Posterior Tibial Artery Perforator Research Articles

Posterior Tibial Artery Perforator Flap for Reconstruction of Soft Tissue Defects in the Middle and Lower Thirds of Leg and Ankle Region: A Prospective Observational Study

Posterior Tibial Artery Perforator Flap for Reconstruction of Soft Tissue Defects in the Middle and Lower Thirds of Leg and Ankle Region: A Prospective Observational Study

Anatomical study of the architecture of the cutaneous branch-chained blood vessels in the medial lower leg in adult

Objective: To investigate the architecture of the cutaneous branch-chained blood vessels in the medial lower leg and provide the anatomical basis for design and clinical application of the cutaneous branch-chained flap from this region. Methods: The experimental research method was used. From March to May 2023, the anatomical study was conducted on the 5 voluntarily donated fresh adult (aged 50 to 70 years, all male) cadaveric specimens from Hangzhou Normal University School of Basic Medical Sciences. The fine anatomy under microscope was performed on each lower leg specimens of 5 corpses (1 lower leg specimen was conducted with digital radiography (DR) scan before fine anatomy), to observe, measure, and record the course of posterior tibial artery, quantity of perforator, the distance between the perforating point of each perforator and the medial condyle of tibia, the external diameter of posterior tibial artery perforator, the length of perforator pedicle, the horizontal distance between the posterior tibial artery perforator and the saphenous nerve, and the course of each perforator within superficial fascia after crossing the deep fascia and the distribution of the cutaneous branch-chains. The DR scan under the perfusion of barium sulfate was conducted in one lower leg specimen to observe the distribution of cutaneous branch-chained vascular network (hereinafter referred to as vascular chain) between perforators. Transparent skin specimen was made from one leg specimen after anatomy to observe the distribution of perforators and vascular chains between perforators. Results: In 5 lower leg specimens, the upper part of posterior tibial artery was located deep in soleus muscle, and the lower part was located between the medial edge of gastrocnemius muscle and flexor digitorum longus muscle. A total of 28 posterior tibial artery perforators were identified, with an average of 5.6 branches in each lower leg. The distance between the perforating point of perforator and the medial condyle of tibia ranged from 6.5 to 36.0 cm, mainly distributed at 22.0 (15.1, 28.1) cm from the medial condyle of tibia, in zones 3 to 6. The external diameters of perforators of posterior tibial arteries were 0.7-1.1 mm. The length of perforator pedicle was 1.0-4.5 cm, and the horizontal distance between the posterior tibial artery perforator and the saphenous nerve was 0.5-3.0 cm. The fine anatomy under microscope showed that the posterior tibial artery perforators had long upward and downward branches after crossing the deep fascia, and the ascending branches and descending branches were anastomosed longitudinally to form the nutrient cutaneous branch-chain in the medial lower leg. DR scan and transparent skin specimen both showed that longitudinal vascular chain was formed between the posterior tibial artery perforators, the transparent skin specimen also showed that longitudinal blood vessel chains included the direct connecting vessels in the adipose layer and the indirect connecting vessels in the subdermal layer. Conclusions: The cutaneous branch-chained vessels in the medial lower leg are constructed by posterior tibial artery perforators, direct connecting vessels, indirect connecting vessels, and traffic branches. The cutaneous branch-chained flap is reliable in terms of vascular anatomy, and can carry the saphenous nerve for partial restoration of its sensation, thus it is an ideal flap.

Clinical application of posterior tibial artery or peroneal artery perforator flap in curing plate exposure after ankle fracture fixation.

