Peroneal Flap Research Articles

Treatment strategies of recurrent jaw osteosarcoma: case report

Osteosarcoma of jaw is a rare malignant neoplasm of the maxillofacial region. Morphologically and radiologically identical to trunk and extremities sarcomas, but clinical features and prognosis of the disease have important differences. The strategy in treatment of gnathic sarcomas extrapolated from peripheral sarcomas, and represents an integrated multidisciplinary approach. The role of neoadjuvant chemotherapy remains controversial as well as adjuvant chemotherapy due to lack of clinical research. Surgical treatment with achievement of clean resection margins is the main favorable prognostic factor. Fibular free flap has been widely used for the last decade for mandible reconstruction. The strategies of treatment recurrent disease directly depend on ability to perform complete resection. Despite increased technical complexity, secondary free peroneal flap reconstruction can be performed safely, reliably, and with similar results to the premier segmental mandibulectomy. The use of radiation therapy is limited to unresectable or recurrent lesions. Well known that jaw osteosarcomas have a relatively higher survival rate and low metastasis rate, however, local recurrences significantly worsen the prognosis of patients. The following is a clinical case of treatment recurrent jaw osteosarcoma using second fibular free flap.

Comparison of the outcomes of anterolateral thigh flap and peroneal flap in total laryngectomy reconstruction.

We usually use an ALT or peroneal flap in total laryngectomy reconstruction, depending on the surgeons' preference. No direct comparison of the outcomes of the ALT flap and peroneal flap exists. From 2014 to 2022, we reviewed patients who had total laryngectomy and were reconstructed with an ALT flap and peroneal flap. Patient characteristics and surgical outcomes were collected and compared. The peroneal group had a significantly higher risk of neopharynx leakage (40% vs. 13.2%, p = .020) and late pharyngocutaneous fistula formation (30% vs. 5.3%, p = .009) than the ALT group. Peroneal flap was found to be the only independent risk factor for neopharynx leakage (p = .025, odds ratio [OR] = 5.5) and late pharyngocutaneous fistula formation (p = .02, OR = 7.7) in multivariate logistic regression. In the reconstruction of total laryngectomy, the ALT flap is preferable over the peroneal flap.

Reconstruction of extensive resection cavities after surgical treatment of the floor of the mouth cancer using two free flaps (ALT and peroneal) on microvascular anastomoses and a free chimeric flap (peroneal)

<br/>INTRODUCTION: The authors present two case reports of patients in whom it was possible to perform a reconstruction of an extensive postoperative cavity created during the resection of the floor of the mouth and the mandible cancer. Due to their size, the cavities had to be reconstructed with the use of specially formed flaps.<br/> <br/>CASES: In the first case, in a patient with local recurrence after previous resection of the floor of the mouth cancer and bilateral neck lymph node surgery with a sagittal flap reconstruction performed in a different clinic, there were created two separate microvascular flaps - an ALT (anterolateral thigh) flap and a peroneal flap. In the second case we present a patient diagnosed with carcinoma of the floor of the mouth and the body of the tongue with infiltration of the mandible with metastases to the lymph nodes of the neck bilaterally. Due to favorable anatomical conditions, it was possible to create a chimeric sagittal flap with two skin islands, and only one microvascular anastomosis was needed for the reconstruction of the cavity.<br/> <br/>DISCUSSION: Single free flaps used in the reconstruction of cavities after resection of cancers of the floor of the mouth are limited by their size and length of the pedicle, specific to the donor areas. These limitations result in the necessity to use two free flaps for the reconstruction of cavities after extensive resections of carcinomas of the floor of the mouth, tongue, mandible and adjacent structures. Chimeric flaps reduce the risk of complications in such a situation, allowing to perform few microvascular anastomoses and reducing the number of dose fields.<br/>

Two-point flap blood glucose measurement for monitoring propeller flap perfusion – a case report

