ORIGINAL PAPER

Reconstruction of soft tissue defects in the Achilles tendonregion with perforator-based fasciocutaneous flaps

Nabi Mopuri & Vasu Karri & Nakul Patel & Niri Niranjan

Received: 3 April 2013 /Accepted: 28 June 2013 /Published online: 20 August 2013# Springer-Verlag Berlin Heidelberg 2013

AbstractBackground Reconstruction of soft tissue defects in theAchilles tendon region can be technically demanding.Perforator-based flaps can be an effective local solution,replacing like-for-like skin. We report our experience withperforator-based flap reconstruction of the Achilles tendonregion with or without rupture of the Achilles tendon.Methods Between January 1999 and 2011, 11 patients hadperforator-based flaps based on peroneal and posterior tibialperforators. There were six V-Y advancement flaps, fourpropeller flaps and one peninsular flap. The mean defect sizewas 19.3 (range 9–36)cm2. One patient had reconstruction ofa composite Achilles tendon defect.Results There were no flap failures. Mean follow-up was26.4 (range 3–120)months. Post-operative complicationsincluded haematoma in one patient and dehiscence of woundbecause of further sloughing of the tendon—at the distaledge of a V-Y advancement flap. This patient needed asecond local flap. There were no wound breakdowns, painfulsensitivity or difficulty with walking. All patients who hadskin and soft tissue reconstruction only were partially weightbearing by 2 weeks and gradually increased weight bearingand fully weight bearing by 4 weeks.Conclusions Perforator-based flaps are a robust method ofcovering small- to medium-sized defects in the Achillestendon region. Presence of multiple perforators on either sideof the Achilles tendon invites a number of flap designs,tailored to the defect.Level of Evidence: Level IV, Therapeutic study.

Keywords Achilles tendon . Perforator . Propeller .

Advancement . Peninsular . Flap

Introduction

The reconstruction of soft tissue defects overlying the Achillestendon is a well-recognised reconstructive challenge. The adventof microsurgery, however, has greatly increased the armamentar-ium of reconstructive methods. Moreover, combined defects ofthe Achilles tendon and soft tissue can now be simultaneouslyaddressed with composite local or free flaps [1–3]. Free flapreconstruction, however, is not without disadvantage.

Long operative time, flap bulkiness, lack of protectivesensation and decreased range of movement at the ankle jointand donor site morbidity are all disadvantages [4–6]. A pa-tient’s inability to undergo long surgery due to co-morbidity orlack of microsurgical facilities may preclude free tissue trans-fer entirely.

With greater understanding of vascular anatomy, distribu-tion of perforating vessels and flap perfusion, the concept ofperforator flaps emerged [7–9]. These flaps represent anevolutionary milestone in reconstructive surgery and havebeen successfully used to reconstruct soft tissue defects inthe lower leg and foot.

Perforator-based flaps are a further refinement, characterisedby preservation of the source artery. If a perforator-based islandflap can be sufficiently advanced or rotated into the defect,dissection and division of the source artery becomes unnecessary.

Perforator-based propeller and V-Y advancement flapshave been used for upper and lower limb reconstructionand are gaining popularity [10–12]. Local perforator-basedflaps not only achieve the goal of reconstruction but alsominimise the degree of donor site morbidity.

Perforator-based flaps for reconstruction of skin and softtissue overlying the Achilles tendon can be based on themultiple perforators that emerge from either side of thetendon. These medial or laterally based flaps can be safelyraised and inset into adjacent defects either by advancementor rotation. The abundance of perforators around the Achil-les tendon region offers a number of flap designs (Fig. 1).

N. Mopuri (*) :V. Karri :N. Patel :N. NiranjanSt Andrews Centre for Plastic Surgery and Burns,Broomfield Hospital, Chelmsford, UKe-mail: nabimopuri@yahoo.co.uk

Eur J Plast Surg (2013) 36:701–706DOI 10.1007/s00238-013-0872-x

Cutaneous nerves can also be preserved with V-Yadvance-ment flaps, thereby providing sensate flap cover, an idealattribute for flap reconstruction over the Achilles tendon.