The study aims to evaluate the clinical application of posterior tibial artery or peroneal artery perforator flap in the treatment of plate exposure after ankle fracture fixation. A posterior tibial artery or peroneal artery perforator flap was used on 16 patients with plate exposure after ankle fracture fixation in our hospital between July 2018 and July 2021. The time required to harvest the flap, the amount of intraoperative blood loss, the duration of postoperative drainage tube placement, the outcome of the flap and the healing observed at the donor site are reported. The sizes of the flaps were 2.5-7.0 cm × 5.0-18.0 cm and averaged 4.0 cm × 12.0 cm. The time required to harvest the posterior tibial artery or peroneal artery perforator flap ranged from 35 to 55 min and averaged 45 min. The amount of intraoperative blood loss ranged from 20 to 50 mL and averaged 35 mL. The duration of postoperative drainage tube placement ranged from 3 to 5 days and averaged 4 days. A total of 15 flaps survived and one flap had partial necrosis and survived after conservative treatment. All donor area defects were directly sewed and stitched without complications. There are multiple advantages of the posterior tibial artery or peroneal artery perforator flap, including simple preparation technique, reliable repair of the defects and without the need for performing microvascular anastomosis. It can be safely used in curing plate exposure after ankle fracture fixation and worth popularizing in grassroots hospitals.

Cross-leg flaps: Case series, review, and proposed classification

BackgroundCross-leg (CL) flap procedures have a long history in reconstructive surgery, having been described for the first time in 1854. The application of these flaps can potentially solve many reconstructive issues with satisfactory outcomes. Patients and methodsDuring our research into the history and development of CL flaps, we identified a variety of flaps for which a classification system can be proposed based on blood supply and flap modifications. In this study, 10 patients with different complaints were managed using posterior tibial artery (PTA) perforator CL flap and superiorly based sural CL flap with satisfactory outcomes. ResultsAll flaps survived and healed smoothly; consequently, the flaps provided stable coverage, and the donor sites were reconstructed using skin grafts, which provided satisfactory results to the patients and/or their guardians. ConclusionTo our knowledge, this is the first study to propose a simple classification and group different types of flaps mentioned in the literature under one category. CL flaps are a common reconstructive option for patients with injuries that limit their mobility.

Revisiting Bipedicled Flaps for Lower Extremity Distal Third Defects.

Lower extremity reconstruction of the distal third of the leg is challenging. Free tissue transfer is the criterion standard. The COVID-19 pandemic encouraged seeking alternatives for resource consuming procedures. Bipedicled flaps are flaps with a dual-source subdermal perfusion. The purpose of this study was to assess outcomes of patients who had bipedicled flaps primary or auxiliary local flap for distal third leg/foot reconstruction. A retrospective review of patients undergoing lower extremity reconstruction (2020-2021) was performed. Inclusion criteria were patients older than 18 years with lower extremity wounds secondary to traumatic injury for which bipedicled flaps were used in the reconstruction. Exclusion criteria included lower extremity wounds secondary to peripheral vascular disease or diabetes. Fourteen patients were included in the study. All patients had distal third of the leg/foot wounds, and 12 patients (87.5%) had concurrent leg fractures. In 8 patients (57.1%), the bipedicled flap was used to decrease the wound size and facilitate another concurrent flap: hemisoleus (21.4%), anterior tibialis muscle turnover (14.3%), medial plantar artery (14.3%), and posterior tibial artery perforator (14.3%). Mean wound size for bipedicle flaps used alone was 42.0 ± 18.3 cm2, whereas wounds that required a bipedicled flap with an additional flap were 69.9 ± 80.8 cm2 (P = 0.187). Two patients had partial flap necrosis (14.3%) but healed their defect. One patient had nonunion (7.1%). Limb salvage rate was 100%. Bipedicled flaps can be used as an alternative to free flaps in distal third leg/foot defects in select patients. If distal extremity wounds cannot be covered with a bipedicled flap alone, the flap can be used an accessory flap to facilitate reconstruction with other local flaps.

