has no muscle coverage.10 Instead, a thin, pliable, and immobile envelope of skin provides protection for the important structures.18 Moreover, there is no major blood flow in the area.21 Branches of three main arteries supply the region, and a lack of circulation in the skin envelope can result in skin necrosis.1,15 Taking into account the above considerations, defects of the lateral malleolus region should therefore be reconstructed promptly and carefully.32 In patients with arterial insufficiency, diabetes, or paraplegia, even a small lesion can become refractory and quickly worsen.1 Loco-regional flaps, including the random pattern rotation flap, perforator-based island flap, propeller flap, and sural artery flap, have been introduced.14,32,33 These flaps have the advantage of being
Lateral Malleolus and Calcaneus Region Reconstruction
5
Figure 2. (a,b) A 3 3 3 cm2 and a 2 3 2 cm2 open wound with device exposure caused by open calcaneal fracture. (a) Lateral and (b) medial views of the wound. (c) A thoracodorsal artery perforator chimeric flap with two skin paddles was harvested. (d,e) An immediate postoperative view of the (d) lateral and (e) medial regions.(f) Six months after the surgery, the flap covered the defect completely in both regions, with no need for a debulking procedure.
easy to elevate, thus saving operation time and preserving major vessels.9,14,32 However, there are limitations to the size and location of these flaps, which can necessitate additional surgical procedures.1,9,10,18,34 The random location of perforators in these regions can result in a flap that has poor vascularity and circulation around the wound1 and is vulnerable to pressure, friction, and shearing forces.3,34 Therefore, even minor complications, such
as wound dehiscence and inflammation, can lead to inadequate coverage and partial necrosis of the flap,15,21 prolonging treatment and hospitalization and delaying rehabilitation. An effective technique must be found for the treatment of various defects in such cases. Free flaps are the last choice for the reconstruction of complex and large defects.33 Perforator flaps have recently been proposed for resurfacing the extremities Microsurgery DOI 10.1002/micr
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Kim et al.
because of their thinness and pliability and minimal donor site morbidity. Several studies have described the use of thin perforator flaps, such as the anterolateral thigh flap,16,35–37 medial sural artery perforator flap,17–19,23 superficial circumflex iliac artery perforator flap,24,25 and thoracodorsal artery perforator flap.26,27 However, there have been few studies of hind foot reconstruction, especially in the lateral malleolus and calcaneus region. An ideal flap for this region must possess certain characteristics. First, it has to be super-thin to allow the patient to wear shoes.21 Coverage of the wound alone does not solve the problems of ambulation and returning to work; the subject also needs to be able to wear a suitable shoe on the reconstructed foot.34 If a flap is bulky and difficult to shape, several stages of debulking and adjustments are required, which delays rehabilitation and ambulation. Reconstruction in a single step using a thin and pliable flap is ideal for foot resurfacing. Second, complex reconstruction is often required. Defects involving the bones or joints can be major, especially in cases of trauma or chronic infection. Such defects require complex reconstruction using multiple components and obliteration of dead space.10 If necessary, a muscle flap should be harvested together with the skin flap to provide sufficient blood supply for bone healing in complicated wounds with fractures and osteomyelitis.5 In contrast, as in one of the cases described above, separate skin flaps may be required to resurface two separate defects. Third, a long vascular pedicle is needed. There are few suitable recipient vessels around the lateral malleolus and calcaneus region. The lateral malleolus region is supplied only by the lateral calcaneal artery, lateral tarsal artery, lateral malleolar artery,22 and additional small branches of the anterior tibial artery, posterior tibial artery, and peroneal artery. Moreover, the surrounding vessels are often affected by the trauma or chronic infection.18 Anastomosis outside the injury zone is mandatory for successful reconstruction. Fourth, donor site morbidity should be taken into account. Perforator flaps have fewer donor site problems than conventional flaps. However, some donor sites require skin grafts, whereas others require the main vessel to be sacrificed to obtain an appropriate pedicle.9,18 In this regard, the superficial circumflex iliac artery free flap is limited in size, which makes it suitable only for small defects, and has a short pedicle length. This makes it inappropriate for complex reconstructions. Harvesting of the sural artery perforator free flap is associated with scarring at the donor site, which can be unacceptable in female patients or children.18 An equivalent result can be achieved with other flaps. In particular, harvesting of the anterolateral thigh flap or thoracodorsal artery perforator flap leaves a donor site defect in the Microsurgery DOI 10.1002/micr
