|Year : 2019 | Volume
| Issue : 4 | Page : 1289-1296
Pedicled perforator flaps for leg reconstruction
Tarek F Keshk1, Tarek M Rageh2, Ahmed A Talaab1, Hashem M R Elragaby3
1 Department of Plastic Surgery, Menoufia University, Shebin Elkom, Egypt
2 Department of General Surgery, Menoufia University, Shebin Elkom, Egypt
3 Department of Plastic Surgery, Shebin Elkom Teaching Hospital, Shebin Elkom, Egypt
|Date of Submission||06-Aug-2018|
|Date of Decision||18-Oct-2018|
|Date of Acceptance||22-Oct-2018|
|Date of Web Publication||31-Dec-2019|
Hashem M R Elragaby
El Mahalla El Kubra
Source of Support: None, Conflict of Interest: None
The objective of this study was to assess the efficacy of perforator flaps for the reconstruction of an injured leg.
Defects of the lower limb remain a health problem. Application of perforator flaps for reconstruction of these defects represents a very good option giving good coverage.
Patients and methods
This was a prospective study. It was performed at Menofia University Hospital and Shebin El-Kom Teaching Hospital during a period of 14 months from February 2017 to March 2018. The study was carried out on 20 patients with leg defects; six types of perforator flaps were used; seven patients were treated by posterior tibial artery perforator flap, seven patients by reversed sural perforator flap, two by peroneal artery perforator flap, two by lateral supramalleolar flap, one by anterior tibial artery perforator flap and one by medial sural artery perforator flap.
The mean ± SD age of the patients was 36.85 ± 16.60 years. Of 20 patients, 15 (75%) were male individuals and five (25%) were female individuals. The mean ± SD area size of the defect was 43.90 ± 33.47 cm. Of 20 flaps, 14 (70%) flaps had no complications, four (20%) flaps were complicated by distal-end congestion, 18 (90%) flaps passed successfully, and two (10%) flaps were complicated by necrosis and failed to survive.
Perforator flaps represent an effective method for reconstruction of leg defects, giving good satisfactory, functional and aesthetic results, as leg defects were successfully covered and healed by using perforator flaps, giving normal function and shape of the leg.
Keywords: leg defects, leg reconstruction, lower limb reconstruction, pedicled flaps, perforator flaps
|How to cite this article:|
Keshk TF, Rageh TM, Talaab AA, Elragaby HM. Pedicled perforator flaps for leg reconstruction. Menoufia Med J 2019;32:1289-96
| Introduction|| |
Soft tissue defects of the leg with exposed deep structures such as bones, tendons, nerves, arteries or veins remain a difficult surgical problem to overcome, as these defects cannot be covered by primary stitching or healed by secondary intention or grafted over these vital structures. Perforator flaps represent a good solution for coverage of these leg defects. Perforator flap refers to tissue that receives its blood supply via a 'perforator'. A perforator is a blood vessel that branches off a major named vessel (source vessel), supplying a particular territory, or angiosome. Angiosome is defined as a composite unit of skin and deeper structures between the skin and bone, supplied by a source vessel . The key element in predicting the survival of any cutaneous flap is the nature of the blood supply that is included . Taylor and Palmer  found that there was a mean 276 cutaneous perforators throughout the whole body. Perforators measure 0.5 mm or larger in diameter per individual, providing the dominant source of circulation for the entire integument. Each perforator was linked to the next, by way of a system of reduced caliber 'choke' vessels, to form a continuous network of suprafascial vessels throughout the body . The pioneers of plastic surgery accepted that flap design that worked well elsewhere on the body commonly failed when applied to soft tissue defects on the leg, especially when these defects were the product of trauma. Traditional advice was to avoid local flaps below the knee unless the defects were small or the surgeon was prepared to use special techniques such as delay incisions . Ger introduced the use of transposed muscle flaps for reconstruction of the leg. Unfortunately, the area least well served by these muscle flaps is the lower third of the leg . The fasciocutaneous flap reported by Ponten  showed that long narrow flaps could be safely raised below the knee as long as the deep fascia was included. The perforator flap was first described in 1989 by Koshima and Soeda . They can be divided into direct, indirect septocutaneous, and indirect musculocutaneous on the basis of the type of perforator vessel used . Pedicled perforator