Der Saphenusperforatorlappen

Abstract

Replacement of full thickness soft tissue defects in the lower leg and ankle, appropriate to the defect and following the course of blood vessels feeding the skin of a distally hinged fasciocutaneous flap most reliably based on the individual anatomy of distal perforators of the posterior tibial artery. Full thickness soft tissue defects, up to 12 cm in length and up to 8 cm in width. Sufficient vascularization of the foot required, in osteomyelitis, and when joints, fractures, implants and tendons are exposed and when a split skin graft, a local flap, a suralis perforator flap or a free flap is not indicated. For patients, in whom a 1-2 h operation is not possible; necessity of angioplasty; decollement or scars around the distal perforators of the posterior tibial artery; local infection or necrosis of soft tissues and/or bone, which cannot be totally excised. Radical debridement; flap dissection without tourniquet; microdissection; design of the flap on the skin: pivot point ~ 10 cm (6-14 cm) proximal of the tip of the medial malleolus; base ~ 5 cm in width, between the course of the saphenous nerve and of the great saphenous vein and the Achilles tendon; adipofascial pedicle up to 15 cm in length sited over the septum between soleus and flexor digitorum muscles, following the course of the saphenous nerve, with a central skin stripe, which expands into a proximal skin island; skin island is outlined similar to the defect, but larger by 1 to 2 cm, surrounded by an adipofascial border: adjustment of the planning as well as of the elevation of these flaps according to the individual position and the caliber of perforators requires in each case the search for a perforator at the estimated pivot point. Delay of transposition, if the division of more than one perforator proximal to the pivot point obviously diminishes circulation. No "tunnelling "of the pedicle; defects of skin due to the elevation of the flap are replaced by split and meshed skin grafts or temporary by "artificial skin". A gap in the bandage over the skin island allows for observation. Protocol of controls of vascularization: color and time for revascularization; antibiotic treatment according to bacteriological testing. In case of edema or discoloration of the flap: immediate removal of sutures, administration of leeches, operative revision. Split skin graft 1 week after flap transposition, if the skin had been temporary substituted. Retrospective uncontrolled study with over 70 saphenous perforator flaps from 1995-2011. Full soft tissue defects 62 times with osteomyelitis, 3 times with endoprothesis, 3 times with fractures, 2 times with exposed tendons. From 1995-2006, 44/50 (88 %) flaps healed completely or at least to 3/4 without the necessity of further flaps; from 2007-2011, 13/20 (65 %) flaps healed completely and 6/20 (30 %) flaps healed at least to 3/4 without the necessity of further flaps, loss of one flap (5 %).