The purpose of this retrospective study is to present ourexperience in using local perforator-based flaps for soft tissuereconstruction in the Achilles tendon region. We also describeour stepwise approach for performing the reconstruction.

Patients and methods

Between January 1999 and 2011, 11 patients (five males, sixfemales, mean age 58.6, age range 26–84) with skin and softtissue defects in the Achilles tendon region had perforator-based flap reconstruction (Table 1). Patients with peripheralvascular disease were excluded. No previous attempts atreconstruction had been made.Fig. 1 Line diagram of arterial network around the ankle. PTA posterior

tibial artery, PA peroneal artery, P perforators, A arches

Table 1 Data on the 11 patients who had perforator-based flap reconstruction

No. Age,sex

Aetiology Defectsize (cm2)

Sourcevessel

Flap typea Donor siteclosure

Follow-up(months)

Complications

1 56,M

Wound breakdownfollowing Achillestendon repair

6×4 Posteriortibial

Propellerb Direct 24 Haematoma

2 46,M

Wound breakdownfollowing Achillestendon repair

4×3 Posteriortibial

V-Yadvancementtype I

Direct 12

3 70, F Melanoma WLE 6×6 Posteriortibial

V-Yadvancementtype III

Direct 6

4 70,M

Wound breakdownfollowing Achillestendon repair

6×4 Posteriortibial

Peninsular STSG 24

5 60,M

Wound breakdownfollowing Achillestendon repair

5×3 Peroneal Propeller STSG 120

6 26,M

Road traffic accident 6×5 Posteriortibial

Propeller STSG 12

7 80, F Melanoma WLE 5×5 Peroneal V-Yadvancementtype III

Direct 24

8 84, F Eccrine poroma WLE 4×3 Peroneal V-Yadvancementtype III

Direct 12

9 42,M

Wound breakdownfollowing Achillestendon repair

4×4 Posteriortibial

Propeller Direct 3

10 52,M

Wound breakdownfollowing Achillestendon repair

3×3 Peroneal V-Yadvancementtype I

Direct 48 Unhealed wound at distal edge of flap;second perforator flap was performed

11 86, F Melanoma WLE 3×3 Posteriortibial

V-Yadvancementtype I

Direct 5

M male, F female, WLE wide local excision, STSG split-thickness skin grafta Flap classification as described by Niranjan et al. [11]b Simultaneous reconstruction of the Achilles tendon with strip of tendon harvested from ipsilateral gastrocnemius

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Fig. 2 Algorithm of theperforator flap technique

Fig. 3 Surgical technique. a Marking of defect and design of the flap. b Surgical defect. c Exploratory incision. d Identification of perforator. eRaising the flap on perforator. f Advancement of flap to the defect

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Six patients had previously undergone open primary repairof the Achilles tendon with subsequent wound breakdown. Inthese patients, a longitudinal incision was used for the repair.Re-repair of the Achilles tendon was not necessary. One patient(no. 1) required radical debridement of an infected and necroticAchilles tendon. This left a combined defect of the tendon (a 7-cm gap) and overlying skin. Tendon reconstruction wasperformed using a strip of ipsilateral gastrocnemius tendon thatwas raised with the flap. Vascularity of this tendon strip waspossibly achieved by reverse flow from the flap.

Of the remaining four patients, three had excision of skincancer and one patient suffered avulsion injury and skin necro-sis of the back of the heel following a road traffic accident. Onepatient (no. 10) had an additional V-Y advancement flap 6-weeks after the first V-Y advancement flap. The second flapwas required to cover a small unhealed wound at the distal edgeof the first flap.

The size of the defects ranged from 3×3 to 6×6 cm and themean area was 19.3 (range 9–36)cm2. There were six V-Yadvancement flaps, four propeller flaps and one peninsular flap.The V-Yadvancement flaps were classified as types I, IIA, IIB,III and IVas previously described [11]. All patients had palpa-ble peripheral pulses.

Surgical technique

Preoperative planning begins with locating the perforatorsarising from peroneal or posterior tibial vessels using a hand-held Doppler probe. The patient is positioned supine or lateraldecubitus and tourniquet is applied without exsanguination of

the limb. This ensures sufficient blood in the perforators to aidtheir identification during the initial exploration. When neces-sary, the wound is thoroughly debrided to reveal the finaldefect size.

