THE USE OF FABRICATED CHIMERIC FLAP FOR RECONSTRUCTION OF EXTENSIVE FOOT DEFECTS BAOQIANG SONG, M.D.,1* JIANWU CHEN, M.D.,2 YAN HAN, M.D.,3 YALAN HU, M.D.,4 YINGJUN SU, M.D.,5 YANG LI, M.D.,6 JUAN ZHANG, M.M.,7 and SHUZHONG GUO, M.D.8

Repair of extensive foot defects requires both adequate tissues for wound coverage and special tissues for functional reconstruction. To maximize its function reconstruction, fabricated chimeric flaps consisting of multiple separate flaps were designed to reconstruct such defects. Five patients suffered extensive foot defects with sizes ranging from 23 3 12 cm to 38 3 14 cm2 in multiple regions including heel, forefoot, dorsum, ankle, anterior leg, and even toes. Causes included crushing injuries, avulsion injuries, and scar excision. Most areas of the defects except heel were first covered by latissimus dorsi muscle flap or anterolateral thigh flap and their pedicles were anastomosed with recipient vessels. Then free medial plantar flaps were transferred for heel reconstruction and their pedicles were further attached to either side branches of the main source vessel or to its distal continuation. All chimeric flaps survived uneventfully and all patients were able to walk in normal footwear during the 1.5- to 4-years follow-up. None of the flaps developed ulcer and flap breakdown. The assessment by Maryland Foot Score showed that four of the five patients gained a “good” recovery and one patient showed moderate improvement of foot functions. Appearances of reconstructed heels were near-normal. The results indicate that fabricated chimeric C 2015 Wiley Periodicals, flap has good design flexibility and may provide an option for functional reconstruction of extensive foot defects. V Inc. Microsurgery 00:000–000, 2015.

Extensive

foot injuries result in defects in multiple regions of a foot. These different regions of foot have their own special anatomical and functional features. The plantar heel area has highly specialized, densely adherent, glabrous skin, while the dorsum has visible contours and a thin layer of soft tissue. How to reconstruct such extensive and divers wounds and restore their functions are the challenges faced by the reconstructive surgeons. Currently, a single large fasciocutaneus, or a skingrafted muscle free flap is commonly used for resurfacing the foot extensive defects.1–3 Although an adequate tissue may be obtained, it is usually difficult to cover an irregularly shaped and three-dimensional soft-tissue defect with a single free flap. Besides, recurrent ulcer

1 Department of Plastic Surgery, Xijing Hospital, Fourth Military Medical University, Xi’an, Shaanxi, China 2 Department of Plastic Surgery, Xijing Hospital, Fourth Military Medical University, Xi’an, Shaanxi, China 3 Department of Plastic Surgery, 301 Military Hospital of China, Beijing, China 4 Department of Plastic Surgery, 260th Hospital of PLA, Shijiazhuang, China 5 Department of Plastic Surgery, Xijing Hospital, Fourth Military Medical University, Xi’an, Shaanxi, China 6 Department of Plastic Surgery, Xijing Hospital, Fourth Military Medical University, Xi’an, Shaanxi, China 7 Department of Plastic Surgery, Xijing Hospital, Fourth Military Medical University, Xi’an, Shaanxi, China 8 Department of Plastic Surgery, Xijing Hospital, Fourth Military Medical University, Xi’an, Shaanxi, China Baoqiang Song and Jianwu Chen contributed equally to this work. *Correspondence to: Baoqiang Song, M.D., Department of Plastic Surgery, Xijing Hospital, Fourth Military Medical University, No. 17 Changle Western Road, Xi’an, Shaanxi, China. E-mail: [email protected] Received 21 August 2014; Revision accepted 7 January 2015; Accepted 17 February 2015 Published online 00 Month 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22399

Ó 2015 Wiley Periodicals, Inc.

