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British Journal o/Plastic surgrry (1994). 47, m-504 6 1994 The British Association of Plastic Surgeons Reconstruction of limb defects with the free posterior tibia1 artery fasciocutaneous flap Y. Y. Li, H. Q. Situ, J. L. Wang and Y. Lu Department of Burns and Plastic Surgery, Red Cross Hospital, Guangzhou, China SUMMARY. There are few reports on the use of free posterior tibia1 artery free flaps. We present four cases of reconstruction of a limb defect with a free posterior tibia1 artery fasciocutaneous flap. There are now several studies on the use of flaps based on the posterior tibia1 artery and veins for cover of lower leg defects. These flaps can be fasciocutaneous’ or adipofascia12 and can be distally based for cover of distal leg, ankle or foot defects.l They have been used, both proximally and distally based, as cross leg flaps.3 Okuda et al. reported using a free posterior tibia1 artery flap to salvage an arm.’ Hwang et al. used free medial leg flaps based on the posterior tibia1 artery in 16 cases with traumatic limb defects.4 Wu et al. reported four cases where they had used free posterior tibia1 artery flaps to reconstruct two upper limbs and two lower limbs.5 We present four cases to illustrate the use of such flaps. 1). At surgery, he had excision of the scar and release of the contractures. The resulting defect, with exposed bone, joints, tendons and arteries, was covered with an 11.5 x 7.5 cm free posterior tibia1 artery fasciocutaneous flap. The posterior tibia1 artery was anastomosed to the ulnar artery and the venae corn&antes were anastomosed to forearm cutaneous veins, all with end-to-end anastomoses. The flap donor site was resurfaced with a split thickness skin graft. The flap survived completely, allowing a good range of movements of the fingers (Fig. 2). Synthetic polyester fibre grafts were used to reconstruct the posterior tibia1 vessels. Three weeks postoperatively, a femoral arteriogram showed a patent posterior tibia1 artery graft. Case 2 Case Reports Case 1 A 3%year-old man sustained an injury to his left hand from an explosion, resulting in loss of the left ring and little fingers. He was initially treated in a local hospital. Six months later he was referred to us. He had scarring of the palm with contractures of the index and middle fingers (Fig. A 28-year-old man sustained a crushing injury by a machine to his left wrist, with extensive necrosis of both the flexor and extensor surfaces of the wrist (Fig. 3). The forearm and hand were swollen. Four days after the injury, the wound was debrided with excision of the skin eschar and the necrosed tendons of palmaris longus, flexor digitorum superficialis, extensor carpi radialis longus, extensor carpi ulnaris, and extensor digitorum communis. The ulnar artery and nerve and the interosseous arteries were necrosed. The flexor Fig. 1 Fig. 2 Figure l-Case 1. Preoperative view with scar contracture of the left hand. Figure Z-Postoperative view at 3 weeks. 502

Reconstruction of limb defects with the free posterior tibial artery fasciocutaneous flap

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British Journal o/Plastic surgrry (1994). 47, m-504

6 1994 The British Association of Plastic Surgeons

Reconstruction of limb defects with the free posterior tibia1 artery fasciocutaneous flap

Y. Y. Li, H. Q. Situ, J. L. Wang and Y. Lu

Department of Burns and Plastic Surgery, Red Cross Hospital, Guangzhou, China

SUMMARY. There are few reports on the use of free posterior tibia1 artery free flaps. We present four cases of reconstruction of a limb defect with a free posterior tibia1 artery fasciocutaneous flap.

There are now several studies on the use of flaps based on the posterior tibia1 artery and veins for cover of lower leg defects. These flaps can be fasciocutaneous’ or adipofascia12 and can be distally based for cover of distal leg, ankle or foot defects.l They have been used, both proximally and distally based, as cross leg flaps.3 Okuda et al. reported using a free posterior tibia1 artery flap to salvage an arm.’ Hwang et al. used free medial leg flaps based on the posterior tibia1 artery in 16 cases with traumatic limb defects.4 Wu et al. reported four cases where they had used free posterior tibia1 artery flaps to reconstruct two upper limbs and two lower limbs.5 We present four cases to illustrate the use of such flaps.