Monitoring flap perfusion is a helpful method of postoperative care allowing for proper early intervention in and salvage of a flap. The basic means of blood supply monitoring include the assessment of color, warmth, skin tension, and a pin-prick examination. Along with advances in microvascular surgery, methods of flap blood circulation assessment have been also developed. This paper presents the case of a peroneal artery propeller perforator flap for the treatment of a secondary wound resulting from an orthopedic complication of ankle arthrodesis. Blood glucose level (BGL) was used to monitor flap perfusion as an early indicator of possible venous congestion. It is well known that in case of vascular compromise, whether arterial or venous, the flap salvage rate depends on how fast the vascular problem is resolved. Arterial insufficiency is easily detectable, and the arterial flow may be also monitored with minidoppler, however venous insufficiency causes symptoms less dynamically. This fact emphasized the importance of early prediction of venous insufficiency before clinical symptoms appear. It is crucial that the time between pedicle impairment and clinical signs is as short as possible.

Peroneal flap: How to harvest and clinical appraisal for head and neck reconstruction

A peroneal flap, the boneless version of fibula flap, is considered as the equivalent of radial forearm flap of the lower leg. Because it is thinner than an anterolateral thigh (ALT) flap, the use of a peroneal flap is a viable option for the repair of soft tissue defects when a thin flap could bring about better functional and cosmetic outcomes. In this article, we describe the details of peroneal flap harvest and present our experience with the use of peroneal flaps for head and neck reconstruction. Between 1996 and 2017, a total of 265 peroneal flaps were used to reconstruct a variety of head and neck defects. With the same vascular anatomy and slight modifications to the harvesting technique of a fibula flap, a peroneal flap can be harvested within 1-2 h. All medical records were retrospectively reviewed. A peroneal flap can be harvested as different types of chimeric flaps to fit a variety of head and neck defects. The peroneal flap failure rate was 3.4% and the postoperative complication rate was 12.8%. A peroneal flap might be an alternative option for the reconstruction of head and neck defects.

Distally based peroneal artery perforator-plus fasciocutaneous flap in the reconstruction of soft tissue defects over the distal forefoot: a retrospectively analyzed clinical trial

BackgroundDistally based peroneal artery perforator-plus fasciocutaneous (DPAPF) flaps are widely used for reconstructing soft-tissue defects of the lower extremity. However, reports on the reconstruction of the defects over the distal forefoot using the DPAPF flaps are scarce. Herein, we describe our experience on the reconstruction of these defects using DPAPF flaps in a considerable sample size.MethodsBetween February 2005 and August 2019, a total of 56 DPAPF flaps in 56 patients were used to reconstruct soft-tissue defects in the forefoot. In order to reduce the length of fascial pedicle and the total length of the DPAPF flaps, the ankles were fixed in dorsiflexion using a Kirschner wire before designing the flaps. The flaps were elevated by the anterograde–retrograde approach. Patient factors and flap factors were compared between the “survival” and “partial necrosis” groups.ResultsOverall, 47 flaps had survived completely in one stage. Partial necrosis developed in nine flaps, with only one remnant defect covered using a local flap. By fixing the ankles in dorsiflexion, the length of the fascial pedicle was reduced approximately 2.35 ± 0.58 cm, the total length of the flap was simultaneously shortened by the same amount as the length of the fascial pedicle. The width of the fascia pedicle varied from 3.0 cm to 6.0 cm. The fascial pedicle width > 4 cm was found in 21 flaps. The partial necrosis rate of the DPAPF flaps with the top edge located in the 8th zone was significantly lower than that in the 9th zone (p < 0.05).ConclusionsThe DPAPF flaps can be effectively used to reconstruct the defects over the distal forefoot because of convenient harvest and reliability. By fixing the ankle in dorsiflexion with Kirschner wire and widening the fascial pedicle appropriately, the top edge and LWR of the flaps will be decreased, and thus the procedures are helpful for the flaps survival.

