The free peroneal perforator-based sural neurofasciocutaneous flap: a novel tool for reconstruction of large soft-tissue defects in the upper limb.

BACKGROUND: The sural neurofasciocutaneous flap has been widely used for reconstruction of soft-tissue defects in the lower leg, ankle, and foot. It can provide a large amount of tissue without compromising the function of the leg. The authors report the applications of the free peroneal perforator-based sural neurofasciocutaneous flap. METHODS: The free sural neurofasciocutaneous flap based on a single peroneal perforator is described. The peroneal perforator, which emerges from the posterior crural septum at the junction of middle and lower thirds of the fibula, was chosen as the pedicle of the flap. Six perforator-based sural neurofasciocutaneous flaps were transferred to resurface large soft-tissue defects in the upper limb. The size of the defects ranged from 15 × 6 cm to 45 × 10 cm. RESULTS: All six flaps survived completely without necrosis. The area of the flaps ranged from 16 × 8 cm to 30 × 10 cm. The average diameter of the peroneal perforator ranged from 1.0 to 1.5 mm, and the length of the perforator pedicles ranged from 4 to 6 cm. One patient developed arterial thrombosis after surgery, which was treated by removal of the thrombus and reanastomosis. No severe venous congestion was observed. All the patients were satisfied with the aesthetic outcome postoperatively at 3 to 12 months' follow-up. There were no serious donor-site complications. CONCLUSION: The free perforator-based sural neurofasciocutaneous flap is a good alternative for reconstruction of extensive soft-tissue defects in the upper limb.

Combined medialis pedis and medial plantar fasciocutaneous flaps based on the medial plantar pedicle for reconstruction of complex soft tissue defects in the hand.

The reconstruction of complex soft tissue defects in hands remains a difficult challenge in reconstructive surgery. In this report, we introduce a combined medialis pedis and medial plantar fasciocutaneous flaps supplied by the lateral and medial branches of the medial plantar artery, which allows a one-stage reconstruction of multiple soft tissue defects in hand. Three combined medialis pedis and medial plantar fasciocutaneous flaps were transferred for repair of the soft tissue defects including palmar and dorsal areas of hand, thumb pulp, and the dorsum of index finger in three patients. All three flaps survived uneventfully with coverage matching the texture and color of the recipients. The donor sites healed without complication. The experience from these cases proves that the combined medialis pedis and medial plantar fasciocutaneous flaps based on the medial plantar pedicle would be a valuable alternative for the reconstruction of complex soft tissue defects in the hand.

The extended peroneal artery perforator flap for lower extremity reconstruction.

The peroneal artery perforator flap and its modifications have been widely used for coverage of soft tissue defects of ankle and foot in the past decade. In this article, we report on a series of upper knee, ankle, and foot reconstructions with a proximally or distally based extended peroneal artery perforator (EPAP) flap supplied by distinct perforating branches off the proximal or distal peroneal artery. Total pedicle length obtained ranged from 6 to 12 cm. Twelve patients with soft tissue defects of the lower extremity underwent reconstruction using the EPAP flap. The flaps were designed with the sizes from 10 x 6 cm to 25 x 15 cm. All 12 flaps survived completely without complications. Our experience demonstrates that the EPAP flap is reliable and versatile and can provide a large amount of soft tissue for coverage of defects in the leg anywhere from knee to forefoot obviating the need for free tissue transplantation.

Peroneal artery perforator chimeric flap for reconstruction of composite defects in extremities.

Large bone defects of extremities, especially those associated with soft tissue defects, represent difficult reconstructive problems. Chimeric flap is a suitable option for reconstruction of complex bone and soft-tissue defects. In this report, we present the experience on use of the peroneal artery perforator chimeric flap for the reconstruction of complex bone and soft tissue defects in the extremities in 16 patients. The bone defects were located in the tibia in 8 patients, in both tibia and fibula in 1 patient, in the ulna in 2 patients, in both ulna and radius in 2 patients, and the metatarsal bone in 3 patients. The flap was created with skin paddle and fibula bone segments based on independent perforators. The sizes of flap ranged from 8 x 6 to 20 x 11 cm(2), and the length of fibular grafts ranged from 6 to 22 cm. All flaps survived completely. Bone union was ultimately obtained in all cases at 5 to 11 months, while two cases suffered from stress fractures in 12 month and 18 month after operation, respectively, which eventually healed with external fixation treatment. The follow-up time ranged from 12 to 37 months. The definite bone hypertrophy was observed from X-ray at 18 months after operation. In conclusion, our results show that the peroneal artery perforator chimeric flap is a good option for reconstruction of complex bone and soft-tissue defects of extremities, particularly for those with three-dimensional defects and bone defects exceeding 6 cm in length.

