Reconstruction of cervical and upper thoracic esophagus with a free posterior tibial artery perforator flap: A case report.

INTRODUCTION: Esophageal window defect in patients with esophageal resection could be challenging to repair. In this case report, a free posterior tibial artery perforator flap (FPTAPF) was used for semi-circumference patch esophagoplasty. PATIENT CONCERNS: For this 47-year-old male patient with recurrent laryngeal nerve schwannoma invading cervical and upper thoracic esophagus, cervical and upper thoracic esophageal reconstruction following tumor resection was needed DIAGNOSIS:: Pathologic result demonstrated recurrent laryngeal nerve schwannoma. Ultrasound examination detected a tumor (7 cm × 6 cm × 3 cm) located behind the right thyroid lobe, and contrast-enhanced computed tomography scan revealed that tumor was located between the cervical esophagus and trachea, and compressed these structures. INTERVENTIONS: The tumor had a size of 7 cm × 6 cm × 3 cm, and the semi-circumference defect of the cervical and upper thoracic esophagus was about 7 cm in length after complete tumor resection. A 7 cm × 4 cm FPTAPF was designed and harvested for esophageal reconstruction. OUTCOMES: The posterior tibial flap survived well and satisfactory recovery of esophageal function was obtained with no significant complications. No local tumor relapse was indicated by computed tomography during the 2-year postoperative follow-up. CONCLUSION: This case highlights the stable performance of FPTAPF when used for the reconstruction of large esophageal window defect.

Efficacy of Treating Chronic Tibial Osteomyelitis With Bone Defect Using a Pedicled Perforator-Layered Flap and Fasciocutaneous Flap of the Posterior Tibial Artery: A Case Report.

INTRODUCTION: Tibial osteomyelitis is a common complication of bone tissue trauma. Obtaining good soft tissue coverage and effective infection management is key to the treatment of chronic osteomyelitis of the tibia accompanied with bone defect and bone exposure. The pedicled posterior tibial artery perforator layered fasciocutaneous flap can be used to repair soft tissue defects and can be used as a long-term, localized anti-infective. CASE REPORT: A 54-year-old male presented with an ulcer, purulent discharge at the left anterior tibia, and a fever 28 years after complete healing of the scar site. The patient received debridement and negative pressure wound therapy (NPWT) in a hospital setting. After presenting to the authors' department, there was difficulty in closing the exposed bone marrow cavity. On the basis of systemic use of intravenous antibiotics, multiple debridements and NPWT were used to effectively remove necrotic tissue and control infection. Afterward, the pedicled posterior tibial artery perforator layered fasciocutaneous flap was designed to fill the bone marrow cavity as well as cover and seal the wound of bone exposure and soft tissue defect simultaneously. The layered fasciocutaneous flap was well established after operation, and no recurrence of osteomyelitis was found. CONCLUSION: Debridement with negative pressure wound therapy can be an effective treatment for the wound bed preparation in advance of surgery, and the pedicled posterior tibial artery perforator layered fasciocutaneous flap can be used for the treatment of several soft tissue defects.

Coverage of exposed bone and hardware of the medial malleolus with tibialis posterior artery perforator flap after ankle fracture surgery complications.

Ankle fractures are among the most common orthopaedic surgical procedures. Skin-related complications of these surgeries are difficult to reconstruct due to the inadequacy of soft tissue in the region. Although free flaps are generally considered as the first choice in reconstruction of this area, free flaps may not be a suitable option especially in patients with advanced age and comorbidities. Perforator flaps offer a fast and safe alternative in lower extremity reconstruction. In the literature, there are a limited number of studies using perforator flaps in managing the postoperative complications of the lower extremity trauma surgeries. In our study, we report our experience with reconstruction of soft-tissue defects of medial malleolar region using posterior tibial artery perforator flap for postoperative complications of ankle fracture-related surgeries.

Posterior Tibial Artery Flap with an Adipofascial Extension: Clinical Application in Head and Neck Reconstruction with Detailed Insight into Septocutaneous Perforators and Donor-Site Morbidity.