Propeller posterior tibial artery perforator flap for reconstruction of the medial malleolar defect: A case report

Abstract Traumatic injury to the distal third of the lower leg remains challenging and often requires free tissue transfer. Reconstructive options for lower leg soft-tissue defects require comprehensive evaluation. A 20-year-old man presented with a medial malleolar soft-tissue defect with exposure of the great saphenous vein, distal tibia, and ankle joint after a traffic accident. Negative pressure wound therapy provided only partial coverage of the exposed tissue. The defect was reconstructed using a local fasciocutaneous propeller flap based on a septocutaneous perforator from the posterior tibial artery. At 1-year follow-up, the patient resumed normal daily activities without functional deficits. We review the options of reconstructing the distal third of the lower leg and surgical pearls of propeller flaps. Propeller flaps provide adequate tissue-like and pliable soft tissue coverage with a short operation time. It can be a useful technique for the reconstruction of distal third lower-leg defects.

Application of augmented reality technique in repairing soft tissue defects of lower limbs with posterior tibial artery perforator flap

To investigate the accuracy and reliability of augmented reality (AR) technique in locating the perforating vessels of the posterior tibial artery during the repair of soft tissue defects of the lower limbs with the posterior tibial artery perforator flap. Between June 2019 and June 2022, the posterior tibial artery perforator flap was used to repair the skin and soft tissue defects around the ankle in 10 cases. There were 7 males and 3 females with an average age of 53.7 years (mean, 33-69 years). The injury was caused by traffic accident in 5 cases, bruising by heavy weight in 4 cases, and machine injury in 1 case. The size of wound ranged from 5 cm×3 cm to 14 cm×7 cm. The interval between injury and operation was 7-24 days (mean, 12.8 days). The CT angiography of lower limbs before operation was performed and the data was used to reconstruct the three-dimensional images of perforating vessels and bones with Mimics software. The above images were projected and superimposed on the surface of the affected limb using AR technology, and the skin flap was designed and resected with precise positioning. The size of the flap ranged from 6 cm×4 cm to 15 cm×8 cm. The donor site was sutured directly or repaired with skin graft. The 1-4 perforator branches of posterior tibial artery (mean, 3.4 perforator branches) in 10 patients were located by AR technique before operation. The location of perforator vessels during operation was basically consistent with that of AR before operation. The distance between the two locations ranged from 0 to 16 mm, with an average of 12.2 mm. The flap was successfully harvested and repaired according to the preoperative design. Nine flaps survived without vascular crisis. The local infection of skin graft occurred in 2 cases and the necrosis of the distal edge of the flap in 1 case, which healed after dressing change. The other skin grafts survived, and the incisions healed by first intention. All patients were followed up 6-12 months, with an average of 10.3 months. The flap was soft without obvious scar hyperplasia and contracture. At last follow-up, according to the American Orthopedic Foot and Ankle Association (AOFAS) score, the ankle function was excellent in 8 cases, good in 1 case, and poor in 1 case. AR technique can be used to determine the location of perforator vessels in the preoperative planning of the posterior tibial artery perforator flap, which can reduce the risk of flap necrosis, and the operation is simple.

Successful Use of WALANT in Local and Regional Soft Tissue Flaps: A Case Series.

A retrospective review was performed. Twenty-one patients who underwent a local or regional soft tissue flap surgery using the WALANT technique from February 2, 2018 to February 25, 2022 were included in our analysis. Overall, one Louvre flap, two posterior tibial artery perforator propeller flaps, two reverse radial forearm flaps, two Quaba flaps, six cross finger flaps, one reverse homodigital island flap, three first dorsal metacarpal artery flaps, two thenar flaps, and two Moberg flaps were performed. Patients were followed up for an average of 11.9 ± 8.1 weeks. During this time, no postoperative complications occurred. All patients demonstrated appropriate healing at donor and recipient sites. Full range of motion was regained for all patients. WALANT is safe and effective for use in local and regional soft tissue flap surgery. Surgeons should consider this technique for more involved procedures such as flap surgery, as preliminary results demonstrate positive outcomes and potentially superior recovery for patients.