flaps have several obvious advantages. They can be performed expeditiously, and this is particularly beneficial in the management of soft tissue defects in multiply injured patients, the elderly, and systemically compromised patients. Local flap surgery limits the scars and morbidity to one extremity. However, pedicled perforator flaps have several potential disadvantages, particularly when used for major post-traumatic soft tissue defects. The principal criticism is that the flap is raised within the zone of injury and that its vascularity could be compromised. Perforator flaps can be transposed up to 180° with the base of the perforator as the pivot point . The vasculature of the skin and subcutaneous tissue is arranged in five vascular plexuses: the subepidermal plexus, dermal plexus, subdermal plexus, subcutaneous plexus, and fascial plexus (subfascial and suprafascial). Conventional musculocutaneous or fasciocutaneous flaps are connected to a source vessel under the muscle, or to vessels at the fascial level. In contrast, a perforator flap is connected to vessels of the subdermal or subcutaneous plexus, which therefore involve a connection to a more distal vascularity than a conventional flap . A variety of soft tissue compositions of flaps is available. Dermoadiposal flaps, adiposal flaps, adipofascial flaps, and myoadipofascial flaps can all be harvested from the same donor sites, allowing for improved tailoring of the flaps and more refinement in their reconstruction . It is generally agreed that a perforator is a vessel that enters the suprafascial plane through a defined fenestration in the deep fascia. Perforator flaps are particularly useful for lower third defects of the leg, wherein other local options can be limited . The aim of this study was to assess the efficacy and versatility of pedicled perforator flaps for the reconstruction of soft tissue defects of the leg.
| Patients and Methods|| |
This study type is a prospective study. It was carried out at Menoufia University Hospitals and Shebin El-Kom Teaching Hospital during a period of time 14 months from February 2017 to March 2018. The study was carried out on 20 patients with various leg defects [Table 1]. A total of six types of perforator flaps were used: (a) posterior tibial artery perforator flaps (seven cases), (b) peroneal artery perforator flaps (two cases), (c) anterior tibial artery perforator flap (one case), (d) reversed sural artery flaps (seven cases), (e) lateral supramalleolar flaps (two cases), and (f) medial sural artery perforator flap (one case). Patient consent was taken from all patients, and local ethical committee approval was taken. Of 20 patients, 15 were male individuals and five were female individuals. The ages of patients ranged from 8 to 65 years, with mean ± SD age of 36.85 ± 16.60 years. Leg defects were due to various causes; road traffic accidents (RTAs) were the most common cause of injury in 16 (80%) patients, in three (15%) patients, the defects were due to chronic leg ulcers, and, in one (5%) patient, the leg defect was caused by a deep burn. The size of leg defects ranged from 1 × 2 to 13 × 8 cm with mean ± SD size of 43.90 ± 33.47 cm 2. The defect site was at the lower third of the leg in seven cases, middle third in seven cases, upper third in two cases, two defects were over tendoachilles, one defect was over medial malleolus and one defect lay at the lateral malleolus. All patients had to have an indication of flap coverage for soft tissue defects (exposed bone, exposed tendon, exposed vessel or nerve …). The appropriate choice for flap coverage for each defect was selected according to the site and size of the leg defect, the condition of the wound and the surrounding tissues, the condition of perforators in and around the affected area, vascular and neurological condition of the leg, and the general condition of the patient. Cases were chosen with healthy surrounding tissue suitable for perforator flaps of the ipsilateral leg. Cases of chronic leg ischemia and uncontrolled diabetes were excluded. Patients were examined for general fitness for surgery and unfit patients were excluded.
|Table 1: Distribution of the studied cases according to defect site (n=20)|
Click here to view
Inclusion criteria: We included patients with significant soft tissue loss in the leg with exposed structures such as bone, joints, tendons, nerves, and vessels characterized by the following conditions:
- Cannot be closed by a primary closure
- Cannot be healed by secondary intention
- Cannot be skin grafted over the exposed structures
- All modes of leg injuries (RTA, burns, unhealed ulcers,…).
