Eur J Plast Surg (1997) 20:266-269 European ~ i l~ l [ __o Jouro~J o~ FI ~II~l'Ib

© Springer-Verlag 1997

Reconstruction of an Achilles tendon skin defect using a local fascial flap

E.P. Fong, R.P.G. Papini, M.V. McKiernan, G.S. Rao

Department of Plastic Surgery, Shotley Bridge Hospital, Consett Co Durham, DH80NB, UK

Abstract. We report a case in which a distally based fas- cial turnover flap supplied by the perforators o f the pos- terior tibial and peroneal arteries was used to resurface a sizeable skin defect overlying the tendo-Achil les. The flap can be raised easily with minimal donor site mor- bidity and provides a good gliding surface for the under- lying tendon without adding unnecessary bulk.

Key words: Tendo achilles skin defect - Local facial flap

approximately 10 cm above the malleoli and course through the intermuscular septum, perforating the fascia over which they ramify to supply the overlying skin. The anatomy of these vessels was well described by Carr- iquiry et al. [11] and this description led us to attempt closure o f a lower limb defect using local fascia.

The fol lowing case relates how a large tendo Achilles skin defect was successfully covered using a local fas- cial flap which also provided a gliding surface. This method leaves a minimal donor defect and is technically easy to perform.

Full thickness skin defects over the distal third o f the leg, and especially over the tendo-Achil les, present one o f the mos t difficult reconstructive challenges in lower limb surgery. Local flaps are scarce and because of their short vascular pedicles, are not reliable [1, 2]. R a n d o m pattern deepithelialised "turnover" flaps have been de- scribed for coverage in this area but can leave buried ep- i thelium producing complicat ions [3].

Lateral calcaneal artery flaps have limited capaci ty to cover large defects and the donor site requires skin graft- ing [4, 5, 6]. The lateral supramalleolar flap provides better coverage in the heel area but leaves a significant donor defect [7].

Distally based fasciocutaneous flaps also leave a sig- nificant donor defect which m a y be aesthetically unsuit- able in younger female patients [8, 9].

For these reasons, free tissue transfer is often consid- ered as the first option, however, free muscle and muscu- locutaneous flaps are bulky and do not provide a gliding surface for the Achilles tendon. The temporoparietal fas- cial free flap [10] has been used in this area but is time consuming and technically demanding.

The segmental septocutaneous vessels arise at inter- vals f rom each of the three vessels in the leg, the last one

Correspondence to: G.S. Rao, Shotley Bridge Hospital, Consett, Co Durham DH80NB, UK

Case report

A 47-year-old diabetic man was referred to us with a non-healing ulcer overlying his left tendo-Achilles. The wound began with a minor laceration some nine years previously and had been treated conservatively until referral. As a teenager he had sustained cir- cumferential flame bums to both legs which had required skin grafting.

Clinical examination revealed an ulcer measuring 5 crux4 cm with a granulating base. The surrounding skin was largely made up of skin graft (Fig. 1). In view of the length of the history, ma- lignant change could not be excluded.

At operation, a wide excision of the ulcer was carried out, which resulted in a defect which measured 8 cmx7 cm, exposing the Achilles tendon in the base of the wound. The wound was ex- tended proximally as a lazy-S incision to the upper third of the calf (Fig. 2). The deep fascia of the posterior compartment was then raised as a flap based distally on the perforators of the poste- rior tibial and peroneal arteries.

The base of the flap was situated 8 cm proximal to the defect and the flap measured 16 cm in length by 8 cm in width (Fig. 3). This was turned down through 180 ° to cover the defect and su- tured in place with absorbable sutures (Fig. 4). Finally, the flap was covered with a split skin graft from the thigh and the access incision closed directly to a level just proximal to the base of the turned over fascia (Fig. 5).

Histological examination of the excised specimen revealed a completely excised, deeply invasive, well differentiated squamous cell carcinoma. The fascial flap and skin graft survived complete- ly resulting in a very satisfactory functional and aesthetic result (Fig. 6).