A study on perforating peroneal artery

Aims. Peroneal flap with vascular pedicles is considered as a good substitute for limb reconstructions or any other soft tissue defects because of the number of perforating branches given from the PA. Purpose of this study is to evaluate the branching and communicating pattern of distal most perforating peroneal artery (PP). Methods. Dissected lower limbs of 48 cadavers were studied for the course and communications of PP. Results. The study encountered usual as well as variant communications of PP. In about 12% of the study sample PP continued as DPA and in about 6% of the cases it was communicated with DPA dorsal to the talar head region. The most frequent finding in the present study is PP piercing the interosseous membrane between tibia and fibula at about 6 to 6.5cm proximal to the tip of lateral malleolus. In one of the specimens it was piercing the LM at the base of LM. Conclusions. The results of present study imply a cautious dissection to locate an appropriate vascular pedicle for the flap surgery as there are small communications of PP with ATA as well as DPA and PP can also take variant course. Because failure to do so may lead to accidental and serious vascular injuries.

Microsurgical repair of soft tissue necrosis after beak-type calcaneal fracture in 8 cases

Objective To investigate the clinical efficacy of microsurgical repair of soft tissue necrosis after beak-type calcaneal fracture. Methods From January, 2012 to March, 2017, surgically flaps were used to repair wounds in 8 patients with soft tissue necrosis after calcaneal beak fracture. Five patients underwent sural neurovascular flap in the first stage of repair, 2 patients were treated with peroneal perforator propeller flap, and 1 patient was treated with posterior tibial artery perforator propeller flap. The donor sites of 3 flaps were directly closed, and donor areas of the remaining 5 were covered with medium-thickness skin grafts without being sutured directly. The size of flap was 5.0 cm × 3.0 cm-7.0 cm × 5.0 cm. Through postoperative outpatient and WeChat follow-up. The patient’s flap survival, infection, flap shape, sensation and ankle function were evaluated. Results All flaps and skin grafts survived post-operatively. All patients were followed-up for 6-12 (mean, 8.4) months. All patients had good flap survival and no complications such as soft tissue and calcaneal infection. The flaps were good in texture, shape and function of ankle. At the last follow-up, according to the British Medical Research Institute (BMRI), the sensory function was divided into 6 levels. The flap sensory function recovered to S2 in 3 cases, and the remaining 5 cases was S1. According to the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-hindfoot Scale (AHS), the results were excellent in 5 cases, and good in 3 cases. All patients had good clinical results and satisfaction at the last followed-up. Conclusion The treatment of soft tissue necrosis after calcaneus beak fractures can be completed in one stage by using flaps, which avoided the occurrence of calcaneal osteomyelitis. It is easy to perform early rehabilitation exercise and the ankle function is well restored. Key words: Calcaneus; Beak fracture; Propeller flap; Sural neurovascular flap; Microsurgical technique

Radioterapia en colgajos peroneos. Revisión de la densidad ósea y complicaciones en colgajos peroneos irradiados frente a no irradiados