1). At surgery, he had excision of the scar and release of the contractures. The resulting defect, with exposed bone, joints, tendons and arteries, was covered with an 11.5 x 7.5 cm free posterior tibia1 artery fasciocutaneous flap. The posterior tibia1 artery was anastomosed to the ulnar artery and the venae corn&antes were anastomosed to forearm cutaneous veins, all with end-to-end anastomoses. The flap donor site was resurfaced with a split thickness skin graft. The flap survived completely, allowing a good range of movements of the fingers (Fig. 2). Synthetic polyester fibre grafts were used to reconstruct the posterior tibia1 vessels. Three weeks postoperatively, a femoral arteriogram showed a patent posterior tibia1 artery graft.

Case 2

Case Reports

Case 1

A 3%year-old man sustained an injury to his left hand from an explosion, resulting in loss of the left ring and little fingers. He was initially treated in a local hospital. Six months later he was referred to us. He had scarring of the palm with contractures of the index and middle fingers (Fig.

A 28-year-old man sustained a crushing injury by a machine to his left wrist, with extensive necrosis of both the flexor and extensor surfaces of the wrist (Fig. 3). The forearm and hand were swollen. Four days after the injury, the wound was debrided with excision of the skin eschar and the necrosed tendons of palmaris longus, flexor digitorum superficialis, extensor carpi radialis longus, extensor carpi ulnaris, and extensor digitorum communis. The ulnar artery and nerve and the interosseous arteries were necrosed. The flexor

Fig. 1 Fig. 2

Figure l-Case 1. Preoperative view with scar contracture of the left hand. Figure Z-Postoperative view at 3 weeks.

502

Free Posterior Tibia1 Artery Flaps 503

Fig. 3 Fig. 4

Figure 3-Case 2. Preoperative view with crushing injury of the left wrist. Figure 4-Postoperative view at 7 months.

surface wound was covered with an 11.5 x 10.5 cm free posterior tibia1 artery fasciocutaneous flap, with anasto- moses of the flap pedicle vessels end-to-side to the radial artery and adjacent veins. The flap donor site was resurfaced with a split thickness skin graft. The extensor surface wound was covered by a pedicled groin flap, 11 x 9 cm. Both flaps healed uneventfully (Fig. 4).

Case 3

A 25-year-old woman had her left lower leg injured in a traffic accident and required amputation of the distal two thirds of the lower leg in a local hospital. This left her with an extensive skin defect and exposed tibia. She was referred to us and, 3 weeks after the accident, we further debrided the leg and covered the wound with a free posterior tibia1 artery fasciocutaneous flap, 7 x 11 cm, taken from the right leg. The flap pedicle vessels were anastomosed end-to-end to the left anterior tibia1 vessels. The flap donor site was resurfaced with a split thickness skin graft. On the first postoperative day, the flap was moderately oedematous, with a blister of the skin over the tibia1 stump because of tension. Three days later, the oedema had subsided and the blistered area was healing. Eventually the flap survived completely.

Case 4

A 17-year-old man had his left arm injured by a machine and required amputation through the upper arm at a local hospital. Two weeks later, we debrided the wound and covered it with a free posterior tibia1 artery fasciocutaneous flap, 12 x 10.5 cm, from the right leg. The flap pedicle vessels were anastomosed end-to-end to the brachial vessels. The flap donor site was resurfaced with a split thickness skin graft. The flap survived completely. Synthetic polyester fibre grafts were used to reconstruct the posterior tibia1 vessels. Three weeks postoperatively, a femoral arteriogram showed a patent posterior tibia1 artery.

Discussion

The posterior tibia1 artery fasciocutaneous flap is a reliable flap. We have used it as a pedicled, distally based flap in 10 cases to reconstruct lower limb defects

and all these flaps, except one which had partial necrosis requiring secondary skin grafting, survived completely. In addition, we have used it as a free flap in the four cases described above. With the free flaps, the pedicle was proximal to the flap, allowing normal antegrade flow in the pedicle.

With all flaps based on major vessels of the lower leg, either pedicled or free flaps, there is concern about the blood supply of the leg. We have relied on clinical examination and doppler examination.

In two cases, we reconstructed the posterior tibia1 vessels with synthetic grafts. The grafts were patent after 3 weeks. However, the indications for such grafts and the reliability of autogenous or synthetic grafts in such free flap donor legs have yet to be established and require further study.