BACKGROUND: The general aim of this study is to describe a new modification to the posterior tibial artery flap and its clinical application in head and neck reconstruction and to investigate the distribution of septocutaneous perforators of the posterior tibial artery. The specific aim of this study is to evaluate the effectiveness of this new modification to the posterior tibial artery flap and describe the flap survival rate and donor-site morbidity. METHODS: From November of 2017 to August of 2018, 85 consecutive patients underwent posterior tibial artery flap reconstruction of the head and neck region after tumor extirpation. All posterior tibial artery flaps were harvested with a long adipofascial extension, and donor-site defects were closed with a triangular full-thickness skin graft harvested adjacent to the flap. Special consideration was given to the harvesting technique, distribution of the posterior tibial artery septocutaneous perforators, flap outcomes, and associated donor-site morbidity. RESULTS: Flap survival was 100 percent. The number of septocutaneous perforators varied from one to five per leg, with a mean of 2.61 ± 1.15, and the septocutaneous perforators were mostly clustered in the middle and distal thirds of the medial surface of the leg. The prevalence of the presence of one, two, three, four, and five septocutaneous perforators per leg was 7, 33, 27, 19, and 14 percent, respectively. Total and partial skin graft loss at the donor site was reported in two and six patients, respectively, who were managed conservatively. There was no statistically significant difference when comparing the preoperative and postoperative range of ankle movements (p > 0.05). CONCLUSION: This new modification to the posterior tibial artery flap allows for the incorporation of more septocutaneous perforators into the flap, omits the need for a second donor site to close the donor-site defect, and provides sufficient tissue to fill the dead space after tumor resection and neck dissection. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Distally Based Posterior Tibial Artery Perforator Flaps for Reconstruction of the Defects in Achilles Region.

BACKGROUND: Patients with Achilles region defects remain a challenge for clinicians. The purpose of this article is to evaluate the surgical procedure to reconstruct the defects in Achilles region using distally based posterior tibial artery perforator flaps. METHODS: Between May 2015 and May 2017, 10 patients (aged from 35 to 68 years. 4 females and 6 males) with soft-tissue defects (sizes from 3 × 2 cm to 8 × 4 cm) in Achilles region received surgical therapy of posterior tibial artery perforator flap transplantation in the Affiliated Hospital of Xuzhou Medical University. RESULTS: The length of hospital stay ranged from 10 to 15 days (mean, 12 days). Local small superficial necrosis (5% of the area) was observed in only 1 case; however, it healed well after dressing was changed. All the others survived and healed well. At follow-up ranging from 12 to 24 months, all patients were satisfied with the aesthetic and functional aspects. CONCLUSIONS: Using the posterior tibial artery perforator flaps to cover the Achilles region defects is a promising, feasible, first-line, safe option and should be extensively applied in clinical therapy.

Posterior Tibial Artery Perforator Flaps Carrying Partial Gastrocnemius Muscle for Repair of Soft Tissue Defects With Dead Space in the Ankle and Foot.

BACKGROUND: Soft tissue defects with dead space in the ankle and foot remain a challenge for surgeons. The aim of the study was to evaluate the surgical technique and clinical significance of posterior tibial artery perforator flaps carrying partial gastrocnemius muscle for patients with soft tissue defects with dead space in the ankle area. METHODS: Between August 2015 and August 2017, 14 patients (2 women and 12 men) between 20 and 58 years old (median age, 42 years) were hospitalized in The First Affiliated Hospital of Soochow University. All injuries involved damage to the ankle area and formation of soft tissue defects with dead space. In all patients, posterior tibial artery perforator flaps carrying partial gastrocnemius muscle were transplanted to cover soft tissue defects with dead spaces. RESULTS: Hospitalization duration ranged from 10 to 20 days (mean, 16 days). All flaps survived and healed well. At follow-up after 6 to 24 months, all cases had recovered successfully in terms of aesthetic and functional aspects. CONCLUSIONS: Posterior tibial artery perforator flaps carrying partial gastrocnemius muscle can be an optimal reconstruction method for repairing soft tissue defects with dead space in the ankle and foot.