267

Fig. 1. Granulating ulcer over tendo- Achilles

Fig. 2. Wound extended proximally by lazy-S incision

Fig. 3. The distally-based fascial flap

Fig. 4. The flap turned through 180 ° to cover the defect

Fig. 5. Split skin graft applied to flap and incision closed directly

Fig. 6. The result at 5 months post-op.; healed, thin conforming flap with mini- mal donor site deformity

Discussion

Ponten [12] described the use of a fasciocutaneous flap to reconstruct defects of the lower leg in 1981 and Bar- clay et al. reported their experiences of 16 such cases the following year [13]. Both noted that occasionally, where marginal skin necrosis occurred, the underlying fascia survived and readily accepted a skin graft. Based on this observation, Thatte described the roll-over fascial flap [14] supplied by the perforators of the saphenous and posterior tibial arteries. The posterior calf fascial free flap was subsequently described [15] and recently a dis- tally based fascial flap nourished by the posterior tibial perforators has been used for reconstruction of distal an- terior tibial defects [16, 17].

The concept of a fascial flap as opposed to the fas- ciocutaneous flap is now established and recently a se- ries of free fascial flaps were reported for use in cover- ing defects over the tendo-Achilles [18]. Fascia has the advantages of providing thin pliable tissue which per- mits tendon gliding, it produces little or no donor site, and donor site morbidity. It can be grafted on both sides and provides early wound coverage and mobility. On ar- eas such as the hand, foot and lower leg, it's thinness and conforming nature offer an advantage over other flaps. The added advantage conferred by using local tis- sue is the time saved performing microvascular anasto- mosis.

The anatomy of the segmental septocutaneous perfo- rators in the leg has been well described by Carriquiry et

268

Medial head of gastrocnemius

22 - 24 cm . . . . 4

~ Lateral popliteal nerve

- 5 - 6 c m f r o m fibular neck

17 - 19 cm

Fig. 7. Diagrammatic cross section of middle third of the leg showing origin and course of the septocutaneous vessels. These vessels originate directly from the main trunk, passing within the intermuscular septum to pierce the deep fascia before anastomo- sing with each other on the superficial surface of the fascia

Soleus

9- 12c[

; - 20 cm

roneus Iongus

• 13cm

al. [11]. The septocutaneous vessels arise from the three main vessels in the leg, run in the intermuscular septum and pierce the deep fascia before dividing into three or four branches ramifying in the subcutanous tissue imme- diately superficial to the fascia, forming a dense prefas- cial plexus (Fig. 7). Longitudinally oriented branches anastomose with similar branches from the adjacent per- forators resulting in anastomotic arcades that lie in an axial orientation along the leg.

The medial row of septocutaneous perforators arise from the posterior tibial artery and traverse along the deep transverse fascial septum that separates the superfi- cial and deep posterior compartments of the leg. The up- per perforators pierce the fascia just behind the medial border of the tibia, passing through the tibial origin of the soleus. Carriquiry et al. [11] located the position of these perforators using a doppler probe at 9-12 cm, 17-19 cm and 22-24 cm proximal to the tip of the medi- al malleolus. Amaranti et al. [9] describe two other con- sistent medial perforators at a lower level, piercing the fascia between the flexor digitorum longus and soleus muscle and Achilles tendon, at 4.5 cm and 6 cm proxi- mal to the tip of the medial malleolus (Fig. 8).

The posteriolateral septocutaneous perforators that originate from the peroneal trunk run along the postero- lateral septum. Perforators in the proximal third of the leg are found between soleus and peroneus longus, while in the lower two thirds of the leg they emerge between the flexor hallucis longus and soleus on one side and pe- roneum brevis on the other side.

Le Hull et al. [19] frequently found a sizeable perfo- rator 10-13 cm proximal to the tip of the lateral malleo- lus and smaller perforators at 4-10 cm and 15-20 cm proximal to the tip of the lateral malleolus. The most

6 cm roneus brevis

4.5 c 10 cm

Flexor digitorum :or hallucis Iongus lUS

~do Achilles

Fig. 8. Diagrammatic illustration of frequently found perforator vessels from the posterior tibial and peroneal arteries of leg

proximal perforator was noted at 5-6 cm below the neck of the fibula.

The anterolateral septocutaneous perforators originate from the anterior tibial trunk. Carriquiry et al. [11] found 6-10 perforators in this row but without any consistent point of origin. However, in the same study, they noticed large longitudinally orientated skin areas measuring up to a maximum of 18 cmxl4 cm being stained, using se- lective dye injection into the perforators.

