• Archives of Plastic Surgery
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• 제32권1호
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• pp.100-104
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• 2005

A soft tissue defect of the lower leg or foot presents a challenging problem. Reconstructive surgeon should be armed at all points of wound site, tendon and bone exposure, injury of major vessel and so on in the lower limb. We reconstructed the defects of lower legs and feet of 25 patients between February, 1997 and December, 2003. Applying reversed adipofascial flap with skin graft on a soft tissue defect of the lower leg or foot is challenging. We did a comparative study of 25 reversed adipofascial flaps with 51 free flaps. All 25 cases of reverse adpofascial flap reconstruction were successful except for a partial loss of skin graft in 3 occasions. The reversed adipofascial flap had a merit of a short operation time and hositalization, a high success rate and minimum complications. Besides major vessels in the lower leg are better preserved and donor morbidity is minimal. However, the flap is unmerited in reconstructing a hug hallowed defect and in the leg with poor blood circulation and once previous surgery. The operators may consider the feasible substitution of reversed adipofascial flap for free flap before applying in the lower leg.

• Archives of Plastic Surgery
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• 제46권3호
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• pp.255-261
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• 2019

Cross-leg flaps are a useful reconstructive option for complex lower limb defects when free flaps cannot be performed owing to vessel damage. We describe the use of the extended distally based sural artery flap in a cross-leg fashion for lower extremity coverage in three patients. To maximise the viability of these extended flaps, a delay was performed by raising them in a bipedicled fashion before gradual division of the tip over 5 to 7 days for cross-leg transfer. Rigid coupling of the lower limbs with external fixators was critical in preventing flap avulsion and to promote neovascular takeover. The pedicle was gradually divided over the ensuing 7 to 14 days before full flap inset and removal of the external fixators. In all three patients, the flaps survived with no complications and successful coverage of the critical defect was achieved. One patient developed a grade 2 pressure injury on his heel that resolved with conservative dressings. The donor sites and external fixator pin wounds healed well, with no functional morbidity. The cross-leg extended distally based sural artery flap is a reliable reconstructive option in challenging scenarios. Adequate flap delay, manoeuvres to reduce congestion, and postoperative rigid immobilization are key to a successful outcome.

• Archives of Plastic Surgery
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• 제32권4호
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• pp.539-542
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• 2005

Reconstructions of soft tissue defect of the posterior ankle including Achilles the tendon should take into account not only coverage but functional outcome. Various methods of tendon transfer and tendon graft have been reported as a single-stage procedure. With advances and refinements in microsurgical techniques, several free composite flaps including tendon, fascia, or nerve have been used in single-stage reconstructions of large defects in this area minimizing further damage to the traumatized leg. However, when free flap is not feasible for some reasons, this cannot be accomplished successfully. Here we present a patient with Achilles tendon and circumferential large soft tissue defect. Because of circulatory compromise of the lower extremity, free flap reconstruction could not be applied. Instead, cross-leg composite flap of the dorsalis pedis flap including the extensor hallucis brevis musle and tendon, and tendon strips of the Second, third and fourth extensor digitorum logus were employed, Functional reconstruction of the tendon and resurfacing were obtained at the same time. The flap was detached 3 weeks postoperatively, and the transplanted flap has survived without any complications. By 3 months after surgery, full weight bearing, tip-toe standing and even walking without crutch assistance was possible. When functional reconstruction with the free flap is unattainable in the large defect of the posterior ankle including the Achilles tendon, cross-leg composite island flap of dorsalis pedis flap and tendon strips of the extensor digitorum longus tendon is a viable alternative.