thigh or axilla that can easily be hidden by clothing. The sural artery perforator free flap is a thin flap that permits freedom of positioning, but it is less likely to be chosen because of the cosmetic problems described above. The anterolateral thigh free flap35–37 and free thoracodorsal artery perforator flap26,27 satisfy the criteria for lateral malleolus reconstruction. Both are large and can be harvested safely even when only a single perforator is available. A vascular pedicle up to 10 cm in length can be obtained, depending on the location and diameter of the recipient vessel. In addition, a super-thin flap can be acquired by excluding the deep adipose layer during flap harvesting. The perforator flap with only a superficial adipose layer can be further thinned to
Reconstruction of the lateral malleolus or calcaneus region is challenging because of poor vascularity, minimal presence of soft tissue, and difficulties with flap positioning during and after the operation. In many cases, local flaps are limited in terms of size, durability, and vascularity. Free tissue transfer can be useful for complicated wounds. We report here on the results of the reconstruction in this region using free thoracodorsal artery perforator flaps. Between October 2010 and October 2013, 16 cases of lateral malleolus or calcaneus defects were reconstructed using free thoracodorsal artery perforator flaps. The defects varied from 2 3 5 cm2 to 12 3 16 cm2, and the flaps from 3 3 5 cm2 to 10 3 15 cm2. Two cases were reconstructed using chimeric-pattern flaps. Only the superficial adipose layers were harvested for all the flaps, without further thinning or debulking process. Five cases with complications occurred, including three cases of partial necrosis of the flap and two cases of venous congestion caused by thrombosis and compression of the venous pedicle, and one flap was totally lost. The mean follow-up duration was 11.8 months. All the patients were able to wear shoes. All but one were able to walk. The thoracodorsal artery perforator flap can be made super-thin, allowing patients to wear shoes, and it can be harvested in a chimeric-pattern for complex defects. Therefore, it may represent a viable alternative choice for the reconstruction of the lateral C 2015 Wiley Periodicals, Inc. Microsurgery 00:000–000, 2015. malleolus and calcaneus region. V
The use of loco-regional and pedicle flaps based on perforators originating from the peroneal artery,1 lateral calsural artery,5–8 and lateral caneal artery,2–4 9,10 supramalleolar artery, and on the peroneus brevis muscle11–14 for the reconstruction of soft tissue defects of the foot and ankle has been documented in the literature. Many surgeons use these flaps in reliable reconstructive procedures for soft tissue injuries in the heel and lateral malleolus regions. However, the use of local or pedicle flaps is limited if the defect is large or complicated by severe traumatic damage, infection, or exposure of the tendons or bones. In addition to size and composition limitations, local or pedicle flaps may leave large scars on the exposed lower leg and require skin grafting for unclosed donor sites.1–3,9,10 Defects of the lateral malleolus and calcaneus region are often associated with bony fractures. In such cases, wide debridement of the injury zone must be performed, and this requires skin and soft tissue coverage exceeding the size of the defect. Moreover, for the internal fixation of plates and screws, 1 Department of Plastic and Reconstructive Surgery, The Catholic University of Korea, Seoul, Korea 2 Department of Plastic and Reconstructive Surgery, College of Medicine, Hanyang University, Seoul, Korea 3 Department of Orthopedic Surgery, College of Medicine, Hanyang University, Seoul, Korea *Correspondence to: Youn Hwan Kim, M.D., Department of Plastic and Reconstructive Surgery, School of Medicine, Hanyang University, 17 Haengdang-Dong, 133-792 Seongdong-Gu, Seoul, Korea. E-mail: [email protected] Sang Wha Kim is currently at Department of Plastic and Reconstructive Surgery, Seoul National University Hospital, Seoul, Korea. Received 14 April 2014; Revision accepted 19 January 2015; Accepted 22 January 2015 Published online 00 Month 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22389
Ó 2015 Wiley Periodicals, Inc.