Map of perforators of the posterior tibial artery and peroneal artery using handheld doppler ultrasound evaluating clinical outcome of perforator flaps which cover soft tissue defects of the lower leg and foot

Background: Soft tissue defects of the lower leg and foot are complicated injuries with numerous causes including trauma, ulcers, and Gout. Widespread treatment of these defects has been effectively applied with perforator flaps of the peroneal artery and posterior tibial artery. Objectives: 1. Construct a map of the perforators of the peroneal artery and posterior tibial artery using a handheld Doppler ultrasound. 2. Evaluate the clinical outcome of perforator flaps to cover soft tissue defects in the lower leg and foot. Materials and method: Cross-sectional study of 34 volunteers with no previous history of vascular diseases and the prospective study of 31 patients with soft tissue defects treated with peroneal artery perforator flap and posterior tibial artery perforator flap. Results: There are, on average, 4.7 peroneal perforating arteries. From the lateral malleolus to the fibula’s head, the percentage of perforating arteries in the 2/10 and 6/10 segments is 85.3% and 97%, respectively. In the 2-3/10 segment, 94.1% have perforator arteries. There are, on average, 3.3 posterior tibial artery perforators. From the medial malleolus to the medial tibial plateau, it was found that 100% of volunteers had perforating arteries in the 3-4/10 segments and 61.7% in the 5/10 segment. Evaluation of postoperative results in 31 patients: 77.49% showed the right flap. The most common complications were edge necrosis (12.9%), partial necrosis (6.44%), and infection (3.23%). The donor sites showed good survival in 96.4% of patients, while partial necrosis resulted in 3.6%. A follow-up examination revealed that 90.32% of flaps had a good result, 9.68% had an average result, and no poor results were shown. 100% of donor sites had good results. Conclusion: An average of 4.7 perforators of the peroneal artery is detected by handheld Doppler ultrasound. Also, there are 1-2 relatively constant perforators in segments 2/10 and 5-6/10 from the lateral malleolus. On average, there are 3.3 perforators of the posterior tibial artery, primarily in the 3-4/10 and 5/10 segments proximally from the medial malleolus. 90.32% of the flap had good results. Key words: Perforator flap, Soft tissue defect, Lower leg, Foot, Reconstruction.

Single centre experience with the superficial circumflex iliac artery perforator (SCIP) flap for traumatic limb defects: A case-series for first year as a regional major trauma network during a global pandemic

The free superficial circumflex iliac artery perforator (SCIP) flap evolved from the traditional groin flap, conferring numerous advantages. The thin nature of the flap avoids the need for secondary revisions and debulking procedures, particularly pertinent when theatre capacity was limited during the COVID-19 pandemic. We present a series reporting our centre's first year experiences undertaking SCIP flap reconstruction for traumatic limb injuries following the establishment of our regional major trauma network. A retrospective analysis of all patients treated for traumatic limb defects in our centre was undertaken between September 2020 to September 2021. Data was collected on patient demographics, injury, flap dimensions and flap survival. Ten patients (M:F 1:1, mean age 45 years) with traumatic limb defects were reconstructed with SCIP flaps performed by the senior authors. All had sustained open fractures. Nine had lower limb defects, most commonly at the medial ankle, one had a volar wrist defect with a devascularised hand. The mean flap dimension was 6.3 × 14.5 cm. All were anastomosed end-to-side to the recipient artery except one end-to-end anastomosis to a posterior tibial artery perforator using super-microsurgery. There was 100% flap survival. Complications consisted of one flap suffering <10% tip necrosis requiring debridement and small skin graft. The SCIP flap provides reliable, thin and pliable tissue without the need for secondary flap revisions and should be considered in the armamentarium of the reconstructive surgeon in extremity trauma reconstruction, particularly in the current environment surrounding the global pandemic. • The free superficial circumflex iliac artery perforator (SCIP) flap evolved from the traditional groin flap, conferring numerous advantages. • The thin nature of the flap avoids the need for secondary revisions and debulking procedures, particularly pertinent when theatre capacity was limited during the COVID-19 pandemic. • We demonstrate that SCIP flap provides reliable, thin and pliable tissue without the need for secondary flap revisions and should be considered in the armamentarium of the reconstructive surgeon in extremity trauma reconstruction, particularly in the current environment surrounding the pandemic.