• Archives of Plastic Surgery
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• 제45권6호
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• pp.601-604
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• 2018

• Archives of Plastic Surgery
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• 제36권4호
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• pp.411-416
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• 2009

Purpose: Malignant melanoma is recognized as the most serious skin cancer. We examined anatomical distribution and 5 - year survival rate of each stage of malignant melanoma on lower leg. Methods: We retrospectively analyzed the medical records of 91 patients(46 males and 45 females) with malignant melanoma on lower leg from 1985 to 2008. Age, sex, anatomical distribution and 5 - year survival rates of each stage of malignant melanoma on lower leg were investigated. Also, 5 - year survival rates of each stage and invasion depth of malignant melanoma on heel pad were investigated. Results: On lower leg, most frequently 32 cases(35.1%) occurred on heel pad, 27 cases(29.7%) occurred on dorsum of foot, 18 cases(19.8%) in toe and 14 cases(15.4%) on others in lower leg. We used the excision margin as 3 ~ 5 cm. After wide excision, in stage III, IV, the patients underwent the immunologic / chemo - therapy. The incidences of each stage were 22 cases(24.2%) in stage I, 47(51.6%) in II, 17(18.7%) in III and 5(5.5%) in IV. The 5 - year survival rates of each stage were 85%, 53.2%, 47.1% and 40%. On heel pad, the incidences of each stage were 5 cases(15.6%) in stage I, 19 cases(59.4%) in II, 7 cases(21.9%) in III and 1 case(3.1%) in IV. The 5 - year survival rates of each stage were 80%, 63.2%, 42.9% and 100%. On heel pad, incidence of local recurrence was 2 and 5 - year survival rate of this case was 100%. And systemic recurrence was 9 and 5 - year survival rate of this case was 55.6%. Conclusion: The 5 - year survival rate of malignant melanoma on heel pad was higher than previous study. To maintain the weight - bearing function of foot, we recommend the active reconstructive surgery for heel pad reconstruction after wide excision of heel pad malignant melanoma.

• Archives of Plastic Surgery
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• 제48권6호
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• pp.699-702
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• 2021

Extensive bone loss associated with severe vascular injury remains a challenge for lower extremity reconstruction. The fibular free flap has been utilized for many decades to reconstruct long-segment tibial defects. We present an unusual scenario of unilateral weight-bearing, wherein we salvaged the sole lower extremity by transfer of the fractured ipsilateral fibula and a bipedicled skin flap. A 38-year-old man sustained a severe crush injury in the right leg with loss of circulation. His left lower leg had a soft tissue defect measuring 20×15 cm with an exposed comminuted fracture and a 17-cm tibial defect, along with a segmental fracture of the fibula. Subsequently, we reconstructed the tibial defect by transferring a 17-cm-long section of the ipsilateral fibula. We covered the soft tissue defect with a bipedicled skin flap. The patient eventually began to ambulate independently after surgery.

• Archives of Plastic Surgery
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• 제35권3호
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• pp.295-302
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• 2008

Purpose: The lower leg often has poor vascularity, proximity to bone, and insufficient soft tissue. The island flaps offer a feasible one stage reconstruction and has a remarkable vascularization and high quality results for soft tissue defect with or without bony problems to occur on regions below the knee. So we reported our experience of island flaps with review of the literatures. Methods: We reconstructed 29 cases of soft tissue and 2 cases of bony defect on regions below the knee by using various island flaps at our hospital from December, 1991 to January, 2006. We used 2 fibular osteocutaneous island flaps, 15 reverse sural island flaps, 6 extensor digitorum brevis muscular island flaps, 2 medial plantar island flaps, 5 saphenous island flaps, and a dorsalis pedis island flap. Results: Partial necrosis was developed in 4 out of 15 reverse sural island flaps and 1 out of 5 saphenous island flaps, but they were healed with secondary skin graft. There was partial loss of skin graft on the donor sites in 2 cases. Conclusion: Island flaps are very useful for reconstruction of regions below the knee because island flaps have good vascularity and less risk of infection. Generous flap size, easy operative technique, lower cost, shorter operative time, and minimal morbidity at the donor site are other advantages. We attained satisfactory results.