espanolIntroduccion: El colgajo peroneo es actualmente una de las tecnicas mas elegidas para la reconstruccion de defectos mandibulares. Muchos de los pacientes reconstruidos con este colgajo presentan patologia oncologica que precisa tratamiento adyuvante con radioterapia. Los efectos adversos de la radioterapia sobre los tejidos son conocidos, pudiendo desembocar en osteoradionecrosis. El objetivo de este estudio es el analisis de la densidad osea de los colgajos peroneos en los pacientes que han recibido radioterapia frente a los que no y su posible correlacion con las complicaciones posteriores. Material y metodos: Realizamos un estudio retrospectivo de los colgajos peroneos realizados por nuestro servicio desde enero 2011 hasta diciembre 2016. Los criterios de inclusion de los pacientes fue el haber sido reconstruidos con un colgajo peroneo y disponer de un TC de control a los tres meses postradioterapia en caso de haberla precisado. Se recogio la edad, densidad osea peronea, desviacion estandar cuerpo mandibular remanente y colgajo peroneo, asi como las complicaciones postoperatorias. Los datos extraidos fueron analizados a traves del Software SAS (Statistical Analisys System). Resultados: En total se recogieron 61 pacientes, siendo la media de edad de 54,46 anos. De estos 61 pacientes se excluyeron 11 al no presentar TC de control; de los 50 pacientes restantes, 27 recibieron tratamiento radioterapico adyuvante (54 %), mientras que 23 no la recibieron (46 %). En los pacientes irradiados, un alto porcentaje (84,62 %) recibieron altas dosis de radioterapia (> 60 Gy). Se encontraron diferencias estadisticamente significativas (p Discusion: Las nuevas tecnicas de radioterapia de intensidad modulada permiten una dosis relativamente uniforme en un objetivo, evitando altas dosis en los tejidos circuncidantes. A pesar del avance en las tecnicas de radioterapia, actualmente en la mayoria de centros se continua realizando un tratamiento completo del volumen del lecho tumoral, que incluye en el campo de irradiacion el colgajo con el que se reconstruye. Los casos de osteonecrosis mandibular que se presentaron fueron en pacientes irradiados y a nivel del cuerpo mandibular remanente. La densidad osea a nivel del colgajo peroneo si que presento diferencias estadisticamente significativas en pacientes irradiados frente a no irradiados; este aspecto puede influir en el indice de complicaciones. Conclusiones: Consideramos, con los resultados del estudio, plantear nuevos estudios prospectivos para valorar la necesidad de irradiar el tejido oseo del colgajo peroneo como parte del volumen del lecho tumoral, siendo que este tejido no ha estado en contacto con el tumor primario, ante el mayor indice de complicaciones asociados a la radioterapia en estos tejidos. EnglishIntroduction: The fibular flap is currently one of the most chosen techniques for the reconstruction of mandibular defects. Many of the patients reconstructed with this flap present oncological pathology that requires adjuvant treatment with radiotherapy. The adverse effects of radiotherapy on tissues are known, and can lead to osteoradionecrosis. The aim of this study is to analyze the bone density of peroneal flaps in patients who have received radiotherapy against those who do not and their possible correlation with subsequent complications. Material and methods: We designed a retrospective study of the fibular flaps performed by our service from January 2011 to December 2016. The criteria for inclusion of patients was to have been reconstructed with a peroneal flap and have a control CT at 3 months after radiotherapy. Age, bone density, standard deviation and further complications were extracted. The extracted data was analyzed through the SAS (statistical Analisys System) Software. Results: 61 patients were collected; the mean age was of 54.46 years. Of these 61 patients were excluded 11 by not presenting control TC, of the 50 patients remaining, 27 received adjuvant radiotherapy treatment (54 %) while 23 did not receive (46 %). In irradiated patients a high percentage (84.62 %) received high doses of radiotherapy (> 60 Gy). Statistically significant differences were found (P Discussion: The new techniques of intensity-modulated radiotherapy allow a relatively uniform dose in a target, avoiding high doses in the circumcising tissues. Despite the progress in radiotherapy techniques, currently in most centers, it continues to perform a complete treatment of the volume of the tumor bed that includes in the field of irradiation the flap with which it is reconstructed. The cases of mandibular osteonecrosis that were presented were in irradiated patients and in the remaining mandible. Bone density at the level of the fibular flap showed statistically significant differences in irradiated patients compared to non-irradiated, this aspect may influence in the index of complications. Conclusions: We consider to propose new prospective studies to assess the need to irradiate the bone tissue of the fibular flap as part of the volume of the tumor bed, knowing that this tissue has not been in contact with the primary tumor, and the high index of complications associated with radiotherapy.