Soft Tissue Reconstruction Around the Ankle with Peroneal and Posterior Tibial Artery Perforator Flaps: A Randomized Controlled Trial

Soft Tissue Reconstruction Around the Ankle with Peroneal and Posterior Tibial Artery Perforator Flaps: A Randomized Controlled Trial

Posterior tibial artery flap versus radial forearm flap in oral cavity reconstruction and donor site morbidity

The repair of soft tissue defects after oral cavity cancer resection is challenging. The aim of this study was to compare the outcomes and donor site morbidity of the radial forearm free flap (RFF) and posterior tibial artery perforator flap (PTAF) for oral cavity reconstruction after cancer ablation. All patients who underwent oral cavity reconstruction with a RFF or PTAF between January 2017 and December 2019 were included retrospectively in this study. All flaps were harvested with a long adipofascial extension. The donor site defects were closed with a triangular full-thickness skin graft harvested adjacent to the flap. Flap outcomes and donor site complications were recorded and compared. The study included 145 patients; 30 underwent reconstruction with a RFF and 115 with a PTAF. No significant difference between the PTAF and RFF was observed concerning the flap survival rate (98.3% vs 96.7%), flap harvest time (53.39 vs 49.28 min), hospital stay (12.3 vs 15.2 days), or subjective functional and cosmetic outcomes. The PTAF showed a larger vascular calibre (P < 0.05), greater flap thickness (P = 0.002), and lower frequency of surgical site infection (P = 0.055) when compared to the RFF. No significant difference was observed between the pre- and postoperative ranges of ankle and wrist movements. The PTAF is an excellent alternative to the RFF for the repair of oral cavity defects, with the additional advantages of a well-hidden scar on the lower extremity, larger vascular calibre, and lower frequencies of postoperative donor site morbidities.

Parallel Cross-Leg Free Flap with Posterior Tibial Artery Perforator Pedicle Propeller Cable Bridge Flap for the Treatment of Lower Extremity Wounds: A Case Series Report

Background A cross-leg flap can be used to treat severely injured lower limbs but associated with complications. Herein, we describe a technique of a parallel cross-leg free flap combined with posterior tibial artery perforator pedicle propeller cable bridge flap for the treatment of lower extremity wounds. Methods The artery and veins of the free flap are anastomosed to the contralateral posterior tibial artery and vein, respectively. The vascular pedicle is wrapped with a posterior tibial artery perforator pedicle propeller flap. The legs are allowed to remain in a straight, relaxed position which is maintained with a bandage or Kirschner wire placed at the distal limbs. Pedicle division is performed around 21 days after flap creation, and the posterior artery is re-anastomosed and pedicled flap returned to its original position. Results From June 2017 to March 2020, 7 patients with lower extremity wounds and tissue loss received reconstruction with this method. The recipient vessels for all flaps were the posterior tibial artery and vein. The average operation time was 5 hours. The average time to ambulation was 4 weeks, and the average follow-up time was 13.7 months. All flaps survived, and limb salvage was successful in all patients. Patients were not uncomfortable with the limbs held in position until pedicle division, and there were no complications. At the final follow-up, the function of all limbs was normal, and the esthetic appearance was acceptable to all patients. Conclusions The method described overcomes the disadvantages of traditional cross-leg flaps for the treatment.

Posterior Tibial Artery Perforator V-Y Advancement Flap for Small-Medium Size Lower Limb Defects.