These findings support the substainable vascularity of the deep fascia of the leg, based on these various septo- cutaneous perforators which led us to attempt closure of a large tendon-Achilles skin defect using deep fascia. Having considered the alternatives, we believe this method of using local deep facia offers distinct advanta-

ges of effectiveness, cosmesis and simplici ty and would r ecommend its use in similar cl inical situations.

Acknowledgements. My sincere thanks to Lynne Allen for typing the manuscript.

References

1. Vasconez LO, Bostwick J, McCraw J (1974) Coverage of ex- posed bone by muscle transposition and skin grafting. Plast Reconstr Surg 53:526

2. Hartrampf CR Jr, Scheflan M, Bostwick J (1980) The flexor digitorum brevis muscle island pedicle flap: a new dimension in heel reconstruction. Plast Reconstr Surg 66:264

3. Thatte RL, Patil D, Talwar P (1983) Deepithelialised "turn- over" axial pattern flaps in the lower extremity. Br J Plast Surg 36:327

4. Grabb BC, Argenta LC (1981) The lateral calcaneal artery skin flap. Plast Reconstr Surg 68:723

5. Holmes J, Rayner CRW (1984) Lateral calcaneal artery island flaps. Br J Plast Surg 37:402

6. Yanai A, Park S, Iwao T, Nakamura N (1985) Reconstruction of a skin defect of the posterior heel by a lateral calcaneal flap. Plast Reconstr Surg 75:642

7. Masquelet AC, Beveridge J, Romana C, Gerber C (1988) The lateral supramalleolar flap. Plast Reconstr Surg 81:74

8. Donski PK, Fogdestam I (1983) Distally based fasciocutane- ous flap from the sural region. Scand J Plast Reconstr Surg 17:191

269

9. Amarante J, Costa H, Reis J, Soares R (1988) A new distally based fasciocutaneous flap of the leg. Br J Plast Surg 39:338

10. Brent B, Upton J, Acland RD, Shaw WW, Finsetz FJ, Rogers C, Pearl RM, Hentz VR (1985) Experience with the temporo- parietal fascial free flap. Plast Reconstr Surg 76:177

11. Carriquiry C, Costa A, Vasconez LO (1985) An anatomic study of the septocutaneous vessels of the leg. Plast Reconstr Surg 76:354-361

12. Ponten BC (1981) The fasciocutaneous flap: it's use in soft tissue defects of the lower leg. Br J Plast Surg 34:215

13. Barclay TL, Cardoso E, Sharpe DT, Crockett DJ (1982) Re- pair of lower leg injuries with fasciocutaneous flaps. Br J Plast Surg 35:127

14. Thatte RL, Laud N (1984) The use of the fascia of the lower leg as a roll-over flap; it's possible clinical applications in re- constructive surgery. Br J Plast Surg 37:38

15. Walton RL, Matory WE Jr. Petry JJ (1985) The posterior calf fascial free flap. Plast Reconstr Surg 76:914

16. Lees V, Townsend PLG (1992) Use of pedicled fascial flap based on septocutaneous perforators of the posterior tibial ar- tery for repair of distal lower limb defects. Br J Plast Surg 45:141

17. Lin S-D, Lai C-S, Chou C-K, Tsai C-W, Tsai C-C (1994) Re- construction of soft tissue defects of the lower leg with the distally based medial adipofascial flap. Br J Plast Surg 47:132

18. Upton J, Baker TM, Shoen SL, Wolfort F (1995) Fascial flap coverage of Achilles tendon defects. Plast Reconstr Surg 95:1056-1061

19. Le Hull G-C, Midy D, Chauveaux D (1985) Anatomic basis of medical radiological and surgical techniques. Surg Radiol Anat 10:5

Eur J Plast Surg (1997) 20:269

European ~-~&l ,~Q

X lf_lflStlC bur gcry © Springer-Verlag 1997

Bostwick III, J., Eaves, F.E, Nahai, F. (eds): Endoscopic plastic surgery. St. Louis: Quality Medical Publishing 1994. 584 pages, US$ 325.00. ISBN 0-942219-65-1.

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