large areas of skin and soft tissue are required to prevent device exposure.15–22 Free tissue transfer can be used in a wider spectrum of cases than loco-regional flaps, which makes it useful for the treatment of complicated wounds. There are few publications describing reconstruction of the lateral malleolus region and calcaneus defects using free flaps, such as the anterolateral thigh flap,16 medial sural artery perforator flap,17,18,23 and superficial circumflex iliac artery perforator flap.24,25 The free thoracodorsal artery perforator flap has been used for the various reconstruction from head and neck region to extremities.26–31 However, there are no reports utilizing the free thoracodorsal artery perforator flap for the reconstruction of lateral malleolus and calcaneus region. We report here the results of using free thoracodorsal artery perforator flaps to recreate the natural contouring in this region. PATIENTS AND METHODS
Between October 2010 and October 2013, 16 patients (3 women and 13 men; mean age 57-years old, ranging 18–73 years old) with soft tissue defects in the lateral malleolus region or the heel underwent reconstructive procedures using thoracodorsal artery perforator flaps. The cause of the defect was acute trauma in seven patients, infection in two patients, chronic ulceration after trauma in two patients, soft tissue necrosis after a burn injury in two patients, pressure sore in one patient with paraplegia, diabetic ulceration in one patient, and one chronic ulceration of unknown cause. The sizes of the defects ranged from 2 3 5 cm2 to 12 3 16 cm2. The characteristics of the patients are listed in Table 1.
73
73
46
28
67
53
73
73
65
73
45
71
18
26
73
50
M
F
M
M
F
M
F
M
M
M
M
M
M
M
M
M
Open fracture
Open fracture Open f racture Infection
Open fracture Infection
None
Open fracture Chronic ulceration Burn
Chronic ulceration
Open fracture Open fracture Unknown
DM
Sore
Cause of defect
Lateral malleolus Lateral malleolus Lateral malleolus Lateral malleolus Lateral malleolus
Lateral malleolus Heel
Lateral malleolus Lateral malleolus Heel
Lateral malleolus Lateral malleolus Heel
Lateral malleolus Heel
Heel
Location of defect
Epidural hemorrhage
RA Angina
None
None
HTN DM
HTN DM Heart failure COPD HTN DM Angina Infarction None
HTN congestive heart failure None
HTN Liver cirrhosis None
None
None
HTN DM RA
DM Infarction
Underlying disease
10x14
3x4
2x5 3x4
7x8
6x8
10x12
9x12
8x10
6x9
12x15
4x7
7x8
12x16
6x8
5x6
3x4
Size of the defect (cm)
8x13
4x4
3x63x 4
6x10
6x10
10x10
10x12
8x10
8x10
10x15
5x7
8 x10
10x15
6x9
5x7
3x5
Size of the flap (cm)
TDp
chimeric TDp TDp
TDp
TDp
TDp
TDp
chimeric TDp1SA TDp
TDp
TDp
TDp
TDp
TDp
TDp
TDp
Type
ATA,AV
ATA,AV
PTA,AV
ATA,AV
PTA,AV
PTA,AV
PTA,AV
ATA,AV
ATA,AV
PTA,AV
PTA,AV
ATA,AV
ATA,AV
PTA,AV
ATA,AV
PTA,AV
Recipient vessels
HTN: Hypertension. DM: Diabetes. RA: Rheumatoid arthritis. COPD: chronic obstructive pulmonary disease. TDp: thoracodorsal artery perforator flap. SA: serratus anterior flap. ATA: anterior tibial artery. PTA: posterior tibial artery. AV: accompanying vein. a Case 1 patient could wear shoes with assistance, however he could not walk due to cerebral infarction after operation.