If a perforator is identified near the defect, a V-Y advance-ment flap based on that perforator is provisionally designed.The length of the flap is approximately twice the diameter of theprimary defect [11]. The flap is oriented in such a manner thatlaxity of the surrounding skin allows direct closure of the donorsite. If the perforator is located away from the defect or antic-ipated advancement is considered too great, a propeller flap isdesigned instead. The length of the propeller flap proximal tothe perforator equals the distance between the perforator and thedistal edge of the defect plus 1 cm. The 1-cm addition takes intoaccount tissue contraction and allows tension-free closure. Re-verse planning can verify the flap dimensions.

An initial exploratory incision through skin and deep fasciais made and the perforator is identified. If any other potentiallyuseful perforators are encountered, these are preserved. Flapdesign can be altered if necessary. Once the dominant perfo-rator has been chosen, the flap is completely islanded andtourniquet is released to check perfusion. For V-Y advance-ment flaps, care is taken to preserve cutaneous veins andnerves. For propeller flaps, the perforator is gently freed fromsurrounding tissue from its origin at the source vessel to thedeep fascia on the under surface of the flap. Side branches areligated and any fascial strands that could inadvertently kinkthe perforator are divided.

Inset of advancement flaps can be modified depending onthe size and orientation of the defect, and degree of

Fig. 4 Patient no. 2: A 46-year-old male with wound breakdownfollowing open repair of theAchilles tendon. a Pre-opappearance with V-Yadvancement flap design, basedon posterior tibial arteryperforator. b Immediate post-opappearance after type Iadvancement

Fig. 5 Patient no. 5: A 60-year-old male with wound breakdownfollowing open repair of theAchilles tendon. a Pre-opappearance. b Post-opappearance after propeller flapreconstruction, based onperoneal artery perforator

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advancement is gained. Nirnajan [11] has classified perforator-based V-Y flaps. Type I is single V-Y flap. Type IIA is double-opposing V-Y flaps of equal size. Type IIB is double-opposingV-Y flaps of unequal size. Type III is fish-mouth V-Y flap andtype IV is adjacent V-Y flaps. Type I or III is the option forsingle advancement flaps. A corrugated drain is placed anddonor defect is closed primarily or with a skin graft. Bulkydressings rather than a plaster of Paris splint are used to keep theankle in a neutral position. Bed rest is maintained for 48 hduring which the drain is removed after 24 h. After 48 h, partialweight bearing is started and continued until 2 weeks, andgradually, the patient is allowed full weight bearing as andwhen the patient is confident.

If simultaneous Achilles tendon reconstruction is neces-sary, a strip of tendon is harvested from the intramuscularportion of the ipsilateral gastrocnemius tendon and suturedto the ends of the remnant Achilles tendon with non-absorbable suture. The interconnecting small tenuous vesselsbetween the deep fascia and gastrocnemius tendon are notdisturbed while harvesting a strip of 2-cm-wide tendon. Thistendon strip was sutured to the defect of the Achilles tendonwith multiple figure-of-8 sutures with 2-0 PROLENE. Theankle is kept in a neutral position. After 48 h, the drain isremoved and a below-knee POP splint is applied for 3 weeks.Partial weight bearing is started thereafter and full weightbearing commenced after 12 weeks (Figs. 2 and 3).

Results

The mean follow-up was 28.5 (range 3–120)months. Post-operative venous congestion was not observed and there wereno flap failures.

Post-operative complications included a non-healingwound at the distal edge of the V-Yadvancement flap (patientno. 10) and post-operative haematoma (patient no. 1). Theformer failed to heal for 6 weeks and was subsequentlyreconstructed with another perforator-based V-Yadvancementflap. The post-operative haematoma required evacuation.Both patients had an unremarkable recovery thereafter.

None of the patients reported painful sensitivity, difficultywith walking or suffered skin breakdown because ofshearing.

All patients (Figs. 4, 5 and 6) were fully weight bearing by4 weeks, except the patient who had simultaneous repair of theAchilles tendon. He became fully weight bearing at 12 weeksand did not suffer tendon re-rupture.