Vertical distraction osteogenesis of a reconstructed mandible with a free vascularized fibula flap: a report of two cases

BackgroundThe free vascularized fibula flap presents many advantages such as sufficient length of the bony segment, good vascularization, better quality of the bone, and a long vascular pedicle, but it is also associated with some disadvantages with regard to prosthetic rehabilitation because of its limited height. Improvement in bone height is necessary for ideal dental implant treatment of reconstructed mandibles.Case presentationFor two squamous cell carcinoma patients, mandibular bone reconstruction was performed secondarily with the peroneal flap after tumor resection. Since the bone height was insufficient at the time of implant treatment, occlusion reconstruction by dental implant was performed after vertical distraction osteogenesis.ConclusionsVertical distraction osteogenesis is a suitable treatment option for alveolar ridge deficiency resulting from fibula transplantation for mandibular reconstruction following tumor surgery.

Obliquely-arranged double skin paddles: A novel design to reconstruct extensive head and neck defects with a single fibula or peroneal flap.

To reconstruct extensive head and neck defects usually necessitates double free flaps, which require a time-and-manpower-consuming surgical procedure. We present using a single fibula or peroneal flap with the novel design of obliquely-arranged double skin paddles to reconstruct an extensive head and neck defect. From 1998 to 2016, eight patients with the age of 52.25 (35-71) years old had extensive head and neck defects after oral cancer ablation. All of the defects were through and through with the size of 16.25 (12-24) cm × 8.8 (4.5-11) cm. Six of the defects were due to buccal cancer. One was due to tongue cancer, and another one was due to gingiva cancer. All the defects were reconstructed with obliquely-arranged double-paddle free fibula or peroneal flaps. The long axis of the skin paddles was arranged at certain angle (30-45 degrees) to the long axis of lower leg, and the two separate skin paddles were used as the form of island flaps by isolating the cutaneous perforators to create a true chimeric flap. The skin paddle sizes were 14 cm × 3 cm-24 cm × 11 cm and 9.5 cm × 4.5 cm-13 cm × 8 cm. The average length of harvested fibula was 19 (10-30) cm. All of the eight flaps survived without obvious donor site morbidity. One patient had partial skin necrosis over recipient site, requiring surgical debridements and closure. One patient had superficial necrosis over the edge of outer skin paddle, which healed spontaneously. After the follow-up periods of 1 month to 3 year and 8 months, two patients died of sepsis. Six of them could resume soft diet and had no saliva drooling. The remaining two remained nasogastric diet and had saliva drooling. With the design of obliquely-arranged double paddles, we may maximize the harvested skin area of lateral lower leg to reconstruct an extensive head and neck defect with a single free flap.

Combination of vascularized fibular head epiphysis and superficial peroneal neurovascular reverse flap repair defects of bone and skin in lateral malleolus in children

Objective To explore the clinical effect of combination of vascularized fibular head epiphysis and peroneal neurovascular reverse flap repair defects of bone and skin in lateral malleolus in children. Methods Eight children with defects of bone and skin in lateral malleolus were recruited from May, 2009 to September, 2014. The age of children was ranging from 4 to 12 years old. Four children were injured by wheel twist, 2 children were injured by traffic accident, 1 was injured by machinery, and 1 was crashed with heavy object. The size of soft-tissue defect was ranging from 3 cm × 5 cm to 7 cm × 9 cm. The flap and bone healing along with ankle joint function scoring were evaluated. Patients were reviewed every 4 to 6 weeks during one year after their surgery, and they were reviewed every 6 months one year later. Results Secondary repair were conducted in all children. The curative effect got well after follow up for 6 months to 2 years(mean, 12 months). The flap and fibular head epiphysis were well developed. The ossification of fibular head epiphysis did not found. According to American Orthopaedic Foot and Ankle Society (AOFAS) ankle function evaluation criteria, the results were excellent in 5 cases, good in 2 cases and poor in 1 at 10 months after operation. The shape and function of ankle joint were good, with one exception. The average motion degree of ankle joint was (68±5.12) °. Conclusion Combination of vascularized fibular head epiphysis and peroneal neurovascular reverse flap repair defects of bone and skin in lateral malleolus in children is effective. Key words: Lateral malleolus injury; Fibular head; Superficial peroneal neurovascular reverse flap; Children

Peroneal Flap for Tongue Reconstruction.

