Eur J Plast Surg (1995) 18:293-296 European 1 ] - ~ 1 ,i g

E l a S t i C bur ery © Springer-Verlag 1995

Turnover cutaneous and fasciocutaneous flaps in the treatment of cutaneous defects of the leg

J. M. Martinez Sahuquillo Mfirquez*

Service of Plastic Surgery, University Hospital "Virgen Macarena", Sevilla, Spain

Abstract. Twenty-n ine cases of skin loss on the legs with bone exposure were studied. As an al ternat ive to other techniques, turnover dermal fat f laps and turnover fascio- dermal fat f laps were used for recons t ruc t ion of the de- fects. Exce l len t funct ional and aesthetic results were ob- tained. These f laps are easy to perform, the hospi ta l stay is short, and there is m in ima l d issec t ion in the leg.

Key words: Cutaneous f laps - Leg defects - Turnover fasc iocu taneous f laps

At present , muscu locu taneous , fasc iocutaneous , muscu- lar and free f laps are ex tens ive ly used for recons t ruc t ion of skin loss in the lower ex t remi ty wi th exposure of bone, tendons, nerves, vessels , etc. However , the use of o lder techniques , which are easy to use, give good func- t ional and aesthet ic results , and require only a short hos- pi ta l stay, should not be ru led out.

Turnover cu taneous and fasc iocu taneous f laps are easy to use for the t rea tment of cutaneous loss in the legs with bone exposure. These f laps wil l success fu l ly solve the p r o b l e m in se lec ted cass.

In both types o f f laps, the ep idermis is removed , and vascular i ty and venous dra inage is p rov ided by vessels which are presen t in the ped ic le running para l le l to the defect. The d i f ference be tween the f laps is the incorpora- t ion o f the fasc ia when indicated.

Materials and methods

Twenty-nine cases of cutaneous loss in the lower extremities with exposed bone were studied. All patients had been treated with turnover cutaneous or fasciocutaneous flaps.

* Fellowship of FPI of the Andalusian Regional Government, Ser- vice of Plastic Surgery, Associate Professor, Department of Sur- gery

Correspondence to: J. M. Martinez Sahuquillo Mfirquez, Marqu6s de Parades, 40, 3 °, E-41001 Sevilla, Spain

Turnover cutaneous flaps were used in 11 cases and turnover fasciocutaneous flaps in the remaining 18. The age of the patients ranged from 12 to 70. Seven were female, and 22 were male.

Although these flaps can be used for repair of all types of skin defects in the legs, regardless of their pathology, they are mainly suited for those cases with exposure of bone or other significant structures in the anteromedial area of the leg. Trauma resulting in bone exposure was the main cause for defects in this series. In 17 cases, external fixators were used, this did not interfere with the use of these flaps (Figs. la, 2a).

Technique to flap elevation

A line is drawn parallel to the defect and approximately 2 to 3 cm from its edge; following this, the defect is outlined with a margin of 2 cm. The flap is now drawn out laterally so that it will cover the planned defect (Fig. 3a). The epidermis of the flap and the pedicle are removed, and following the lines that have been drawn, a flap with a pedicle between the two parallel lines will be traced (Fig. 2b). The flap, including the fascia, is turned over its pedicle, which has a width of approximately 2 to 3 cm (Fig. lb). The flap edge is sutured to that of the defect. The donor site and the undersurface of the flap are covered with a split thickness skin graft (Figs. lc, 2c, 3b). The donor site defect of the fasciocutane- ous flap can be stabilized by suturing the dermis of the skin around the defect to the underlying muscle before placing the skin graft. Initially, the fascia was not included in the flap, but with its inclusion the length and width of the flap can be increased, and it was safer and more robust.

If there is a scar which could cause vascular impairment of the flap, a delay is recommended. This was performed in four cases. In these cases, the flap was traced and partially dissected and su- tured to the original site. A week later the entire flap was dissect- ed, de-epithelialized and placed over the defect following the aforementioned technique.

Discussion

Cutaneous defects in the lower l imb, espec ia l ly i f s ignif- icant structures are exposed, present a cha l leng ing repai r p rob l e m for the p las t ic surgeon. A great var ie ty of tech- niques have been descr ibed to repai r these defects .

The s imples t way to cover a lower l imb skin defec t is a free skin graft. This, however, cannot be appl ied to

Fig. 1. a A 17-year-old patient showing exposed bone on the ante- rior aspect of the leg resulting from infection after osteotomy for limb lengthening, b Excision of all skin surrounding the involved area with repair using a turnover fascio-dermal fat flap. e Free skin graft to the undersurface of the flap and the donor site. d Re- sults after 1½ months

Fig. 2. a A 31-year-old patient with an open fracture of the superi- or one-third of the leg resulting from a traffic accident. External fixators were applied but skin necrosis occurred, b Fascio-dermal fat flap de-epithelialized, c Turnover flap covered with free skin graft, d Results after five months

Fig. 3. a Skin loss with exposed bone; plane of resection and skin flap drawn out. Note the area of the pedicle between the flap base and planned resection, b De-epithelialized fascio-dermal fat flap turned over and sutured into the defect, e Postoperative results

complex injuries with bone exposure, when other local interventions have to be performed or when the area has to be filled or padded.