and flap breakdown are often unavoidable at the weightbearing areas.2,4,5 Taking both function and aesthetics into account, Hollenbeck et al. proposed to divide the foot into 7 subunits and the defect of each subunit needs to be reconstructed with corresponding free flap.6 Chimeric flap, consisting of multiple separate flaps with separate vascular supplies attached to a common pedicle, is uniquely suited for reconstruction of extensive foot defects.7–10 Because it can simultaneously provide multiple tissue types to fill any volume deficit and allows for an immediate coverage and also has a good maneuverability for reconstructing any defect with irregular shape and dimension. At present, intrinsic chimeric flaps based on anterior tibial vessels or thoracodorsal vessels have been successfully used in head, neck and limb reconstruction,11–14 and various flap donor sites such as the deep circumflex iliac, lateral femoral circumflex, subscapular, thoracodorsal, and radial arterial systems have been explored.9 Fabricated chimeric flap was constituted with different subunit flaps which were harvested from different donor sites other than the same donor sites, thus it has better design flexibility and more diverse component parts.8 It also complies well with subunit-specific principle and can maximize function reconstruction. Thus, its applications in reconstruction of complicated defects have been reported for a long time, such as two radial forearm flaps for the reconstruction of an entire esophagus and the bilateral lattissimus dorsi musculocutaneous flaps for the repair of extensive defect of lower leg.15,16 However, the use of fabricated chimeric flaps for foot reconstruction has not been widely reported. In this article, we report the application of five fabricated chimeric flaps for resurfacing extensive foot defects that all involved weight-bearing areas.

Microsurgery DOI 10.1002/micr

88/good 2 years None

71/average 1.5 years

Skin graft partial loss Skin graft partial loss None Scar excision 34/M 5

Crushing injury 25/M 4

MP: medial plantar flap; LD: latissimus dorsi; ALT: anterolateral thigh flap.

16 3 12

30 3 10

MP 1 LD muscle flaps with skin graft MP 1 LD muscle flap with skin graft MP 1 LD muscle flap with skin graft 38 3 14

Plantar area/toes/ dorsum/anterior leg Plantar area/ dorsum/ankle Forefoot/dorsum 26/M 3

Crushing injury

25 3 14 46/M

Avulsion injury

Second skin graft

79/good 3.25 years

85/good 2.5 years Flap bulkiness and heel pain

Flap debulking and removal of bony prominences Second skin graft

95/excellent None None

MP 1 LD muscle flap with skin graft MP 1ALT 1 tensor fasciae latae flap 23 3 12

Heel and medial plantar area/medial ankle Heel/ankle/ Achilles tendon Avulsion injury

2

Age/sex Patient

Four patients underwent reconstruction with combination of the MP and LD muscle flap plus skin graft, and one patient underwent reconstruction with MP and ALT (Table 1). All flaps survived, but two patients had partial loss of skin graft. After the second skin grafting, they healed subsequently. There were no complications related to donor sites. During the follow-up from 1.5 to 4 years, no patient developed ulcer and flap breakdown at the surgical weight-bearing areas. All patients were able to walk in normal footwear and satisfied with the aesthetic

Causes

RESULTS

13/M

Therapy Size (cm)

Patients first underwent removal of all devitalized tissue, control of infection, fixation of fractures and vacuum-assisted closure therapy. When the wounds were prepared, two different flaps were transferred simultaneously for foot reconstruction. One of them was the medial plantar flap (MP), which was mainly used to reconstruct weight-bearing area such as heel and forefoot. The other one, either latissimus dorsi (LD) muscle flap or anterolateral thigh flap (ALT), was used to cover the remaining defects. Pedicles of LD muscle flap or ALT were first anastomosed with the recipient vessels (posterior tibial or anterior tibial vessel), and then MP was attached through its pedicle to either the side branches of LD (thoracodorsal vessel) or to the distal continuation of ALT (lateral femoral circumflex vessel) (Figs. 1a and 1b). Meanwhile, the medial plantar nerve was also incorporated to provide sensibility to the transferred flap. After anastomosis of vessels and nerve, a skin graft was applied over the LD muscle flap and remaining defects. Donor sites were closed by either primary suture or a split-thickness skin grafting. Postoperatively, drains were commonly used, and platelet glycoprotein IIb/IIIa inhibitors and dextran were administered intravenously for 1 week to enhance blood flow. Functional evaluation was done at latest follow-up using the Maryland Foot Score (MFS), which was specific to foot and ankle function. In the 100-point MFS, >89 points was an excellent result, 75–89 points was a good result, 50–74 was an average result, and

The use of fabricated chimeric flap for reconstruction of extensive foot defects.

Repair of extensive foot defects requires both adequate tissues for wound coverage and special tissues for functional reconstruction. To maximize its ...
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