Background For large tongue defects, reconstructive surgeons have devised a variety of feasible options, such as radial forearm free flap and anterolateral thigh (ALT) flap. In our institution, peroneal flap has been the workhorse flap for the soft tissue defect in head and neck reconstruction. We present our experience using peroneal flap in tongue reconstruction. Patients and Methods The study included 47 patients who had undergone tongue reconstructions with peroneal flaps after tumor resection. The size and location of the defect after tumor resection determined whether the peroneal flaps could be harvested as pure septocutaneous flaps to solely reconstruct the neotongue or to carry an additional muscle bulk to fill the adjacent defect. Retrospective chart review was used to look for postoperative complications and to perform functional assessments (which were also performed through telephone inquiry). Results Of the 47 patients, 3 (6%) had flap failure and 1 (2.1%) had partial flap necrosis. The hemiglossectomy group had better results than the total glossectomy group with respect to speech and diet, but neither of these results reached statistical significance (p = 1.0 for speech and p = 0.06 for diet). The results of the subtotal glossectomy group were better than those of the total glossectomy group with respect to diet (p = 0.03). No statistically significant differences were noted among the three groups with respect to cosmetic aspect (p = 0.64). Conclusions Considering its reasonable postoperative complication rates and functional results, peroneal flap can be considered a feasible option for tongue reconstruction.

A Novel Application of Double-Paddle Peroneal Chimeric Flap as External Sentinel Monitor in Hypopharyngeal Reconstruction

Monitoring the viability of buried free flaps in hypopharyngeal reconstruction is difficult. Various methods have been proposed to monitor these buried flaps, but limitations remain. We present a method of using double-paddle chimeric peroneal flaps that permanently externalizes a flap skin paddle as a monitoring paddle in hypopharyngeal reconstructions. This study was performed in a medical center in southern Taiwan; between 2013 and 2015, 10 patients underwent double-paddle chimeric peroneal flap reconstruction in advanced stages of hypopharyngeal cancer. We retrospectively reviewed the medical records from these surgeries, searching for either short-term postoperative complications or long-term follow-up morbidity and researched relevant articles for comparisons with other monitoring methods. None of the 10 flaps underwent total loss. The rate of stenosis and that of fistula formation was 10%. The average postoperative hospital stay was 39 days. Six of 10 patients were able to resume at least a soft diet after reconstruction, and none of the patients experienced significant complications. The peroneal flap is a useful flap because it is thin and pliable, has minimal donor site morbidity in patients without peripheral vascular disease, and has the potential of multiple skin paddles so that one skin paddle can be used for monitoring the buried flap. Using this method, direct clinical monitoring is feasible, and early detection of vascular complications is possible. Furthermore, the drawbacks of using a monitoring paddle produced by a deepithelialized bridge can be avoided.

Peroneal Flap: Clinical Application and Cadaveric Study.

BackgroundThe goal of this study was to investigate the anatomy of the peroneal artery and its perforators, and to report the clinical results of reconstruction with peroneal artery perforator flaps.MethodsThe authors dissected 4 cadaver legs and investigated the distribution, course, origin, number, type, and length of the perforators. Peroneal artery perforator flap surgery was performed on 29 patients.ResultsWe identified 19 perforators in 4 legs. The mean number of perforators was 4.8 per leg, and the mean length was 4.8 cm. Five perforators were found proximally, 9 medially, and 5 distally. We found 12 true septocutaneous perforators and 7 musculocutaneous perforators. Four emerged from the posterior tibia artery, and 15 were from the peroneal artery. The peroneal artery perforator flap was used in 29 patients. Retrograde island peroneal flaps were used in 8 cases, anterograde island peroneal flaps in 5 cases, and free peroneal flaps in 16 cases. The mean age was 59.9 years, and the defect size ranged from 2.0 cm×4.5 cm to 8.0 cm×8.0 cm. All the flaps survived. Five flaps developed partial skin necrosis. In 2 cases, a split-thickness skin graft was performed, and the other 3 cases were treated without any additional procedures.ConclusionsThe peroneal artery perforator flap is a good alternative for the reconstruction of soft tissue defects, with a constant and reliable vascular pedicle, thin and pliable skin, and the possibility of creating a composite tissue flap.