Free posterior tibial artery perforator flap for 2-stage tracheal reconstruction in patients after resection of well-differentiated thyroid carcinoma invading the trachea.

BACKGROUND: The present study was conducted to explore the efficacy of using a free posterior tibial artery perforator flap (FPTAPF) for trachea reconstruction after resection of well-differentiated thyroid carcinoma (WDTC) invading the trachea. METHODS: We retrospectively collected and analyzed clinical and surgical data from 14 patients who underwent tracheal reconstruction using a FPTAPF after resection of WDTC invading the trachea between August 2014 and July 2017. RESULTS: Satisfactory tracheal structure and functional recovery were obtained in 11 of the 14 patients. One patient had breathing difficulties after tracheostomy closure tests because of bilateral recurrent laryngeal nerve damage caused by disease invasion. Tracheostomy incision was not closed in 2 patients because they received postoperative adjuvant radioactive iodine 131 treatment. CONCLUSION: Satisfactory tracheal reconstruction results were achieved in patients with resection of WDTC invading the trachea, indicating that a FPTAPF is a safe and reliable choice for management.

Reconstruction of the Heel, Middle Foot Sole, and Plantar Forefoot with the Medial Plantar Artery Perforator Flap: Clinical Experience with 28 Cases.

BACKGROUND: Defects in the weight-bearing region of the foot sole can represent a substantial restriction in quality of life and pose a challenge for reconstructive plastic surgery. The purpose of this article is to report the authors' experience with the use of the medial plantar artery perforator flap for reconstruction of defects of the foot sole in three different regions: heel, middle foot sole, and plantar forefoot. METHODS: From January of 2003 to May of 2016, 28 patients (13 male and 15 female patients) with an average age of 54 years (range, 12 to 84 years) underwent reconstruction with 28 medial plantar artery perforator flaps. Twenty-six flaps were harvested as pedicle perforator flaps and two as free perforator flaps. All flaps were raised from the ipsilateral instep area. The defect locations included the heel (20 cases), middle foot sole (four cases), and forefoot (four cases). The causes of reconstruction were tumors in 18 patients, decubitus in eight patients, and trauma in two patients. RESULTS: The flap sizes varied from 2.5 × 2.5 cm to 5.5 × 9.5 cm. All of the flaps survived completely after surgery, apart from one. The donor sites were all covered with a split-thickness skin graft. Follow-up observations were conducted for 4 to 12 months, and all patients had good functional recovery with satisfactory cosmetic results. CONCLUSION: The medial plantar artery perforator flap can be considered an optimal method of foot sole reconstruction not only for covering the weight-bearing area of the heel but also for the middle and forefoot plantar region. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Early experience with the medial sural artery perforator flap as an alternative to the radial forearm flap for reconstruction in the head and neck.

The medial sural artery perforator (MSAP) flap has been well-described but has yet to find popularity in the United Kingdom. We describe our early experience of its use in 6 patients and our simplified method of marking up. Flaps ranged in size from 7×4cm to 12×5.5cm, and were thin (between 4 and 10mm). Pedicles were between 11 and 14cm long, arterial diameters were 1-2mm, and venous calibres were 2-6mm. We raised 4 flaps without the use of a tourniquet and found it helpful. Straightening the leg as the popliteal fossa was approached also eased dissection. There can be 2 separate pedicles. The donor site was closed primarily in 5 cases and all flaps survived. The MSAP is easier to do than the radial artery forearm free flap (RAFFF) and is a reliable alternative with low morbidity.

Reconstruction of the oropharynx with free posterior tibial flap after tonsillar cancer extirpation.

