FLAPS OF THE LOWER EXTREMITY & FOOT JESSE E. SMITH, M.D., F.A.C.S. Facial Plastic & Reconstructive Surgery University of Texas Southwestern Medical Center at Dallas Foot Soft Tissue Reconstructive Pyramid Free Tissue Transfer Pedicle Flaps Local Muscle Flaps Local Random Flaps Skin Grafting Bioengineered Tissue Alternatives Negative Pressure Wound Therapy Primary Closure SCCa Oasis Wound Matrix Post Op Mohs 10 days after wound sheeting • ICU Levophed for Septic Shock • Multiple exposed metatarsals • Non-healing exposed tendons • ICU Levophed for Septic Shock • Multiple exposed metatarsals • Non-healing exposed tendons One Week after STSG and Bone Debridement 2 weeks after 2nd STSG and bone debridement 6 weeks after 2nd Bone debridement and STSG Surgical Options for Foot Reconstruction Dimension Extension Localization Type of Flap < 3 cm2 Soft tissue Weightbearing areas Local flap < 3 cm2 Soft tissue Nonweightbearing areas Skin grafts >3 cm2 Soft tissue Weightbearing areas Free flap (free fasciocutaneous, musculocutaneou s flaps, muscle free flap plus skin graft) >3 cm2 Soft tissue and bone loss Weightbearing areas Free osteocutaneous flap Medial Plantar Flap • Sensitive cutaneous flap harvested from nonweightbearing (NWB) area of the sole • Maximum dimensions - 10 X 7 cm Medial Plantar Flap Medial Plantar Flap • Pedicle - Medial plantar artery either proximal or distally based • Uses: Defect of calcaneum, medial malleolar area, distal weightbearing (WB) areas on the heads of metatarsus Medial Plantar Flap Abductor Brevis Hallucis • Muscular flap along the medial border of the foot • Pedicle - Branches from the medial plantar artery • Arc of rotation Medial area of the calcaneum Flexor Brevis Hallucis • Muscular flap that can be harvested alone or with the abductor brevis hallucis from the medial forefoot margin • Pedicle - Medial plantar artery and first web space artery • Arc of rotation Dorsum of the foot, distal forefoot sole on the medial side 1. lateral plantar artery 2. medial plantar artery, common trunk 3. medial plantar artery, superficial branch 4. medial plantar artery, superficial branch 5. flexor hallucis brevis. Abductor Hallicus flexor hallucis brevis Flexor Brevis Digitorum Flap • Muscular flap localized under the plantar aponeurosis, indicated to cover small bone exposure (A sensitive myocutaneous flap also can be harvested.) Flexor Digitorum Brevis Flap: Artery: Lateral plantar artery Pivot point: Distal plantar heel Lateral Plantar Artery Flexor Brevis Digitorum Flap • Pedicle - Lateral plantar artery • Uses: Defect of calcaneum and of medial malleolar area Lateral Plantar Artery Abductor Digiti Minimi Flap Artery: Lateral plantar artery Rotation Point: Posterior DOMINANT PEDICLE Dorsalis Pedis Flap • Sensitive fasciocutaneous flap or a myocutaneous flap (including the extensor brevis digitorum muscle) that can be harvested from the dorsum of the foot • Pedicle - Dorsalis pedis artery, which is the terminal branch of the anterior tibialis artery • Contraindicated if AT or DP flow is compromised Dorsalis Pedis Flap • Arc of rotation - Medial or lateral dorsal area, malleolar areas Lateral Calcaneal Artery Skin Flap • Cutaneous sensitive flap below the lateral malleolar area along the lateral side of the foot Lateral Calcaneal Artery Skin Flap • Pedicle - Lateral calcaneal artery, which is the terminal branch of the peroneal artery; reinnervation is provided by branches from the sural nerve • Arc of rotation - Achilles tendon and lateral malleolar area Distal Based Lateral Supermalleolar Adipofascial Flap • From ascending perforating branch of the peroneal artery. • Can extend half way up the fibula. • Between Tibialis Anterior and Ext Dig Long. • Usually 2-3 cm Wide • Up to 50% minor complication rate. Distal Based Lateral Supermalleolar Adipofascial Flap Distal Based Lateral Supermalleolar Adipofascial Flap Distal Based Lateral Supermalleolar Adipofascial Flap Distal Based Lateral Supermalleolar Adipofascial Flap Distal Based Lateral Supermalleolar Adipofascial Flap Reverse-Flow Island Sural Flap • Distally based sural artery flap • Supplied by most distal perforating artery of peroneal artery which is located approximately 5-7 cm above tip of lateral malleolus Reverse-Flow Island Sural Flap • Includes the superficial sural artery, sural nerve, and the short saphenous vein. • Most make the point of rotation 5-7 cm superior to the lateral malleolus. Reverse-Flow Island Sural Flap • According to Ríos-Luna et al, the sural fasciocutaneous offers technical advantages such as easy dissection with preservation of more important vascular structures in limb, complete coverage of soft tissue defect without need of microsurgical anastomosis Ríos-Luna et al. Versatility of the sural fasciocutaneous flap in coverage defects of the lower limb. Injury. 2007 Jul;38(7):824-31. Reverse-Flow Island Sural Flap • Complications 21 26% • 50% loss if tobacco use • Flap loss 3.2 - 4.2% • Venous insufficiency and increased age were risk factors for loss Reverse Sural Flap Pedicle Path 2 cm Wide Pedicle 6 cm Superior STSG used to decrease venous congestion Free Flap Reconstruction • • • • • • • • Gracilis Latissimus Dorsi Ructus Serratus Anterior Tensor Fascia Latae Vastus Lateralis Anterolateral Thigh Radial Forearm ALT Free Flap ALT Free Flap ALT Free Flap ALT Flap Skin Paddle Anterior TFL Radial Artery Vastus Lateralis LFC Artery ALT Flap ALT Flap ALT Flap ALT Free Flap Gracilis Free Flap • A muscle flap. It can be harvested with a skin paddle (see TUG Flap). • Innervation: Branch from the obturator nerve to gracilis. • Blood supply: Gracilis vessels from the medial femoral circumflex system. • Artery: Usually small caliber, from 1 to 2 mm. • Vein(s): Two venae, one usually slightly larger than the artery. • Pedicle length: up to 6 cm. Gracilis Free Flap Gracilis Free Flap Gracilis Free Flap Gracilis Free Flap The Latissimus Flap • Muscle flap. May be harvested with a skin paddle. • Innervation: The thoracodorsal nerve. • Blood supply: Thoracodorsal artery via the subscapular artery. • Artery: Can be up to 2 or 5 mm if harvested up to the subscapular artery. • Vein(s): Comparable to the artery. A single venae commitans. • Pedicle length: Up to 15 centimeters. Lat Dorsi Free Flap Serratus Muscle Free Flap • Muscle flap. May be harvested with a skin paddle. • Innervation: The long thoracic nerve. • Blood supply: Serratus artery via the subscapular artery. • Artery: Can be up to 3 or 4 mm if harvested up to the subscapular artery. • Vein(s): Comparable to the artery. A single venae commitans. • Pedicle length: Up to 15 centimeters. Serratus Muscle Free Flap
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