All four of our free flap patients were young, aged 17-38 years. Similarly, the four cases of the free posterior tibia1 artery flap reported by Wu et al. were aged 19-40 years’ and the 16 cases of Hwang et al. were aged 17-42 years.4 Although Hong et al. used reverse flow pedicled posterior tibia1 artery flaps in patients less than 40 years of age,’ others have used such pedicled flaps in older patients.5 Our series of pedicled flaps includes patients aged 57, 64 and 75 years old, in all of whom the distally based flap and donor leg healed satisfactorily.

The details of the cutaneous branches of the pos- terior tibia1 artery have been described elsewhere. Amarante et al. studied 10 cadavers and found that there were always two perforating cutaneous arteries and accompanying veins at about 4 and 6.5 cm above the medial malleolus (varying from 2.8 to 4.2 cm and from 5.2 to 7.5 cm respectively).6 Wu et al. considered the lower leg in four zones, beginning distally, and found most of the direct cutaneous branches were in Zone II, with another common location being zone III.’ Others have also noted most of the perforators are in the lower half of the leg,’ while Satoh et al. found them mainly 5-19 cm proximal to the medial mal- leoius.’ This distribution of the perforators is con- venient for the design of free posterior tibia1 artery flaps with their pedicles extending proximal from the flap. We designed our free flaps on the posteromedial

504 British Journal of Plastic Suraerv

aspect of the lower leg, ensuring inclusion of one or two cutaneous branches. Hwang et al. advise inspect- ing the cutaneous branches at surgery before elevating the flap because in one of their cases they found only a single, small cutaneous branch which was not adequate for the flap.4

Our largest free flap was 12 x 10.5 cm. Hwang et al. successfully used a free flap of 18 x 8 cm, Wu et al. used a 10 x 17 cm flap on an arm, Okada et al. used a 22 x 9 cm free posterior tibia1 artery flap to salvage an arm and Chen et al. used a 30 x 10 cm flap to reconstruct an oesophagus.’

Our series is not large but confirms earlier reports that the free posterior tibia1 artery fasciocutaneous flap is a reliable and useful flap for reconstruction of limb defects.

References

1. Hong G, Steffens K, Wang FB. Reconstruction of the lower leg and foot with the reverse pedicled posterior tibia1 fascio- cutaneous flap. Br J Plast Surg 1989: 42: 512-16.

2. Lin S-D, Lai C-S, Chou C-K, Tsai C-W. The distally based posterior tibia1 arterial adipofascial flap. Br J Plast Surg 1992; 45 : 284-7.

3. Sharma RK, Kola G. Cross leg posterior tibia1 artery fascio- cutaneous island flap for reconstruction of lower leg defects. Br J Plast Surg 1992; 45: 62-5.

4. Hwang W-y, Chen S-z, Han L-y, Chang T-s. Medial leg skin flap: vascular anatomy and clinical applications. Ann Plast Surg 1985; 15: 489-91.

5. Wu W-c, Chang Y-p, So Y-c, Yip S-f, Lam Y-l. The anatomic basis and clinical applications of flaps based on the posterior tibia1 vessels. Br J Plast Surg 1993; 46: 47&9.

6. Amarante J, Costa H, Reis J, Soares R. A new distally based fasciocutaneous flap of the leg. Br J Plast Surg 1986; 39: 33840.

7. Liu K, Li Z-T, Lin Y, Cao Y. The reverse-flow posterior tibia1 artery island flap : anatomic study and 72 clinical cases. Plast Reconstr Surg 1990; 86: 312-18.

8. Satoh L, Sakai M, Hiromatsu N, Ohsumi N. Heel and foot reconstruction using reverse-flow posterior tibia1 flap. Ann Plast Surg 1990; 24: 318-27.

9. Chen H-c, Tang Y-b, Noordhoff MS. Posterior tibia1 artery flap for reconstruction of the oesophagus. Plast Reconstr Surg 1991; 88: 98t%6.

The Authors

Ye Yang Li, MD, Vice chief surgeon He Qi Situ, MD, Vice chief surgeon Jht Lun Wang, MD, Resident surgeon Ye Lu, MD, Resident surgeon

Department of Burns and Plastic Surgery, Red Cross Hospital, 396 Tong Fu Zhong Rd., Guangzhou 510220, China.

Requests for reprints to Dr YY Li at the above address,

Paper received 24 January 1994. Accepted 20 June 1994, after revision.