Exclusion criteria were as follows:
- Chronic untreated leg ischemia
- Uncontrolled diabetes
- Perforators inside the zone of trauma or damaged by trauma.
Clinical evaluation was carried out by full history taking, local examination of the defect and the affected limb, a general examination of the patient to evaluate fitness for surgery, and complete clinical, laboratory and radiological investigations were carried out for all patients. Preparation of the wound was carried out by thorough wound cleaning and irrigation, good debridement of nonviable tissue to prevent wound infection, and debridement was carried out as early as possible in the first 18 h of injury. The injured limb was washed by soapy solution; thereafter, the skin was prepared by povidone iodine 10% solution. The tissue was assessed from superficial to deep (skin, fat, muscle, bone), and the wound was examined well with the surrounding tissues. Nonviable skin, fat, muscle and bone were excised. Small bone fragments that were nonviable were removed. Microbiological tissue sampling (tissue culture and sensitivity) was carried out in patients with a delayed presentation or in patients transferred from other hospitals. The wound was then fully irrigated with saline, but high pressure was avoided, because this may drive devitalized tissue and bacteria deeper into the tissues, and predisposes to infection and delayed union. Antibiotics are given parenterally. Usually, we used double or triple antibiotic therapy in the form of amoxycillin–clavulinic acid, ceftriaxone and metronidazole in early presented (within 24 h) cases with a crushed injury. Fluids were given as an antishock measure and analgesia (mostly narcotics) for severe painful wounds and fractures. After wound debridement, the proper method of reconstruction was determined concerning the wound condition and the available perforators on which flaps can be raised for reconstruction. Assessment of perforators was carried out by using hand-held Doppler ultrasound scanner guided by the anatomical background of normal sites of perforators. Anterior tibial artery perforators were looked for along the anterolateral intermuscular septum, which separates between the anterior muscle group of the leg (extensors), and lateral muscle group of the leg (peronii). Posterior tibial artery perforators were looked for along the medial posterior intermuscular septum (deep transverse), which separates between superficial posterior calf muscle group, and deep posterior group. The surface anatomy of this septum is 1–3 cm posterior to the medial border of the tibia above the tip of the medial malleolus, usually the most reliable perforators lie at 8–12 cm above the tip of the medial malloelus. The average number of posterior tibial perforators is seven, and the most distal two perforators lie within 8 cm above the tip of the medial malleolus. Peroneal artery perforators were looked for along the posterolateral intermuscular septum that separates between the lateral muscle group of the leg (peronii) and the deep posterior muscle group (flexors). The surface anatomy of this septum is about 1–3 cm posterior to the imaginary line extending between the fibular head and the tip of the lateral mallelous. The average number of peroneal perforators is six, and the most distal two perforators lie within 10 cm above the tip of the lateral mallelous. Medial sural artery perforator was heard about 8 cm along a line drawn from the middle of the popliteal crease to the medial malleolus. During operations, wound defect was prepared by excision of any remnant of devitalized tissues and removal of even doubtful tissues, leaving only healthy vital clean normal bleeding tissues. Incision was carried out along the previously performed skin marking of the flap design (trust your marker), by using a scalpel blade and diathermy; the incision extended through the deep fascia of the leg (fascia dissection), down to the level of the subfascial plane, to ensure that the suprafascial vascular plexus was incorporated within the flap (fasciocutaneous) for better vascular supply of the flap. The perforators chosen to obtain an advancement movement were carefully dissected for 2–3 cm by gently teasing the muscular fibers. The perforators were irrigated intermittently with 2% lidocaine solution during flap dissection to relieve the vascular spasm of the perforators, which may have resulted from surgical manipulation during dissection. Extensive intramuscular dissection is not required and is recommended only when