PURPOSE: Oropharyngeal reconstruction after tonsillar tumor resection is a great challenge for head and neck surgeons. The aim of the present study was to explore the reconstruction efficacy of the free posterior tibial flap in the primary reconstruction of oropharynx defects after tonsillar squamous cell carcinoma (SCC) ablation. MATERIALS AND METHODS: From August 2009 to March 2012, 12 patients with tonsillar SCC underwent oropharynx reconstruction with a free posterior tibial flap at the Department of Otolaryngology Head and Neck Surgery, West China Hospital of Sichuan University. Their clinical and surgical data were retrospectively collected and analyzed. RESULTS: Of the 12 patients, 8 were male and 4 were female (age range 41 to 66 years, mean 55.1). The average size of the free posterior tibial flap was 9.2 × 6.3 cm (range 7 × 5 to 12 × 7), the average flap thickness was 1.1 cm (range 0.9 to 1.3), and the average pedicle length was 10 cm (range 7 to 12). Despite the multistep and time-consuming procedure, all patients tolerated oropharynx reconstruction with the free posterior tibial flap. The transferred free posterior tibial flaps survived well. No donor site complications were observed during the follow-up period. All 12 patients acquired satisfactory swallowing and speech function preservation. CONCLUSIONS: Satisfactory reconstruction results were achieved for all 12 patients, indicating the free posterior tibial flap should be considered a potential treatment option for reconstruction of oropharynx defects. However, additional prospective studies with a larger sample size are required to validate our results.

Anterior tibial artery perforator flap for reconstruction of intraoral defects.

PURPOSE: The present clinical study assessed the feasibility of using an anterior tibial artery perforator (ATAP) flap for the reconstruction of an intraoral defect after ablative surgery for oral cancer. PATIENTS AND METHODS: A cohort of consecutive patients with oral cancer requiring reconstruction of an intraoral defect using an ATAP flap were enrolled after ablative surgery for oral cancer and ipsilateral neck dissection. RESULTS: Twelve patients had primary oral squamous cell carcinoma (8 with tongue cancer and 4 with buccal cancer). All patients received intraoral defect repair using an ATAP flap from the lower left leg. The flap measured 7 × 4 to 8 × 6 cm(2). Flap thickness was approximately 4.8 mm (3 to 6 mm). Anastomosis of all ATAP flaps was straightforward because of the long and high-caliber vessel pedicle. All flaps survived and yielded excellent esthetic results for intraoral reconstruction. No major complications occurred in any patient. CONCLUSION: The main advantages of the ATAP flap included the thin and pliable tissue characteristics and a long and high-caliber pedicle. For small and medium-size intraoral defects, the ATAP flap is a reliable alternative to the radial forearm free flap.

[Anatomic study and clinical application of thinned posterior tibial artery perforator flap].

OBJECTIVE: To explore the feasibility and therapeutic effect of thinned posterior tibial artery free perforator flap for the reconstruction of soft tissue defects at dorsum of hands. METHODS: Six fresh adult lower limbs specimens were injected with red latex via arterial cannula and dissected. The number, distribution, branches, and outer diameter of posterior tibia artery perforators were observed. Based on the anatomic study, the perforator flaps were designed to reconstruct soft tissue defects at dorsum of hands and wrists. The redundant fat on the flaps was removed, but preserving the nutrient vascular system. 11 flaps were used with the size ranging from 2 cm x 5 cm to 10 cm x 14 cm. RESULTS: 43 skin perforators of posterior tibial artery were observed in six lower limbs, 29 perforators with the outer diameter is greater than 0.5 mm when they threading over the deep fascia plane, on average every 4.8 bundles of sides. The mean outside diameter of perforating artery is (1.8 +/- 0.5) mm, and the length is (44 +/- 15) mm. 6 perforators were founded both in the second and fifth zone which could be used for anastomosis for its better diameters. All flaps survived completely without any complication at donor sites. 7 cases were followed up for 3-12 months. Both satisfactory functional and cosmetic results were achieved with a soft and thinned appearance. CONCLUSIONS: The thinned posterior tibial artery free perforator flap has a reliable blood supply and good appearance. It is very suitable for the reconstruction of small or medium-sized defects at the dorsum of hands and wrists.

[Vacuum sealing drainage and free coupling chain-link posterior tibial artery flap in the reconstruction of degloving injury of propodium].