Therefore, the best procedure in these cases is to use flaps since they supply their own vascularity and can provide more tissue to fill the defect. There are numer- ous kinds of flaps that can be used to repair these defects successfully, each having its particular indication.

The classic local flaps using advancement rotation or transposition, formed by skin and subcutaneous cellular tissue, are very limited in the leg and can only be used for specific areas and for small cutaneous loss. Never- theless, with the incorporation of the fascia to these flaps their vascularization and security have been improved, as has been demonstrated by a study carried out on ca- davers and experimental animals [1, 2], in addition to a histological study of the deep fascia and its clinical ap- plication [3, 4]. In addition to this, the incorporation of fascia limits its advancement or rotation.

Distant flaps, such as the cross leg flaps, have solved many cases, but have many disadvantages: long immobi- lization in an uncomfortable position; the complicated fixators needed for maintaining the position; and the use of a healthy limb with the aesthetic and lymphatic disor-

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ders that may arise. They are contraindicated for certain patients because of their age or the state of their joints which impede long immobilization or the use of fixators in the area.

The muscular and musculocutaneous flaps are a good alternative. They supply a large amount of tissue with appropriate vascularization necessary in the case of os- teomyelitis or chronic ulcers. However, their range is limited.

Microvascular free flaps are the solution for many cases, but the results obtained in the lower limb are infe- rior to those achieved in other areas. They provide good vascularity and sufficient tissue in most cases. However, they cannot be used when the patient has an underlying vascular pathology, as in the case of diabetic patients.

Finally, cutaneous and fasciocutaneous turned flaps can also be preformed.

All those procedures, from the most simple to the most complex, give good results if they are used ade- quately and applied to the specific needs of each individ- ual case.

Fasciocutaneous flaps have been extensively used for filling cutaneous defects, to cover pressure areas and as interpositional material in cavities, joints, arthroplasties, etc. [5-71.

In 1975, Lemos [8] described the use of a turnover flap to reconstruct skin loss in the leg. This was a two- stage procedure, and the flap was based on scar tissue.

In 1976, Lazo presented a turnover cutaneous flap to repair skin defects in legs with exposed bone, the under- surface of the flap and the donor site were skin grafted. This turnover cutaneous flap has been used previously by Tulenko [9] for treating ischial decubitus ulcers; he reported satisfactory results.

Cutaneous and fasciocutaneous flaps can be based in perforating vessels, located anatomically, such as the distally based flap suggested by Gumener et al. [10] or the fasciocutaneous island flaps described by Behan et al. [11]. In this case the cutaneous and fasciocutaneous flaps are based in the three vessel plexi which course through the fasciocutaneous tissue. These are also used by Ramakrishnan et al. [12]. The most superficial is the dermal plexus; deep to this is the larger caliber subder- real plexus. The deepest plexus is the suprafascial plex- us. The deep fascia is perforated by septal, axial and per- forators from the muscle which in the suprafascial plane form an extensive interconnecting suprafascial plexus [13]. Since these systems anastomose abundantly in the suprafascial plexus, the combination of these systems are used in perfusion of fasciocutaneous flaps. The blood supply of the fasciocutaneous flap is provided by subjacent muscle perforators, septocutaneous vessels and axial vessels.

The turnover flap has the following advantages: the nutrition of the flap is done through its primary pedicle; it is a staged procedure; age is no limit; fixators in the defect area do not cause problems; it is simple to per- form and the results are good. The inclusion of the fascia in this flap has improved its vascularity, and this allows its use in the reconstruction of large cutaneous defects with exposed bone.

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As long as the skin and cellular subcutaneous tissue adjacent to the area o f the defects is o f good quality, these flap scan be used to repair cutaneous loss in legs, especially when there is exposed bone. When os teomy- elitis is present, muscle and muscle cutaneous flaps should be used in order to allow a better vascularization and a faster osseous recovery.

Conclusion

Turnover cutaneous and fasciocutaneous flaps are versa- tile techniques for repairing cutaneous defects in the an- teromedial surface o f the leg when there is exposed bone and other structures. This is a simple one-stage proce- dure which can be used in the presence o f external fix- ators regardless o f the patient 's age.

We believe that these techniques should continue to be considered by the plastic surgeon since without elimi- nating more recently described procedures they are still valid and offer satisfactory results if they are applied properly.

References

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2. Haertsche PA (1981) The blood supply to skin of the leg, A postmortem investigation. Br J Plast Surg 34:470

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