pedicle elongation is needed to improve flap advancement. After completion of dissection, flap elevation was performed; during the elevation, the fascia was sutured to the skin to be fixed, to prevent shearing or separation of the fascia and the skin, to preserve suprafascial vascular plexus, and to ensure sufficient blood supply to the flap according to the concept of fasciocutaneous flap. After raising the flap, a pneumatic tourniquet was deflated to observe the vascularity of the flap by evaluating the bleeding points of the distal ends of the flap. Hemostasis was achieved by cautery of bleeding spots; larger vessels were ligated or clipped to control any bleeding. Flap elevation proceeds until it is enough for the new positioning of the flap in the recipient site without any tension or excessive twisting or kinking of flap vascular pedicle, which may lead to the obliteration of the feeding perforators, leading to flap congestion or ischemia. Flap inset was performed in its new position to cover the defect by suturing the flap edges to healthy surrounding tissue around the defect without tension. The donor site was grafted in most of the cases (17) cases, and, in three cases, the donor site was a closed primary. Postoperative care and follow-up was carried out by flap monitoring by evaluating its temperature, color, capillary refilling, bleeding from pricking points and consistency of the flap. A hand-held Doppler was used to hear the sound of the perforators that supply the flap. A loud pulsatile sound indicates good vascularity of the flap, while weak muffled sound reflects low flap vascular perfusion. Monitoring the viability of the flap through these parameters was carried out postoperatively, starting 2 h after operation, then every 4 h during the first 48 h, then once daily in the first week. Light dressing was applied to all flaps, with a window for flap monitoring; tight dressing was avoided. Limb elevation of the patient's leg about 45° above the body level to decrease venous congestion was ensured. No pressure was applied over the site of the pedicle of the flap. Warm ambient temperature was ensured to avoid flap ischaemia resulting from surrounding cold weather. Complications of flaps included venous congestion, ischaemia, flap necrosis, hematoma due to uncontrolled bleeding, seroma due to excessive surgical manipulation, infection, wound dehiscence and unpleasant flap appearance which may annoy the patient, as well as donor site morbidity such as paraesthesia due to cutting the related donor site sensory nerve during the flap dissection, hypertrophic scar, hyperpigmentation or hypopigmentation of the donor site, infection of the donor site and nontake of the graft over the donor site [Figure 1], [Figure 2], [Figure 3].
|Figure 1: Illustration of a case of peroneal artery perforator flap. (a) The defect. (b) Flap elevation. (c) Peroneal perforator during flap dissection. (d) Flap inset. (e) Late postoperatively (3 months). (a) Preoperative defect such as a chronic ulcer in right leg. (b) Intraoperative elevation of the flap. (c) Dissection of peroneal artery perforator (d) flap inset and grafting of the donor site. (e) Late postoperative view after 3 months showing good coverage of defect with complete healing.|
Click here to view
|Figure 2: Illustration of a case of posterior tibial artery perforator flap. (a) The defect. (b) Flap elevation with dissected perforator. (c) Flap inset. (d) Postoperatively. (e) Late postoperatively after flap separation. (a) Defect over tendoachilles of the right leg. (b) Flap dissection with perforator. (c) Flap inset with grafting of donor site (d) postoperative view (e) postoperative view after second-stage flap pedicle separation.|
Click here to view
|Figure 3: Illustration of a case of medial sural artery perforator flap. (a) The defect. (b) Flap design. (c) Flap elevation. (d) Flap inset. (e) Flap postoperatively. (a) The defect is chronic ulcer over tibia of the right leg. (b) Flap design with marking perforators (c) flap is elevated with fascia sutured to it, preventing shearing movement. (d) Flap inset (e) postoperative view showing satisfactory flap coverage of ulcer defect.|
Click here to view
Data were fed to the computer and analyzed using IBM SPSS software package version 20.0 (IBM Corp., Armonk, New York, USA). Qualitative data were described using number and percent. Quantitative data were described using range (minimum and maximum), mean, SD, and median. The significance of the obtained results was judged at the 5% level.