OBJECTIVE: To present the methods of vacuum sealing drainage and free coupling chain-link flap of posterior tibial artery flap and medial plantar flap in the reconstruction of degloving injury of propodium. METHODS: From Oct. 2008 to Dec. 2011 five cases with degloving injury of propodium underwent debridement and vacuum sealing drainage on the first stage. Free chain-link flap of posterior tibial artery flap and medial plantar flap were applied to close the wound at the secondary stage. The nerve was included in the coupling flaps. The size of posterior tibial artery flap ranged from 14 cm x 10 cm to 11 cm x 8 cm,and the size of medial plantar flap ranged from 12 cm x 8 cm to 8 cm x 6 cm. RESULTS: All flaps were survived with no vascular crisis. The flap sensation recovered to S3-S3 during the follow-up period of 6-21 months. The texture and appearance of flaps were satisfied. The plantar had not ulcer and corpus callosum. CONCLUSION: Vacuum sealing drainage and free chain-link flap of posterior tibial artery flap and medial plantar flap with nerve are the ideal methods for the reconstruction of degloving injury of propodium.

Latissimus dorsi flap coverage of soft tissue defect following below-knee amputation: emphasis on flap design and recipient vessels.

High-energy trauma to the lower extremity often results in amputation of the limb. For maximal preservation of limb length during amputation, free tissue transfer is often necessary. In this study, we report our experience of stump coverage using latissimus dorsi musculocutaneous flaps with an emphasis on flap design and recipient vessels. Between January 2005 and September 2010, twelve patients with severe traumatic injuries to the lower leg underwent below-knee amputations with stump coverage using latissimus dorsi free flaps. The primary and secondary cases were approached differently regarding the flap design and recipient vessels. All flaps survived completely. There were 8 primary cases and 4 secondary cases. In the primary cases, the anterior tibial artery was used as the recipient vessel in 6 cases, and in 2 cases, the descending geniculate artery was used. In the secondary cases, the descending geniculate artery was used in all cases. There were two cases of ulceration on the grafted non-weight-bearing site, but after the usage of collagen-elastin artificial dermis, no ulcerations were seen. The latissimus dorsi musculocutaneous flap is the most feasible option for coverage of amputation stumps. In flap design, the width of the skin paddle must match the anteroposterior diameter of the defect at the stump. The latissimus dorsi muscle must sufficiently wrap the bony stump for padding. We recommend using the anterior tibial artery as a recipient vessel in primary cases, and the descending geniculate artery in secondary cases.

Tibial artery autografts: alternative conduits for high flow cerebral revascularizations.

BACKGROUND: Extracranial-to-intracranial (EC-IC) bypass is a valuable tool in treating intracranial diseases requiring flow replacement or parent vessel sacrifice. Radial artery grafts (RAGs) and saphenous vein grafts (SVGs) have been used as conduits to provide adequate high flow revascularizations. It is a therapeutic challenge when these grafts are unavailable. METHODS: All EC-IC high flow cerebral revascularizations performed using conduits other than RAGs or SVGs were identified from a prospective cerebrovascular registry. These patients were retrospectively reviewed for surgical technique, graft patency, graft flow, and clinical outcomes. RESULTS: Three patients (all women) underwent EC-IC bypass surgery using tibial artery grafts (two anterior tibial artery and one posterior tibial artery) because of the nonavailability of RAG or SVG. The two anterior tibial artery graft bypasses were patent with good flow at 8 and 3 months. The posterior tibial artery graft occluded intraoperatively. None of the patients developed vascular complications in the lower extremity due to tibial artery harvest. CONCLUSIONS: Tibial arteries are safe, contingent alternatives to conventional conduits for performing high flow cerebral revascularizations and conduit reconstructions.

The diabetic patient has a higher benefit from infrapopliteal revascularization than the non-diabetic patient: a 10-year retrospective study.