The retrospectively analysis of risk factor with free transplanted compound tissue necrosis

Objective To analyse the risk factor of vascular crisis following free compound tissue transplantation in order to avoid the risk factor and improve the survival rate of free compound tissue. Methods Sixteen patients with free compound tissue transplantation were retrospectively reviewed between June, 2010 and December, 2015. The age, sex, injury reason, operation time, injury site and donor vessel of the patients were recorded and analysed.The risk factors of free transplanted compound tissue necrosis were concluded. Results Of 16 cases, 5 cases were anterolateral thigh flap, 4 cases medial peroneal artery flap, 2 cases osteocutaneous flap, 1 case toe transplantation, 1 case medial plantar artery flap, 1 case forearm reverse interosseous posterior artery flap and 1 case groin flap. In 16 patients with free compound tissue transplantation, there was no difference in sex and age (P>0.05) . The percentage was higher in the patients injured by vehicle than the patients injured by non-vehicle (P<0.05) . The percentage was lower in the patients with operation within 4 weeks after wound than beyond 4 weeks (P<0.05) .Transplanted tissue necrosis was prone to appear in the patients with low limb injury. The incidence of transplanted tissue necrosis was higher in low limb than in upper limb, and the highest in foot (P<0.05) . If the donor vessel was the dorsalis pedis artery, anterior tibial artery or posterior tibial artery, the incidence of transplanted tissue necrosis was very high. The highest rate was the dorsalis pedis artery (P<0.05) . Conclusion Injury by vehicle, surgery happening beyond 4 weeks after wound and injury in low limb were the high risk factor of tissue necrosis following free compound tissue transplantation. Key words: Surgical flap; Vascular crisis; Necrosis; Risk factor; Retrospectively analusis

Double-paddle peroneal flap for extensive lip defect reconstruction.

Today, reconstructive surgeons offer an array of options to reconstruct the lip defects. Herein we present our experience of using free double-paddle peroneal flaps for extensive lip defect reconstruction. From 1996 to 2014, 16 patients with extensive lip defects after tumor ablation were included. Free double-paddle peroneal flaps were used for reconstructions. In terms of flap design, one skin paddle superiorly placed on the lateral lower leg was used to reconstruct intraoral defects, whereas the other was inferiorly located and was used to reconstruct extraoral defects. A part of the inner skin paddle was everted, and the suture line with the outer skin paddle became the new vermilion border. A portion of the outer skin paddle could be de-epithelized and tucked into the fold of the inner skin paddle, leading to greater fullness of the new lip. Skin paddle sizes were 10-15 cm × 3-13 cm and 4-10.5 cm × 2.5-10.5 cm. Venous thrombosis occurred in one patient but was salvaged, and one flap had superficial necrosis over the outer paddle that was conservatively treated. In the 0.5-33 month follow-up period, all patients were able to close their mouths without obvious drooling. Free double-paddle peroneal flap transfer could augment lip definition, deepen the labial vestibule, and provide an acute-angle oral commissure, leading to satisfactory oral competency and improved cosmetic results. Therefore, this technique may be considered a viable option for extensive lip defect reconstruction.

Antegrade Peroneal Flap through the Interosseous Membrane for Knee and Distal Femur Coverage.