Discussion

Reconstruction of skin and soft tissue overlying the Achillestendon presents a significant challenge to the reconstructivesurgeon. Poor vascularity of the Achilles tendon, paucity ofavailable local tissue and the need to preserve anatomicalcontour to allow shoe fitting all add to the difficulty ofreconstruction. Reconstruction is made more complex whenthere is a concurrent defect in the Achilles tendon.

A number of reconstructivemethods have been described andinclude reverse sural artery flap, medial plantar flap, dorsalispedis flap, abductor hallucis flap and free flaps [13–17].

Although each reconstructive method has its own merits,a ‘Gold standard’ does not exist. The varying presentation ofthe wound, heterogeneous patient population and lack ofaccess to microsurgical facilities ensure that no single meth-od is universally applicable.

The ideal reconstruction should be a short single-stageprocedure, simple to perform, robust, preserve the anatomi-cal contour of the ankle and restore tendon continuity andglide when necessary. In this context, perforator-based flapreconstruction does offer a number of advantages: the flapsare relatively easy to raise, there is a degree of flexibility intheir design, like-for-like skin is replaced, the reconstructionis robust, anatomical contour of the ankle is preserved andthe flaps can be sensate. Furthermore, preservation of thesource artery avoids compromising foot circulation. In thisseries, ankle range of motion was unimpaired and partlyreflects the pliable nature of the flaps.

Reconstruction of the Achilles tendon region with peronealand posterior tibial perforator-based flaps has been previously

Fig. 6 Patient no. 8: An 84-year-old female with soft tissue defectfollowing wide local excision ofan eccrine poroma. a V-Yadvancement flap based onperoneal artery perforator hasbeen islanded and ready for inset.b Immediate post-op appearanceafter type III advancement

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described. Lu et al. reported seven patients with defects in theAchilles tendon and/or hindfoot region that had peronealperforator-based fasciocutaneous flaps [6]. Three were pro-peller, two advancement and two were peninsular. In contrastto our findings, only one of their donor sites could be closeddirectly. However, mean flap size in their series was muchgreater than our mean defect size, 74.1 and 20.3 cm2, respec-tively. As one would expect, with increasing flap size, itbecomes more difficult to achieve direct closure of the donorsite. Furthermore, using large perforator-based propeller flapsto cover the Achilles region carries the risk of marginal necro-sis, particularly in those who smoke or have diabetes [18].

The authors stated that advancement flaps could only beused if advancement was less than 4 cm. Although this isbroadly in keeping with our own observations, we believe thereis no hard-and-fast rule governing the degree of advancement.Location of the perforator in the flap and the manner in whichthe perforator connects to the source vessel are influencingfactors.

In accord with Lu et al., we also believe that the likelihoodof not finding a suitable peroneal perforator in the distal leg isvery low. Due to abundance of perforators in the Achillesregion, we always found a perforator on which to base the flap.

Cavadas and Landin have reported successful reconstruc-tion with posterior tibial perforator-based flaps [19]. Flapswere dissected subcutaneously and based on the most distalperforator of the posterior tibial artery. The presence of con-stant perforators from the posterior tibial artery in the distal legoffers considerable assurance for local reconstructive options.Indeed, the majority of our patients (60 %) had posterior tibialperforator-based flaps. A major concern with propeller flaps ispost-operative venous congestion. This was not seen in ourfour patients. We believe meticulous dissection around theperforator to clear any fascial strands and tension-free insetof the flap are key to preventing venous congestion.

The successful use of a perforator-based flap in one patient(no. 6) with degloving of the heel suggests that this flap isreliable in this situation, providing that the perforator is clearlyvisualised. We concede it is difficult to draw any firm conclu-sions based on a single observation.

In our opinion, reconstruction of skin and soft tissue of theAchilles tendon region can be successfully achieved withperoneal or posterior tibial perforator-based fasciocutaneousflaps. Flap design is dynamic and resultant reconstructionfulfils many of the reconstructive goals for this region. Pa-tient selection is paramount and those with small- tomoderate-sized defects are well suited.