Background:The posterior tibial artery perforator flap has been described as a good option for small to moderate lower extremity defects with consistent anatomy and caliber. Different geometrical designs are found in the literature for posterior tibial artery perforator flaps and are mostly executed as propeller, peninsular, and island flaps. Upon literature review, V-Y advancement flaps were not commonly used, despite the clear design, persistent anatomy, and straight execution. Our aim was to report our case series to present the validity of such design and the success of reconstruction.Method:Over 1 year, three cases were reconstructed successfully with posterior tibial artery perforator flaps with V-Y advancement design. Clinical evaluation was done for all patients as well as follow-up in the outpatient clinic until complete healing of the wounds was achieved. Multiple modifications were done intraoperatively to enhance flap reach and minimize the complications, including designing V-Y advancement flaps larger than the defect, careful perforator dissection, and finally, strict postoperative course.Results:All three cases healed completely with no complications. The average follow-up time in the clinic was 3 months.Conclusions:Posterior tibial artery perforator flap with V-Y advancement design is a viable option for reconstructing medium sized lower limb defects, but requires careful design and execution. The suggested steps will increase the survival of the flap and reconstruct the defect successfully.

Posterior tibial artery perforator propeller flap for lower extremity skin defect with vascular Ehlers-Danlos syndromes—a case report

Posterior tibial artery perforator propeller flap for lower extremity skin defect with vascular Ehlers-Danlos syndromes—a case report

A Case of Extensive Heel Degloving Injury Reconstructed with Pedicled Medial Plantar Flap and Posterior Tibial Artery Perforator Flap

A Case of Extensive Heel Degloving Injury Reconstructed with Pedicled Medial Plantar Flap and Posterior Tibial Artery Perforator Flap

Clinical comparative study of free posterior tibial artery perforator flap and radial forearm free flap for head and neck reconstruction

Objective: To compare the clinical application results of the FPTF (free posterior tibial artery perforator flap) and RFFF (radial forearm free flap) for reconstruction of head and neck defects. Methods: A retrospective analysis of 27 cases treated with FPTF (19 males and 8 females, aged 14-69 years) and 24 cases with RFFF (11 males and 13 females, aged 22-69 years) for head and neck defect reconstruction at Beijing Tongren Hospital of Capital Medical University from January 2015 to December 2020 was conducted. Flap size, vascular pedicle length, matching degree of recipient area blood vessels, preparation time, total operation time, hospital stay, recipient area complications, donor area complications and scale-based patient satisfaction were compared between two groups of patients with FTPF and RFFF. SPSS 26.0 statistical software was used for statistical analysis. Results: There was no statistically significant difference between the two groups of patients in tumor T staging (P=0.38), primary sites (P=0.05) and mean flap areas ((53.67±29.84) cm2 vs. (41.13±11.08) cm2, t=-1.472, P=0.14). However the mean vascular pedicle length of FPTF was more than that of RFFF ((11.15±2.48)cm vs. (8.50±1.69)cm, t=-4.071, P<0.01). The donor sites of 4 patients in FPTF group could be sutured directly, while all the 24 patients in RFFF group received skin grafts from the donor sites. There was no statistically significant difference in the recipient area arteries between two groups of flaps (P=0.10), with more commonly using of the facial artery (RFFF: FPTF=21∶27), but there was significant difference in the recipient area veins (P<0.01), with more commonly using of the external jugular vein in RFFF (14/24) than FPTF (4/32) and the posterior facial vein in FPTF (27/32) than RFFF (9/24). There were 10 recipient complications and 3 donor complications in RFFF group; no recipient complication and 3 donor complications occurred in FPTF group. With patient's subjective evaluation of the donor site at 12 months after surgery, FPTF was better than RFFF (χ²=22.241, P<0.01). Conclusions: FPTF is an alternative to RFFF in head and neck reconstruction and has unique advantages in aesthetics and clinical application.

Caveats of Local Fasciocutaneous Flaps for Distal Leg Defects—Anatomical Study and Clinical Application