Age (years)
Sex
135
165
190
265
155
210
165
200
210
315
215
180
245
220
315
230
Operation time (min)
Table 1. Summary of Patient Characteristics
Primary closure Primary closure Primary closure Primary closure Primary closure Primary closure Primary closure Primary closure Primary closure Primary closure
Primary closure Primary closure Primary closure Primary closure Primary closure Primary closure
Donor site
Partial necrosis
None
None
None
Venous congestion None
None
None
Venous congestion Total loss Partial necrosis None
None
Partial necrosis None
None
None
Complication
4
2
6
4
3
2
11
6
13
14
15
17
8
24
31
29
Follow up (months)
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Wearing shoes
With Walk aid
Yes
Yes
Yes
Yes
With walking aid Yes
Yes
With walking aid Yes
Yes
Yes
Yes
Yes
Yes
Noa
Ambulation
Lateral Malleolus and Calcaneus Region Reconstruction
Surgical Technique
Before the operations, all patients underwent computed tomographic angiography to confirm their vascular status. If the wound required serial debridement, a negative-pressure dressing was applied for 2–3 weeks between debridement procedures, until the wound was clear and prepared for coverage. To harvest free thoracodorsal artery perforator flaps, patients were placed in a supine position with the arm abducted and elevated. An incision was made along the midline between the border of the pectoralis major and latissimus dorsi (LD) muscles. To avoid missing very small perforators, traction and counter-traction were applied. If no perforators piercing the LD muscle were found, septocutaneous or direct cutaneous perforators were often located instead. The branch of the thoracodorsal artery perforator pedicle that entered the perforators to the skin paddles was dissected. If muscle component was required, the other branches of the thoracodorsal artery, such as transverse branches feeding the latissimus dorsi muscle, could be harvested with latissimus dorsi muscle flaps. In addition, a serratus anterior muscle flap could be harvested with the same vascular pedicle, which drained into the subscapular arterial system via the thoracodorsal vessels. After identifying suitable vessels for the flap, an outline appropriate for the defect size was made. The flap was then harvested in the caudocephalic direction. We ensured that the pedicle length was at least 15 cm, which was sufficient for any locations of the recipient vessels. If a thin flap was required, the flap included only the superficial adipose layers, and the deep adipose layers were removed. Micro-anastomosis was performed after insetting the flap into the defect. The anterior tibial or posterior tibial artery was identified as the recipient vessel. The anastomosis was completed using 9-0 sutures, and primary closure of the entire donor site was completed. RESULTS
The dimensions of the flaps from 3 3 5 cm2 to 10 3 15 cm2. Chimeric-pattern flaps were used in two cases, one with two skin paddles using two separate thoracodorsal artery perforators and the other using a thoracodorsal artery perforator flap and a serratus anterior flap. The recipient vessel was the anterior tibial artery in eight cases and the posterior tibial artery in the remaining eight cases. Only the superficial adipose layers were harvested for all the flaps, and no further tinning or debulking was performed. The mean operation time was 213 min (ranging 135–315 min). All the donor sites were closed primarily. There were five cases with complications, including two cases of venous congestion and three cases of partial
3
necrosis of the flap. In one case of venous congestion, a vein was blocked by a thrombus, and a greater saphenous vein graft was used for salvaging. The flap survived without further complications. In the other case of venous congestion, the flap was totally lost because of the compression of the vein. The salvage procedure was too late and the venous congestion already proceeded to the capillary level. Therefore the falp was replaced by a serratus anterior muscle flap with a split-thickness skin graft. In the three cases of partial loss of the flap, necrotic tissue was removed and the regions was covered with a split-thickness skin graft. No complications were related to the use of chimeric-pattern flaps or to the thinning procedure. The mean follow-up duration was 11.8 months (ranging 2–31 months). All the patients were satisfied with the functional and aesthetic results. During the follow-up period, all the patients were able to wear shoes, and no debulking procedures were required. One patient was able to wear shoes but could not walk because of cerebral infarction. However, all the other patients were able to walk, and only three patients among them required walking aids. CASE REPORTS Case 1
