Electrosurgery Injuries in the Operating Room



Title: Distally Based Lateral and Medial Leg Adipofascial Flaps: Be Cautious in Old and Diabetic Patients

Authors: Yener Demirtas, MD, Suhan Ayhan, MD, Yakup Sariguney, MD, Fulya Findikcioglu, MD, Onur Cukurluoglu, MD, Osman Latifoglu, MD, Seyhan Cenetoglu, MD

Defects around the ankle result from various etiologic factors. Repair of extensive diabetic ulcers requiring a flap represents a major concern for plastic surgeons dealing with lower extremity reconstruction, since the incidence of peripheral vascular disease in these patients is at least four times higher and increases with the patient’s age and duration of diabetes. There is a predilection for occlusive disease to involve primarily the tibial and peroneal arteries between the knee and the ankle,1 and coverage of the malleolus, Achilles tendon or heel has been specially troublesome.2 These defects are very difficult to resurface using random flaps because the skin vascular territory of the random flaps is limited in this region.3

Lateral and medial leg adipofascial flaps distally based on perforators originating from the peroneal and posterior tibial arteries, respectively, were reported to be encouraging in reconstruction of the defects around the ankle.2,4,5-8 Presented here is our clinical experience with these two flaps particularly emphasizing the complicated attempts in diabetic patients.

Material and Methods: Seven patients (2 male and 5 female) having complex skin defects with bone or tendon exposure around the ankle were treated with lateral and medial leg adipofascial flaps.

The lowermost perforators of the peroneal or posterior tibial artery were identified preoperatively with a hand-held Doppler and a straight incision, through skin only, was made proximal to this perforator down to the adipose tissue and long enough to allow tension-free positioning of the flap. The skin edges were dissected in the subdermal plane leaving only a thin layer of superficial adipose tissue on the skin flaps. With the skin flaps reflected, the adipofascial flap was than raised in the subfascial plane. The perforators to be retained in the base were located and the flap was then turned over to cover the defect so that the adipose tissue laid deep and the fascia became superficial followed by application of a split-thickness skin graft over the flap. Donor site was closed primarily.

Results: The ages of the patients ranged from 25 to 80 years, and the size of the flaps ranged from 3 x 5 cm to 7 x 10 cm. Follow-up time varied from 1 to 11 months (Table). Four defects were reconstructed with lateral leg adipofascial flap and medial leg adipofascial flap was utilized in three.

Two flaps (1 lateral and 1 medial) healed uneventfully. Partial or total graft loss and partial flap necrosis were observed in 5 patients, 4 of whom were diabetic (Figure). Debridement and secondary grafting (third in 2 cases) were performed in these diabetic patients to achieve a stable reconstruction.

Conclusion: Leg adipofascial flaps with advantages including a wide arc of rotation, minimal donor site morbidity and an easy dissection without sacrifice of a major artery, offer a valuable option for repair of defects around the ankle in many cases. However, diabetic ulcers constitute a significant fraction of these lesions and adipofascial flaps should be used with caution in old and diabetic patients. Yet when performed, the probability of a second or third procedure should be considered, or skin grafting might perhaps be delayed until the viability of the flap is certain.

Table: Clinical data of the patients.

|Case |Age/Sex |Lesion |Size of primary |Site of flap|Complication |Follow-up (months)|

| | | |wound (cm2) | | | |

|1 |75/F |Rt. calcaneus; external |7x10 |Lat. |Skin graft, partial flap |11 |

| | |splint for calcaneal | | |and donor site marginal | |

| | |fracture, open wound with | | |necrosis. Third graft | |

| | |exposure of calcaneus, | | |needed | |

| | |diabetic, smoker | | | | |

|2 |80/F |Rt. calcaneus; diabetic |4x5 |Lat. |Skin graft and donor site |9 |

| | |ulcer with bone exposure | | |marginal necrosis. Third | |

| | | | | |graft needed | |

|3 |56/F |Lt. medial malleolus; |6x10 |Med. |Skin graft necrosis. Tip |8 |

| | |diabetic ulcer with bone | | |necrosis of flap | |

| | |exposure | | | | |

|4 |25/F |Rt. lateral malleolus; |3x5 |Lat. |Partial graft loss |6 |

| | |calcaneal fracture, | | | | |

| | |post-ORIF bone exposure | | | | |

|5 |42/M |Lt. lower leg; tibial |4x10 |Med. |Nil |6 |

| | |fracture, post-ORIF bone | | | | |

| | |exposure | | | | |

|6 |66/M |Lt. heel, diabetic ulcer |4x8 |Med. |Partial graft loss |4 |

|7 |52/F |Rt. lateral malleolus; |3x5 |Lat. |Nil |1 |

| | |calcaneal fracture, | | | | |

| | |post-ORIF bone exposure | | | | |

[pic]

Figure (Case 3): A; diabetic ulcer on the medial malleolus, skin incision and the lowermost perforator of the posterior tibial artery are marked. B; postoperative thirteenth day, skin graft did not take well. C; postoperative day 40, after debridement of the necrotic graft, granulation tissue covered the flap. D; one month after second grafting (75 days after the first operation), no problems were observed thereafter.

References

1. Reiber, GE,Lipsky, BA, Gibbons, GW. The burden of diabetic foot ulcers. Am J Surg. 176 (Suppl 2A): 5S, 1998.

2. Lee, S, Estela, CM, Burd, A. The lateral distally based adipofascial flap of the lower limb. Br J Plast Surg. 54: 303, 2001.

3. Koshima, I, Itoh, S, Nanba, Y, Tsutsui, T, Takahashi, Y. Medial and lateral malleolar perforator flaps for repair of defects around the ankle. Ann Plast Surg. 51: 579, 2003.

4. Lin, SD, Lai, CS, Chou, CK, Tsai, CW, Tsai, CC. Reconstruction of soft tissue defects of the lower leg with the distally based medial adipofascial flap. Br J Plast Surg. 47: 132, 1994.

5. Lin, SD, Chou, CK, Lin, TM, Wang, HJ, Lai, CS. The distally based lateral adipofascial flap. Br J Plast Surg. 51: 96, 1998.

6. Lin, SD, Wang, HJ, Chou, CK, Kung, FP, Lai, CS. Endoscopically-assisted adipofascial flap harvest for soft tissue defects of the lower leg. Br J Plast Surg. 51: 38, 1998.

7. Cavadas, PC. Reversed saphenous neurocutaneous island flap: clinical experience and evolution to the posterior tibial perforator-saphenous subcutaneous flap. Plast Reconst Surg. 111: 837, 2003.

8. Hashimoto, I, Yoshinaga, R, Toda, M, Nakanishi, T. Intractable malleolar bursitis treated with lateral calcaneal artery adipofascial flap. Br J Plast Surg. 56: 701, 2003.

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