| Results|| |
A total of 20 flaps were made in this study with six types of perforator flaps: (a) posterior tibial artery perforator flaps (seven cases), (b) peroneal artery perforator flaps (two cases), (c) anterior tibial artery perforator flap (one case), (d) reversed sural artery flaps (seven cases), (e) lateral supramalleolar flaps (two cases), (f) medial sural artery perforator flap (one case) [Table 2]. In all, 15 of 20 (75%) cases were male individuals and five (25%) were female individuals. The ages of cases ranged from 8 to 65 years with a median age of 40 years, mean ± SD age was 36.85 ± 16.60 years. With regard to the cause of defect in the leg, 16 (80%) defects were due to RTA, three cases were due to chronic ulcers over the tibia (15%), and one (5%) defect was caused by a deep burn of the 20 total cases. According to patient comorbidity, eight of 20 cases were smokers, and two of them had a history of hypertension. According to the site of leg defect, seven defects were at the lower third of the leg (35%), seven defects were at the middle third of the leg (35%), two (10%) defects were at the upper third of the leg, one (5%) defect was over the lateral malleolus, one (5%) defect was over the medial malleolus, and two (10%) defects with exposed tendoachillis [Table 1]. The sizes of the defects ranged between 2 × 1 and 13 × 8 cm, with a mean ± SD area size 43.90 ± 33.47 cm, and mean ± SD size of defect edges 7.60 ± 3.28 cm. Of the 20 cases, seven (35%) patients suffered skeletal fractures, five (25%) of them with fracture of the middle third tibia, one (5%) case with fracture of the lower third tibia and one (5%) case with combined middle and lower third tibial fractures. A total of five (25%) cases were operated acutely within the first 48 h of injury, six (30%) cases were operated within 1 month of injury, six (30%) cases were operated after 1–3 months from injury time, and three (15%) cases were operated after 3 months from time of injury. In this study, we used six different types of perforator flaps: seven (35%) cases were covered by posterior tibial artery perforator flap, seven (35%) cases with reversed sural artery perforator flap, two (10%) cases were covered by peroneal artery perforator flap, two (10%) cases were covered by the lateral supramalleolar flap, one (5%) case was covered by the anterior tibial artery perforator flap, and one (5%) case was covered by the medial sural artery perforator flap [Table 2]. In four (20%) cases, the flaps were complicated by congestion and necrosis of the distal-end of flap from which one case was secondary operated due to flap advancement after removal of the distal necrotic end, while the other three flaps passed conservatively. A total of two (10%) cases were complicated by complete flap congestion and necrosis, while 14 (70%) cases passed without any apparent complications [Table 3]. Donor site flaps of 17 (85%) cases were covered by split thickness skin graft (STSG), while in the other three (15%) cases, the donor site was a closed primary without grafting. In a total of two cases of 20 (10%), second-stage operation was carried out after the main flap surgery; in one of them, we performed flap separation of flap pedicle after 3 weeks from definitive surgery, and, in the other one, we performed flap advancement to replace the distal congested end of the flap after 2 weeks from primary flap operation. In this study, 18 cases of 20 (90%) passed freely with good and complete coverage of the defect site, whereas the remaining two (10%) cases developed flap congestion and necrosis and were treated by negative pressure wound therapy (NPWT) (VAC therapy) and then covered by STSG over good granulation tissue. In this study, perforator flaps give good functional and esthetic results, as leg defects in 18 cases of 20 were successfully covered and healed with satisfactory normal function and shape of the leg, and two flaps were complicated by necrosis and failed to survive (10%), with a high success rate (90%) and a low failure rate of only 10%.