A 73-year-old man presented with a 5 3 4 cm2 overgranulated wound with hyperkeratosis of the lateral malleolus of the left ankle (Fig. 1a). There was no underlying disease. The wound originated from a trauma with a nail that had occurred 10 years before, and a small defect had persisted. The region had been injured again 5 months before the presentation, and the size of the wound had increased as a result. In the initial operation, the entire hyperkeratotic mass was removed, leaving an 8 3 10 cm2 deep defect that included the joint space (Fig. 1b). A negative-pressure wound dressing system was applied for 8 days. A chimeric-type flap consisting of an 8 x 10 cm thoracodorsal artery perforator flap and a 3 3 3 cm2 serratus anterior muscle flap was then harvested (Fig. 1c). The serratus anterior muscle was packed into the joint space defect, and the thoracodorsal artery perforator flap was resurfaced over the serratus anterior muscle. The flap was anastomosed to the anterior tibial artery. Primary closure of the donor site was performed. The flap survived; the patient started to walk 2 weeks later and was discharged after 20 days (Fig. 1d). On the 13-months follow-up, the patient was able to wear shoes and walk without aid. Case 2
A 26-year-old man had suffered an open fracture of the calcaneus, which had been treated at a local hospital Microsurgery DOI 10.1002/micr
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Figure 1. (a) An over-granulated wound with hyperkeratosis of the lateral malleolus of the left ankle. (b) After debridement, an 8 3 10 cm2 deep defect remained and the joint space was exposed. (c) A chimeric-type flap including the thoracodorsal artery perforator flap and the serratus anterior muscle was harvested. (d) The serratus anterior muscle was packed into the defect, and the thoracodorsal artery perforator flap was resurfaced over the muscle.
by open reduction and internal fixation with a titanium plate and screws. An open wound penetrating the calcaneus had been present in the medial and lateral aspects of the hind foot. The fixation site and medial wound had not healed, and the fixed plate had been exposed. When the patient came to our hospital after 3 months, there was a 3 3 3 cm2 skin defect in the lateral aspect of the hind foot with exposure of the plate and the presence of methicillin-resistant Staphylococcus epidermidis infection (Fig. 2a). A 2 3 2 cm2 skin defect with a large dead space was present in the medial aspect of the hind foot (Fig. 2b). To cover both defects, a thoracodorsal artery perforator chimeric flap, comprising 3 3 4 cm2 and 3 3 6 cm2 skin flaps, was harvested (Figs. 2c–2e). The arterial and venous pedicles were anastomosed to the posterior tibial artery and accompanying vein. The flap was survived without any complications. After 6 months of follow-up, the patient was able to wear shoes and walk without further intervention (Fig. 2f). Microsurgery DOI 10.1002/micr
DISCUSSION
The lateral malleolus and calcaneus region is critical for ambulation,21 with many important structures, such as the Achilles tendon, ankle joint, and distal tibia and fibula, providing functional stability.9 However, this region has no muscle coverage.10 Instead, a thin, pliable, and immobile envelope of skin provides protection for the important structures.18 Moreover, there is no major blood flow in the area.21 Branches of three main arteries supply the region, and a lack of circulation in the skin envelope can result in skin necrosis.1,15 Taking into account the above considerations, defects of the lateral malleolus region should therefore be reconstructed promptly and carefully.32 In patients with arterial insufficiency, diabetes, or paraplegia, even a small lesion can become refractory and quickly worsen.1 Loco-regional flaps, including the random pattern rotation flap, perforator-based island flap, propeller flap, and sural artery flap, have been introduced.14,32,33 These flaps have the advantage of being
Lateral Malleolus and Calcaneus Region Reconstruction
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Figure 2. (a,b) A 3 3 3 cm2 and a 2 3 2 cm2 open wound with device exposure caused by open calcaneal fracture. (a) Lateral and (b) medial views of the wound. (c) A thoracodorsal artery perforator chimeric flap with two skin paddles was harvested. (d,e) An immediate postoperative view of the (d) lateral and (e) medial regions.(f) Six months after the surgery, the flap covered the defect completely in both regions, with no need for a debulking procedure.