Conflict of Interest None

References

1. Lee JW, Yu JC, Shieh SJ et al (2000) Reconstruction of the Achillestendon and overlying soft tissue using antero-lateral thigh free flap.Br J Plast Surg 53:574–577

2. Kim SW, Hong JP, Lee WJ et al (2003) Single-stage Achillestendon reconstruction using a composite sensate free flap ofdorsalis pedis and tendon strips of the extensor digitorum longusin a complex wound. Ann Plast Surg 50:653–657

3. Kim CH, Tark MS, Choi CYet al (2008) A single-stage reconstruc-tion of a complex Achilles wound with modified free compositelateral arm flap. J Reconstr Microsurg 24:127–130

4. Koski A, Tukiainen E, Suominen S et al (2003) Reconstruction ofiatrogenic skin defects of the Achilles tendon region: an analysisof 25 consecutive patients. Eur J Plast Surg 26:298–303

5. Attinger CE, Ducic I, Hess CL et al (2006) Outcome of skin graftversus flap surgery in the salvage of the exposed Achilles tendon indiabetics versus nondiabetics. Plast Reconstr Surg 117:2460–2467

6. Lu TC, Lin CH, Lin CH et al (2011) Versatility of the pedicledperoneal artery perforator flaps for soft-tissue coverage of the lowerleg and foot defects. J Plast Reconstr Aesthet Surg 64:386–393

7. Whetzel TP, Barnard MA, Stokes RB (1997) Arterial fasciocutaneousvascular territories of the lower leg. Plast Reconstr Surg 100:1172–1183

8. Heitmann C, Khan FN, Levin SL (2003) Vasculature of the pero-neal artery: an anatomic study focused on the perforator vessels. JReconstr Microsurg 19:157–162

9. Attinger CE, Evans KK, Bulan E et al (2006) Angiosomes of the footand ankle and clinical implications for limb salvage: reconstruction,incisions, and revascularization. Plast Reconstr Surg 117:216S–293S

10. Venkataramakrishnan V, Mohan D, Villafane O (1998) Perforatorbased V-Yadvancement flaps in the leg. Br J Plast Surg 51:431–435

11. Niranjan S, Price RD, Govilkar P (2000) Fascial feeder andperforator-based V-Y advancement flaps in the reconstruction oflower limb defects. Br J Plast Surg 679–89

12. Ono S, Sebastin SJ, Yazaki N (2011) Clinical applications ofperforator-based propeller flaps in upper limb soft tissue reconstruc-tion. J Hand Surg Am 36:853–863

13. Wei FC, Chen HC, Chuang CC et al (1998) Reconstruction ofAchilles tendon and calcaneous defects with skin-aponeurosis-bonecomposite free tissue from the groin region. Plast Reconstr Surg81:579–589

14. Babu V, Chittaranjan S, Abraham G et al (1994) Single-stage recon-struction of soft- tissue defects including the Achilles tendon usingthe dorsalis pedis arterialized flap along with the extensor digitorumbrevis a as bridge graft. Plast Reconstr Surg 93:1090–1094

15. Haas F, Seibert FJ, Koch H et al (2003) Reconstruction of combineddefects of the Achilles tendon and overlying soft tissue with a fascialata graft and free fasciocutaneous lateral arm flap. Ann Plast Surg51:376–382

16. Michlits W, Gruber S, Windhofer et al (2008) Reconstruction ofsoft tissue defects overlying the Achilles tendon using the superextended abductor hallucis muscle flap. J Trauma 65:1459–1462

17. Abhyankar SV, Kulkarni A, Agarwal NK (2009) Single stage recon-struction of ruptured tendo-achilles tendon with skin cover usingdistally based superficial sural artery flap. Ann Plast Surg 63:425–427

18. Jakubietz RG, Jakubietz DF, Gruenert JG, Schmidt K, Meffert RH,Jakubietz MG (2010) Reconstruction of soft tissue defects of theAchilles tendon with rotation flaps, pedicled propeller flaps andfree perforator flaps. Microsurgery 30(8):608–613

19. Cavadas PC, Landin L (2006) Reconstruction of chronic Achillestendon defects with posterior tibial perforator flap and soleus ten-don graft: clinical series. Plast Reconstr Surg 117:266–271

706 Eur J Plast Surg (2013) 36:701–706