OBJECTIVE: The objective of this article is to evaluate the limb salvage and patency rates after crural arterial revascularization, differences between graft material and co-morbidities. PATIENTS AND METHODS: All patients with crural artery bypasses were analysed retrospectively in a single centre (Department of Vascular Surgery, Thüringen Kliniken Saalfeld, Rudolstadt, Germany) over a 10-year period (1996-2006); 157 patients with 170 consecutive arterial reconstructions could be included. RESULTS: Follow-up time was 55 months (6-119). Median age of the 56 women and the 101 men at the time of operation was 70 years (45.6-93.6). The five-year secondary patency rates were 71.5 ± 6.22% (vein), 44.3 ± 10.8% (composite; p = 0.0011), 52.6 ± 13.4% (prosthetic graft with distal vein cuff/patch; p = 0.00953) and 42 ± 12% (prosthetic graft without distal vein cuff/patch; p = 0.00443). Limb salvage rates after five years were 79.5 ± 5.8%, 61.6 ± 10.3%, 77.9 ± 11.3% and 70.1 ± 14.7%, respectively. Cumulative limb salvage rate was significantly higher in diabetic patients (78.9 ± 4.9%), than in non-diabetic patients (66.6 ± 6.8); p = 0.023. CONCLUSION: Crural reconstruction is a suitable method for peripheral arterial occlusive disease to prevent amputation, particularly in diabetics.

Repairing proximal and middle lower-leg wounds with retrograde sartorius myocutaneous flap pedicled by perforating branches of medial inferior genicular artery or posterior tibial artery.

BACKGROUND AND OBJECTIVES: The blood supply of the lower one-third of the sartorius muscle is mainly provided by the descending genicular artery (saphenous artery). The terminal branches of the saphenous artery, together with the perforators of the posterior tibial artery and medial inferior genicular artery, form a stable and rich anastomotic network in the genus inferior medialis. Based on this anatomy, we designed a retrograde sartorius myocutaneous flap to repair wounds in the proximal and middle thirds of the lower leg. METHODS: A sartorius myocutaneous flap with the posterior tibial (or medial inferior genicular) artery perforators as the pedicle was designed. The flap was based on a retrograde flow route: medial inferior genicular and posterior tibial artery perforators, the vascular network at the inferomedial knee, the saphenous artery, saphenous artery perforators, to the sartorius muscle. With this design, the flap can be transferred to the middle and proximal tibia. Between January 2007 and June 2010, 12 patients with middle/proximal lower-leg wounds were successfully treated with this method. RESULTS: Ten of 12 myocutaneous flaps survived with primary healing of wounds. Two cases developed a small degree of distal superficial skin necrosis but with normal muscular blood supply and healed after conservative treatment. CONCLUSION: Retrograde sartorius myocutaneous pedicle flaps from the perforating branches of the medial inferior genicular artery or posterior tibial artery have advantages in terms of reliable blood supply, ease of operation and minimal amount of damage, and can be used to repair proximal and middle lower-leg wounds. They are especially applicable when lower-leg flaps are unavailable due to poor soft-tissue conditions following trauma or multiple operations. However, the safety flap size needs to be determined in future studies.

Selection of recipient vessel in traumatic lower extremity.

The main focus of this paper is the selection of proper vessels for successful free tissue transfer in lower extremities which have suffered extensive trauma. The selection of proper recipient vessels for traumatized lower extremities still presents difficulties for surgeons. This review will provide a general guideline for the selection of proper recipient vessels in traumatic lower extremity reconstruction and describe the possible reasons why some recipient vessels present more problems than others.

A new experimental flap design: the saphenous artery periosto-fasciocutaneous flap of the rat.

Vascularized periosteal graft is a frequently applied flap model for bone prefabrication studies due to its inhabitance of osteoprogenitor cells and osteoinductive potential. Various bones such as rib and fibula are reported as a potential source for the harvest of the periosteal flap in experimental studies on higher species such as dogs and pigs, which necessitates a rather complicated and expensive experimental setting. Therefore a reliable and inexpensive small animal model on vascularized periosteal flaps is necessary for future research. A new saphenous artery based periosto-fasciocutaneous flap model in rats is described here, which is easily dissected and monitorized. In this experimental study, 15 male Sprague Dawley rats were operated and killed following a 3-month-long follow-up period . The histological analysis revealed heterotopic osteoneogenesis in 12 of 15 flaps (80%), whereas 14 flaps (93.3%) exhibited signs of angioneogenesis originating from the periostofasciocutaneous flap. The presented flap model promises to be an appropriate alternative for new studies where bone prefabrication methods are evaluated.