|Table 2: Distribution of the studied cases according to coverage method (types of perforator flaps) (n=20)|
Click here to view
|Table 3: Distribution of the studied cases according to complications of perforator flap (n=20)|
Click here to view
| Discussion|| |
In this thesis, 20 cases suffered from defects of the leg with exposed bone, vessels, tendons or nerves and were treated by using perforator flap operations to cover these leg defects. The aim of this study was to evaluate the versatility and the value of these perforator flaps to satisfactorily cover the leg defects and cover the exposed structures of the leg. With regard to the cause of leg defects in our study, the majority of cases were due to RTAs, that is, 16 patients of 20 (80%), three (15%) defects were due to chronic ulcers, and one (5%) defect was caused by a deep burn. In a study by Dong et al. , a total number of 20 cases were operated by propeller pedicled perforator flaps to cover leg defects, five cases were caused by spokes, four cases were caused by infection with skin necrosis, two cases were caused by trauma with heavy objects, and nine cases were caused by RTA. Thus, RTA is the commonest cause of leg defects in our and other studies. In our study, the site of leg defect was over the lower third of the leg in seven cases of 20 (35%). A total of seven (35%) defects were over the middle third of the leg, two (10%) defects were over the upper third of the leg, two (10%) defects were over the tendoachilles, one (5%) defect was over the medial malleolus, and one (5%) defect was over the lateral malleolus. In a study by Masoodi et al.  about coverage of leg defects caused by car accidents, 110 cases were covered by fasciocutaneous flaps; in 72 (65%) cases of them, the defects were at the lower third of the leg. In 25 (23%) cases, the defects were at the middle third of the leg. In 13 (12%) cases, the defects were at the upper third of the leg. Thus, from our study and that of Masoodi et al. , the most common site of leg injuries and defects is the distal lower third of the leg, followed by the middle third and, finally, the upper third of the leg. With regard to, comorbidities of patients in our study, eight of our 20 (40%) cases were associated with comorbidities; all of the eight patients were smokers, and two (10%) of them were proved to be hypertensive. All associated morbidities were controlled before operations to ensure the fitness of patients for surgery and to improve the results of surgeries and flap survival postoperatively. In a study by Mateev and Kuokkanen  for lower limb reconstruction, 11 cases were successfully operated upon, two of the cases were smokers, and two of the cases were with diabetes mellitus. The results of the surgeries were satisfactory after good management of coexisting comorbidities before the operation. Associated comorbidities play a very important role in the outcome of flap surgery and survival of flaps postoperatively. Thus, from our experience and also from other reported studies about lower limb reconstruction, we inferred that proper management of coexisting comorbidities preoperatively leads to good results. Smoking cessation and good control of hypertension and diabetes before flap surgery, improve the outcome and increase the survival rate of the flaps and decrease postoperative complications, giving good satisfactory results. A total of 20 cases were submitted for perforator flap surgery in our study to cover defects in the leg; in seven cases we used posterior tibial artery flap, in the other seven cases we used reversed sural artery flap, in two cases we constructed peroneal artery perforator flaps, another two cases were covered by a lateral supramalleolar flap, one case was covered by anterior tibial artery perforator flap and, finally, one case was chosen to be covered with medial sural artery perforator flap. Selection of these different types of perforator flaps was based on multiple factors leading us to choose specific flap type to manage every case separately. The site of the defect in the leg and the presence of a good audible, sizable perforator close to it and not affected by trauma (out of the zone of trauma) determine the type of flap. All cases were examined well, and the site of defects was determined carefully. Hand-held Doppler was used in all cases to determine sizable, loud and reliable perforators from which flaps could be constructed upon. In posterior tibial flaps, perforators of the posterior tibial artery were heard by Doppler at the medial side of the leg above the medial malleolus; at least 2–3 loud posterior tibial perforators were heard in each case. In two cases with peroneal perforator flaps, peroneal artery perforators were heard by Doppler at the lateral part of the leg above the lateral malleolus. A total of 2–3 sizable, loud perforators were heard by Doppler before each of the two cases. In cases wherein patients were planned to undergo reversed sural artery flap, hand-held Doppler was used to hear at least 2–3 perforators from reversed flow peroneal artery in all seven cases of the sural flap. One case was covered by anterior tibial artery perforator flap, as the defect was close to the anterior aspect of the leg, and