Antegrade peroneal flaps can be rotated around the fibula to cover defects in the lower leg and lateral knee. However, these flaps cannot reliably cover the distal femur and anterior and medial knee. In the present article, the authors describe a novel technical modification that involves creating a tunnel through the interosseous membrane, through which the flap can be passed, circumventing the need to rotate around the fibula, allowing it to reach the entire knee and distal femur. An anatomical study was performed in five cadaveric specimens to measure the gain in pedicle reaching distance when the flap is tunneled compared to transferred around the fibula. A clinical study in 12 patients was also performed to measure the gain in pedicle reaching distance and the long-term viability of the tunneled interosseous flap. In the anatomical study, the mean reaching distance was 7.4 ± 0.9 cm for the flaps rotated around the fibula and 17.0 ± 1.6 for the tunneled interosseous flaps (p < 0.001). In the clinical study, the mean reaching distance was 2.6 ± 1.4 cm for the flaps rotated around the fibula and 11.4 ± 2.4 for the tunneled interosseous flaps (p < 0.0000000001). Patients were followed for up to 4 years (mean, 2.5 years). All flaps survived completely, and there were no complications. By passing the antegrade peroneal flap through the interosseous membrane, instead of around the fibula, the flap reaching distance can be increased by approximately 8 cm, allowing for effective coverage of distal femur and knee defects. Therapeutic, IV.

Perforator Peroneal Artery Flap for Tongue Reconstruction.

Reconstruction has evolved long way from primary closure to flaps. As time evolved, better understanding of vascularity of flap has led to the development of innovative reconstructive techniques. These flaps can be raised from various parts of the body for reconstruction and have shown least donor site morbidity. We use one such peroneal artery perforator flap for tongue reconstruction with advantage of thin pliable flap, minimal donor site morbidity and hidden scar. Our patient 57yrs old lady underwent wide local excision with selective neck dissection. Perforators are marked about 10 and 15 cm inferiorly from the fibular head using hand held Doppler. Leg is positioned in such a way to give better exposure during dissection of the flap and flap is harvested under a tourniquet with pressure kept 350 mm Hg. The perforator is kept at the eccentric location, so as to gain length of the pedicle. Skin incison is placed over the peroneal muscle and deepened unto the deep facia, then the dissection is continued over the muscle and the perforator arising from the lateral septum. The proximal perforator about 10 cm from the fibular head is a constant perforator and bigger one, which is traced up to the peroneal vessel. We could get a 6 cm of pedicle length. Finally the flap is islanded on this perforator and the pedicle is ligated and flap harvested. Anastamosis was done to the ipsilateral side to facial vessels. The donor site is closed primarily and in the upper half one can harvest 5 cm width flap without requiring a skin graft along with a length of 8 to 12 cm. Various local and free flap has been used for reconstruction of partial tongue defects with its obvious donor site problems, like less pliable skin and not so adequate tissue from local flaps and sacrificing a important artery as in radial forearm flap serves as the work horse in reconstruction of partial tongue defects, Concept of super microsurgery was popularized by Japanese in 1980s and the concept of angiosome proposed by Taylor paved the way for development of new flaps. True perforator flaps are those where the source vessel is left undisturbed and overlying skin flap is raised. Yoshimura proposed cutaneous flap could be raised from peroneal artery (Br J Plast Surg 42:715-718, 1989). Wolff et al. (Plast Reconstr Surg 113:107-113, 2004) first used perforator based peroneal artery flap for oral reconstruction. Location of perforators vary, hence pre operative localisation can be done by ultrasound doppler, CT angio or MR angiography. Disadvantages over radial flap include varying anatomic location of perforators, need for imaging and difficult dissection of delicate vessels through muscles and hence a learning curve. Our patient had an arterial thrombus within few hours post-operatively which was successfully salvaged with immediate re-exploration and re-anastomosis of artery. Post-operative healing was uneventful and donor site was closed primarily without the need for graft. Perforator peroneal flap serves as a useful armamentarium for reconstruction of moderate size defects of tongue, buccal mucosa and floor of mouth with advantages of thin pliable flap, minimal donor site morbidity and hidden scar.

A reversed superficial peroneal neurocutaneous island flap for reconstruction of defect of heel

A reversed superficial peroneal neurocutaneous island flap for reconstruction of defect of heel