• Archives of Plastic Surgery
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• 제36권5호
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• pp.583-590
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• 2009

Purpose: In the cases of a vascular compromised condition in an injured lower extremity, soft tissue coverage with free tissue transfer presents a challenging problem to the reconstructive surgeon. For this reason, cross - leg flaps are still used in unusual circumstances. Advances in surgical technique has made the cross - leg free flap possible although it may require long operation time along with significant donor site morbidity. Therefore, a pedicled cross - leg muscle flap may be an alternative treatment modality when local flap or free flap is not possible. Methods: Twelve patients(9 males and 3 females) underwent the operation between October of 2001 and December of 2008. The patients' age ranged from 6 to 82 years. The unusual defects included the regions such as the knee, popliteal fossa, distal third of the tibia, dorsal foot, and the heel. Indications for the cross - leg gastrocnemius flap are inadequate recipient vessels for free flap(in eight cases), extensive soft tissue injuries(in three cases) and free flap failure(in one case). The muscle flap was elevated from contralateral leg and transferred to the soft tissue defect on the lower leg while both legs were immobilized with two connected external fixator systems. Delay procedure was performed 2 weeks postoperatively, and detachment was done after the establishment of the adequate circulation. The average period from the initial flap surgery to detachment was 32 days (3 to 6 weeks). Mean follow - up period was 4 years. Results: Stable coverage was achieved in all twelve patients without any flap complications. Donor site had minimal scarring without any functional and cosmetic problems. No severe complications such as deep vein thrombosis or flap necrosis were noted although mild to moderate contracture of the knee and ankle joint developed due to external fixation requiring 3 to 4 weeks of physical treatment. All patients were able to walk without crutches 3 months postoperatively. Conclusion: Although pedicled cross - leg flaps may not substitute free flap surgery, it may be an alternative method of treatment when free flap is not feasible. Using this modification of the gastrocnemius flap we managed to close successfully soft tissue defects in twelve patients without using free tissue transfers.

• Archives of Plastic Surgery
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• 제47권2호
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• pp.165-170
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• 2020

Background Perforator mapping has been well described in the literature. Once the suprafascial plane is reached, the course of perforators is considered constant. However, the surgeon must be aware of whether an anastomosis exists between perforators superficially to the fascia, in order to choose the best vessel upon which to base the reconstruction. Our retrospective in vivo anatomical study of lower leg perforator flaps presents the first description of variations in the suprafascial path of perforators, which may influence preoperative flap design. Methods An anatomical study of lower limb perforators was performed on 46 nonconsecutive patients who were referred to our department from June 2012 to October 2018. Reconstruction with perforator-based propeller flaps was planned for each of the patients. In total, 72 perforators were preoperatively identified and surgically isolated. The suprafascial course of each perforator was reported. Results During suprafascial surgical exploration, branching patterns were observed in four perforators. These perforators had been classified as single vessels in the preoperative ultrasonographic analysis. However, after surgical dissection, distal converging branches were noted in two of them. Conclusions Our study is the first description in the literature of suprafascial converging perforators, which might constitute an obstacle to planned reconstruction procedures. Despite the accuracy of preoperative evaluations, anatomical variations were present. Knowledge of suprafascial perforator variations may help surgeons to choose the correct perforator upon which to base a planned flap.

• Archives of Reconstructive Microsurgery
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• 제25권2호
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• pp.69-71
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• 2016

Reconstruction of the lower extremities is difficult due to a lack of skin laxity and muscular tissues. Here, we present a case of lower extremity reconstruction via the anterior tibial artery perforator based segmental muscle island flap. Our patient was a 75-year-old male with a chronic ulcerative wound on the right lower leg from an old car accident. A $5.0{\times}0.5cm$ size ulcerative wound with tibial bone exposure was noted. We planned to reconstruct the lower extremity defect with a free flap, but the vessel status was severely compromised intraoperatively. Thus, we found the anterior tibial artery perforator using Doppler ultrasound, elevated the tibialis anterior muscle segment flap, and transposed it to cover the defect successfully. The flap presented with a nice contour and the skin graft covering the flap survived completely. There were no complications of the surgical site at three months follow-up and no gait morbidity. This is a meaningful case applying the concept of segmental muscle flap based on a perforator that had advantages including proper bulkiness, vascularization, and preservation of function, which were well applied, leading to great success.