loud perforators from the anterior tibial artery were heard by Doppler at the anterior part of the leg, two fingers breadth in front of the imaginary line from the lateral malleolus to the head of the fibula. In lateral supramalleolar flaps, Doppler was used to identify perforators from anastomosis of the peroneal artery and anterior tibial artery at the sinus tarsus. In one case, the defect was at the upper third of the leg, exposing the tibia at the anterior aspect of the leg. Medial sural artery perforators were identified by hand-held Doppler 2–3 cm below the popliteal crease at an imaginary line connecting the mid popliteal to the medial malleolus. In a study by Mateev and Kuokkanen  about perforator flaps, Doppler was used to determine perforators before each flap. Of a total of 11 cases, three cases were covered by posterior tibial artery perforator flap to cover defects in the medial part of the distal part of the leg. A total of four cases were covered by peroneal artery perforator flap to cover defects in the lower part of the leg in its posterior, anterior and lateral aspect. In two cases, lateral supramalleolar flap was used to cover defects in the lower leg in the lateral and posterior aspects. In one case, dorsalis pedis artery flap was used to cover the defect in the plantar surface of the foot. Anterior tibial artery perforator flap used in one case to cover the defect in the upper part of the leg in its medial aspect. In our study, four of a total of 20 cases were complicated by venous congestion in the distal part of the flap. Three of them were treated conservatively and passed without further surgical intervention; one of these four flaps required a second surgery to perform flap advancement after debridement of the distal congested end, which was lying on the exposed bone. In two cases of our 20 operated ones, complete venous congestion and flap loss occurred. NPWT (VAC therapy) was used over the flaps postoperatively to deal with flap venous congestion, and STSG were performed later over the resultant granulation tissue to replace the lost flaps. In a study reported by Kneser  about venous congestion that occurs with extended reversed sural flap, venous congestion of the flap and even partial or total flap necrosis has been reported when the flap was extended up to the popliteal crease, or in the presence of concomitant diseases such as diabetes or peripheral vascular disease. Because of these concerns, the use of small-sized sural flaps has been recommended by some authors. The outcome of our reconstructive surgery for coverage of various defects in the leg was quite acceptable and satisfactory for most of the cases. Of a total of 20 operated cases, 14 (70%) cases passed freely without any complication. Three (15%) cases were complicated by venous congestion in the distal part only of the flap, which was passed successfully without any further surgical interference. One (5%) case complicated by distal venous congestion was required to be secondarily operated to be removed and to advance the flap to replace the congested debrided distal edge. Two (10%) cases failed, as they were complicated by complete venous congestion and necrosis of flap; NPWT was used in these two cases over the failed flaps to prepare a healthy bed for grafting; thereafter, STSG was performed. Near results were reported in a study by El-Sabbagh ; 34 skin perforator flaps were raised in 33 patients. A total of 13 flaps were raised as peroneal artery perforator flap, 16 flaps were executed as posterior tibial artery perforator flap, and five flaps as medial sural medial gastrocnemius muscle perforator skin flap. A segmental perforator was dissected and retained. A total of 32 flaps passed completely with none exhibiting venous compromise. In one case, the flap was lost completely, and the other showed partial tip necrosis. Complicated flaps responded to conservative treatment. Similar results were reported by Tos et al.  in a study in which 22 cases of perforator-based flap surgeries were performed over a period of 4 years. In this study, there were postoperative complications two patients' cases were complicated by partial flap necrosis, and five patients' cases were complicated by superficial epidermolysis. Minor complications were seen in three patients who showed transient venous congestion of the flap. In all but one patient healing was achieved without further major surgical procedures. In three cases, secondary skin grafts were performed. In most of the cases, the aesthetic result was optimal, and patients were fully satisfied. Another study by Bhattacharya et al.  reported similar results in a series of 10 cases in which one case showed total loss of the flap. Thus, from our study and the previously mentioned studies about perforator flap for leg reconstruction, good satisfactory outcome of surgery depends on many factors including good preparation of the patient generally and local preparation of the wound preoperatively. Selection of good reliable nearby perforators that can supply the flap safely, selection of ideal flap type and good flap dissection, and postoperative close follow-up are the key factors for good satisfactory results of perforator flap surgery.