easy to elevate, thus saving operation time and preserving major vessels.9,14,32 However, there are limitations to the size and location of these flaps, which can necessitate additional surgical procedures.1,9,10,18,34 The random location of perforators in these regions can result in a flap that has poor vascularity and circulation around the wound1 and is vulnerable to pressure, friction, and shearing forces.3,34 Therefore, even minor complications, such
as wound dehiscence and inflammation, can lead to inadequate coverage and partial necrosis of the flap,15,21 prolonging treatment and hospitalization and delaying rehabilitation. An effective technique must be found for the treatment of various defects in such cases. Free flaps are the last choice for the reconstruction of complex and large defects.33 Perforator flaps have recently been proposed for resurfacing the extremities Microsurgery DOI 10.1002/micr
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because of their thinness and pliability and minimal donor site morbidity. Several studies have described the use of thin perforator flaps, such as the anterolateral thigh flap,16,35–37 medial sural artery perforator flap,17–19,23 superficial circumflex iliac artery perforator flap,24,25 and thoracodorsal artery perforator flap.26,27 However, there have been few studies of hind foot reconstruction, especially in the lateral malleolus and calcaneus region. An ideal flap for this region must possess certain characteristics. First, it has to be super-thin to allow the patient to wear shoes.21 Coverage of the wound alone does not solve the problems of ambulation and returning to work; the subject also needs to be able to wear a suitable shoe on the reconstructed foot.34 If a flap is bulky and difficult to shape, several stages of debulking and adjustments are required, which delays rehabilitation and ambulation. Reconstruction in a single step using a thin and pliable flap is ideal for foot resurfacing. Second, complex reconstruction is often required. Defects involving the bones or joints can be major, especially in cases of trauma or chronic infection. Such defects require complex reconstruction using multiple components and obliteration of dead space.10 If necessary, a muscle flap should be harvested together with the skin flap to provide sufficient blood supply for bone healing in complicated wounds with fractures and osteomyelitis.5 In contrast, as in one of the cases described above, separate skin flaps may be required to resurface two separate defects. Third, a long vascular pedicle is needed. There are few suitable recipient vessels around the lateral malleolus and calcaneus region. The lateral malleolus region is supplied only by the lateral calcaneal artery, lateral tarsal artery, lateral malleolar artery,22 and additional small branches of the anterior tibial artery, posterior tibial artery, and peroneal artery. Moreover, the surrounding vessels are often affected by the trauma or chronic infection.18 Anastomosis outside the injury zone is mandatory for successful reconstruction. Fourth, donor site morbidity should be taken into account. Perforator flaps have fewer donor site problems than conventional flaps. However, some donor sites require skin grafts, whereas others require the main vessel to be sacrificed to obtain an appropriate pedicle.9,18 In this regard, the superficial circumflex iliac artery free flap is limited in size, which makes it suitable only for small defects, and has a short pedicle length. This makes it inappropriate for complex reconstructions. Harvesting of the sural artery perforator free flap is associated with scarring at the donor site, which can be unacceptable in female patients or children.18 An equivalent result can be achieved with other flaps. In particular, harvesting of the anterolateral thigh flap or thoracodorsal artery perforator flap leaves a donor site defect in the Microsurgery DOI 10.1002/micr
thigh or axilla that can easily be hidden by clothing. The sural artery perforator free flap is a thin flap that permits freedom of positioning, but it is less likely to be chosen because of the cosmetic problems described above. The anterolateral thigh free flap35–37 and free thoracodorsal artery perforator flap26,27 satisfy the criteria for lateral malleolus reconstruction. Both are large and can be harvested safely even when only a single perforator is available. A vascular pedicle up to 10 cm in length can be obtained, depending on the location and diameter of the recipient vessel. In addition, a super-thin flap can be acquired by excluding the deep adipose layer during flap harvesting. The perforator flap with only a superficial adipose layer can be further thinned to