Free peroneal perforator-based sural neurofasciocutaneous flaps for reconstruction of hand and forearm.

BACKGROUND: Sural neurofasciocutaneous flap has been popularly used as an excellent option for the coverage of soft tissue defects in the lower third of leg, ankle and foot, but its free transplantation has been rarely reported. The objective of our work was to investigate the operative technique and clinical results of repairing the soft tissue defects of hand and forearm with free peroneal perforator-based sural neurofasciocutaneous flap. METHODS: Between May 2006 and March 2007, 10 patients including 7 men and 3 women were treated. Their ages ranged from 22 to 51 years. They presented to emergency with large soft tissue defects of 16 cm x 7 cm to 24 cm x 10 cm in size in hand and forearm after injured by motor vehicle accidents (2 cases) or crushed by machine (8 cases). Thorough debridements and primary treatments to associated tendon ruptures or bone fractures were performed on emergency. And free peroneal perforator-based sural neurofasciocutaneous flaps were transplanted when the wound areas were stable at 5 to 7 days after emergency treatment. The flaps were designed along the axis of the sural nerve according to the shape and size of the soft tissue defects, with the peroneal perforator above the lateral malleolus as the pedicle and along with a part of the peroneal artery for vascular anastomosis. Then the flaps were harvested to repair the recipient sites with the peroneal artery anastomosed to the radial (or ulnar) artery and the peroneal veins to one of the radial (or ulnar) veins and the cephalic vein respectively. The flap sizes ranged from 18 cm x 8 cm to 25 cm x 12 cm. The donor areas were closed by skin grafts. RESULTS: All of the 10 flaps survived after surgeries. Marginal necrosis occurred in only 2 cases. The skin grafts survived entirely in the donor sites, and no obvious influence on the donor legs was observed. All of the transplanted flaps presented favourable contours and good functions at 9 to 12 months' follow-up. CONCLUSIONS: Peroneal perforator-based sural neurofasciocutaneous flap has favourable appearance, constant vascular pedicle, reliable blood supply, large size of elevation, and minimal influence on the donor site. The free transplantation of this flap offers a satisfactory alternative for repairing the large soft tissue defects of forearm and hand.

Reconstruction of thumb loss complicated by skin defects in the thumb-index web space by combined transplantation of free tissues.

OBJECTIVE: To introduce a new technique of 1-stage reconstruction for thumb loss complicated by thumb-index web space contracture and to report its clinical effectiveness. METHODS: From November 1994 to September 2004 there were 11 patients with thumb loss and contracture in the thumb-index web space who had a combined transplantation of free tissues to reconstruct the missing thumb and to rebuild the web space. The reconstructive procedure used the second toe and the anterolateral thigh flap in 5 patients, the second toe and the scapular flap in 2, the big toe wraparound flap and the anterolateral thigh flap in 3, and the big toe wrapround flap and the scapular flap in 1. The 2 independent free tissues were connected together by a vascular combination to form an assembly with 1 common vascular pedicle, which then was anastomosed to the selected vessels in the recipient hand. In this vascular series the dorsalis pedis artery and the greater saphenous vein served as the common vascular pedicle of the flap transfers and the radial artery and the cephalic vein provided the recipient vessels. The outcomes of the reconstructions were evaluated using the Michigan Hand Outcomes Questionnaire. RESULTS: The flaps survived completely in all patients except 1. In this patient a small area in the distal part of the transplanted anterolateral thigh flap became necrotic but healed after dressing changes without the need for further surgical intervention. A mean follow-up period of 3.6 years showed a mean increase of 4.3 cm in the width of the thumb-index web space and a considerable improvement in overall hand function was noted on the Michigan Hand Outcomes Questionnaire with effect sizes of greater than 3 (large effect) in all domains. CONCLUSIONS: Combined transplantation of the second toe or the big toe wraparound flap and a free skin flap is suitable to reconstruct a missing thumb and repair the associated skin defect in the adjacent thumb-index web space. We found good functional recovery and an acceptable appearance in this series of patients. Type of study/level of evidence: Therapeutic, Level IV. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.