A Simplified Technique of Using Bipedicled Fasciocutaneous Flaps in Closure of Soft Tissue Defects of the Anterior Leg in Patients With Fasciotomy Wounds

Abstract

Many cases of lower limb trauma present with compound fractures and the patients undergo fasciotomies to relieve intracompartmental pressure in the muscular compartments of the leg at the time of bony fixation. A fraction of these patients also present with soft tissue defects of the leg with exposed bone or tendons after moderate to severe lower extremity injuries. Bone is often exposed in such wounds on the anterior aspect of the leg because in this area the anterior tibia is a subcutaneous structure. The exposure of bone demands complex reconstructive procedures such as microvascular tissue transfer to treat these wounds. The options for soft tissue reconstruction of these traumatic defects of the leg depend on several factors including the location and size of the defect, the nature of the tissues at the base of the wound (viable fascia or muscle, tendons, or bone), the condition of the adjacent tissues, and the presence of patent vascular structures. The solutions range from simple to complex procedures and include direct closure, split-skin grafting, local fasciocutaneous flaps, and free microvascular tissue transfer. We suggest a relatively simple, and often overlooked option for reconstruction of relatively narrow ( 2.5 cm) longitudinal defects involving the middle third of the anterior leg in patients who have undergone fasciotomies. There have been several reports in the literature of the use of bipedicled fasciocutaneous flaps to cover soft tissue defects of the leg. However, to the best of our knowledge, none has commented on the usefulness of these alreadycreated flaps after fasciotomies of the leg. The strips of intact soft tissue between the traumatic and fasciotomy wounds, on each side, when undermined, are in effect bipedicled fasciocutaneous flaps. To create these flaps, the bridge of tissue is undermined by dissecting the plane between the fascia and the muscle to include the fascia into the flap. On raising the flap, the musculocutaneous perforators, if found, are sacrificed because the blood supply to these flaps is derived from the direct cutaneous vessels that run parallel above the muscle and fascia and are included in the flaps. The flaps can be raised along part or the entire length of the fasciotomy wound. This is dictated by the safe length to width ratio of the flap and the amount of flap mobility needed to provide adequate soft tissue closure of the defect in a tension free manner. The safe length to width ratio of the bipedicled fasciocutaneous flap still remains indeterminate. Ponten and Barcklay found a 3:1 length to breadth ratio to be satisfactory in unilateral fasciocutaneous flap. However, extrapolation to assume a 6:1 ratio would be safe may be invalid as tissue viability of the distal pedicle variants has been less reliable. The ratio we advise is the one used by Hallock, which is 3:1 or less. This technique would not be possible if the fasciotomy wounds were either absent or directly closed. In this regard, every attempt should be made to resist the urge to directly close fasciotomy wounds in such cases since this would impair the mobility of the bipedicled fasciocutaneous flaps. Instead, these fasciotomy wounds should be closed using split-thickness skin grafts (Fig. 1). The usefulness of this technique is, however, limited to defects, which are relatively narrow ( 2.5 cm) and shorter than the fasciotomy wounds with healthy surrounding soft tissues and with the presence of fasciotomy wounds. As in all cases of reconstructive surgery, because of these limitations, careful patient selection is important. Although the cosmetic outcome of split-skin grafting of the fasciotomy wounds is not superior to the linear scar of direct closure, this technique, if applicable, can prevent more complex reconstructive procedures that may be associated with less than ideal cosmetic and functional implications. Despite the numerous reports in the literature of the various techniques to close fasciotomy wounds to avoid skin grafting, this may not be applicable to all cases. We think that this relatively simple principle of sacrificing direct closure of fasciotomy wounds can result in the direct closure of Submitted for publication October 3, 2004. Accepted for publication July 6, 2007. Copyright © 2007 by Lippincott Williams & Wilkins From the Lancashire Teaching Hospitals, Royal Preston Hospital, Manchester, United Kingdom. Address for reprints: Deemesh Oudit, MRCSEd, Apt 1006 Sovereign Point, 31 The Quays, Salford, Manchester M50 3AY, United Kingdom; email: plastnt@hotmail.com.