| Conclusion|| |
Perforator flaps represent a very good solution for reconstruction of different leg defects due to various causes (trauma, burn, ulcers,…) with exposed structures (bones, tendons, vessels or nerves) that cannot be closed primary or healed by secondary intention or grafted, with good coverage of the defects and acceptable satisfactory functional and aesthetic results, as leg defects in 18 cases of 20 were successfully covered and healed with satisfactory normal function and shape of the leg.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Brown DL, Borsche GH, Levi B. Michigan manual of plastic surgery. 2nd
ed, Philadelphia: Lippincott Williams & Wilkins/Wolters Kluwer Health, 2014; 5
Milton SH. Pedicled skin-flaps: the fallacy of the length: width ratio. Br J Surg 1970; 57:502–508.
Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J Plast Surg 1987; 40
Taylor GI, Doyle Mand McCarten G. The Doppler probe for planning flaps: anatomical study and clinical applications. Br J Plast Surg 1990; 43
Quaba O, Quaba A. Plastic. Semin Plast Surg 2006; 20
Ger R. The technique of muscle transposition in the operative treatment of traumatic and ulcerative lesions of the leg. J Trauma 1971; 11
Ponten B. The fasciocutaneous flap: its use in soft tissue defects of the lower leg. Br J Plast Surg 1981; 34
Koshima I, Soeda S. inferior epigastric artery skin flaps without rectus abdominis muscle. Br J Plast Surg 1989; 42
Hallock GG. Direct and indirect perforator flaps: the history and the controversy. Plast Reconstr Surg 2003; 111
Grover R. The impact of perforator number on deep inferior epigastric perforator flap breast reconstruction. Arch Plast Surg 2014; 41
Jeong JH. Face reconstruction using lateral inter costal artery perforator-based adipofascial free flap. Arch Plast Surg 2014; 41
Niranjan NS, Price RD, Govilkar P. Fascial feeder and perforator-based V–Y advancement flaps in the reconstruction of lower limb defects. Br J Plast Surg 2000; 53
Dong KX, Xu YQ, Fan XY. Perforator pedicled propeller flaps for soft tissue coverage of lower leg and foot defects. orthopaedic Surgery 2014; 6
Masoodi Z, Ahmad I, Khurrametal F. Management of post road traffic accident compound leg defects using fasciocutaneous flaps. J Wound Care 2013; 3
Mateev MA, Kuokkanen HOM. Reconstruction of soft tissue defects in the extremities with a pedicled perforator flap: series of 25 patients. J Plast Surg Hand Surg 2012; 46
Kneser U, Bach AD, Polykandriotis E. Delayed reverse sural flap for staged reconstruction of the foot and lower leg. Plast Reconstr Surg 2005; 116
El-Sabbagh A. Skin perforator flaps: an algorithm for leg reconstruction. J Reconstr Microsurg 2011; 27
Tos P, Innocenti M, Artiaco S. Perforator-based propeller flaps treating loss of substance in the lower limb. J Orthop Traumatol 2011; 12
Bhattacharya V, Reddy GR, Goyal S. Skeletonised retrograde distal perforator island fasciocutaneous flaps for leg and foot defects. J Plast Reconstr Aesthet Surg 2007; 60
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]