The present trend for the management of distal leg defects is to opt for a free flap with local flaps being relegated to the backseat. We studied the perforator anatomy of the distal leg in the Indian population to see if there were any ethnic differences and then correlated it with a clinical study of local flaps used for the coverage of distal leg defects. A prospective observational study was carried out in 2 phases—anatomical study and clinical study from December 2018 to March 2020. In the anatomical study, 8 fresh cadavers, i.e., 16 lower limbs were dissected and the perforator anatomy in the distal leg was identified. In the clinical study, all patients undergoing local, pedicled fasciocutaneous flap cover for defects involving distal third leg were included with ages between 15 and 60 years. In the anatomical study, posterior tibial artery perforators in the distal-most part were found as a group of up to 3 perforators. In the clinical study, a total of 47 patients were included with a mean age of 38.0 ± 10.9 (range 17-55) years and female:male ratio being 1:2.6. The largest defect size was 120 cm2 (mean 28.2 ± 23.8 [range 6-120] cm2) and the most commonly used flap was the reverse sural artery flap in 20 (42.6%) cases. Overall, complications were seen in 7 (14.9%) cases and there was no case of flap failure. Thus, local flaps are an excellent option for coverage of distal leg defects and offer results comparable to free flaps.

Radiological Evaluation of Postsurgical Course of Perforators in Retrograde Posterior Tibial Fasciocutaneous Flaps for Distal Leg and Foot Defects.

Background Mapping of vascular perforators by various methodologies have been described for planning of a variety of flaps in the lower limbs. We attempted to assess the changes in posterior tibial perforators after transfer of fasciocutaneous flaps for leg defects. Methods 20 patients with distal leg and foot defects were studied by computed tomography angiography (CTA) and preoperative audio Doppler to ascertain perforators of posterior tibial artery. Fasciocutaneous flaps were raised, based on these perforators, depending on the site and size of soft-tissue defects. The number of perforators and their distance from the medial malleolus were also studied. Postoperative CTA was performed on the 7th to 10th day, with emphasis on postoperative changes of the perforators on which the flaps were based. Results One to four posterior tibial perforators were found between 5 cm and 8 cm proximal to the medial malleolus. After flap transfer, the perforators could be traced to variable distance through the total length of the flap. The perforators formed small vascular loop in 12 patients, following retrograde posterior tibial flap transfer. The height of the loop, the number of such loops, the dilatation and tortuosity of the perforators, and their longitudinal orientation were studied in detail. Most of the findings can be explained by mechanical realignment of perforators as well as by the delay phenomenon associated with retrograde fasciocutaneous flaps. Conclusion It was concluded that the morphological changes associated with the perforators explained the vascular rationality and success of these flaps.

Different Modalities of Flap Coverage of Achilles Tendon Region Defects: Functional and Aesthetic Outcomes

Abstract Background: In the decision-making process toward covering various Achilles' tendon region, knowledge about patient related outcomes after surgery and rehabilitation is important. Therefore, we aimed to present an overview of outcomes and select the most appropriate flaps used for covering soft tissue defects over Achilles' tendon region. Aim of Study: Study aimed to analyse and determine the suitable reconstructive surgical options for Achilles' tendon coverage and to evaluate the clinical, functional and aesthetic outcomes. Patients and Methods: Between September 2017 and December 2019, 25 patients with skin loss over Achilles' tendon region were admitted to Menoufia University Hospital and Shebin-Elkom Teaching Hospital. The soft tissue defects ranged from 3x2 to 16x12 cm. Six types of flaps were used for the coverage of concomitant skin defects. Results: There was no complete flap loss and all flaps survived. Lateral supra malleolar flap (28%) was used in seven patients, distally based peroneus brevis muscle flap (16%) in four patients, posterior tibial artery perforator flap (24%) in six patients, peroneal artery perforator flap (4%) in one patient, reversed sural artery flap (24%) in six patients, and free latissimus dorsi musculocutaneous flap (4%) in one patient. Two patients were subjected to debridement and covered with split thickness skin graft (STSG). One patient suffered from chronic ulcer formation which was covered with lateral supra malleolar artery flap. The algorithm of one-stage reconstruction was established, according to the defect size of skin. Conclusion: Perforator flaps, lateral supra malleolar artery flap, and the distally based peroneus brevis muscle flap were a suitable option for coverage of small to intermediate sized defects; reversed sural artery flap is best for coverage of moderate to large size defects and free flaps are the best choices for complex wide reconstructions.