SLR - January 2017 - Kelley Rouse
Reference: Lee KJ, Lee SH, Kim MB, Lee YH. Adipofascial Fold-Down Flaps Based on the Posterior Tibial Artery Perforator to Cover the Medial Foot and Ankle Defects. J Plast Reconstr Aesthet Surg. 2016 Dec; 69(12):e229–e237.Scientific Literature Review
Reviewed By: Kelley Rouse, DPM
Residency Program: Heritage Valley Health System, Beaver, PA
Podiatric Relevance: Many podiatric surgeons struggle with large defects in the medial foot and ankle region, especially over exposed hardware. Various local flaps have been previously described in the literature, including a distally based adipofascial flap based off the location of a posterior tibial artery perforator (PTAP). The purpose of this article is to describe an adipofascial fold down flap technique and to report clinical outcomes of these flaps in small- to medium-sized defects of the medial foot and ankle.
Methods: A total of nine patients (five males and four females) underwent surgery. All had soft-tissue defects and/or wounds small to medium-sized in the area of the medial malleolus with exposed bone, tendon or hardware. The average wound size was 24 cm2. The defect size was based on postsurgical wound debridement measurements. The defects were caused by trauma or postoperative wound dehiscence with infection. The procedure was performed with the patient supine, under general anesthesia with a thigh tourniquet. A handheld Doppler was used to find the most distal perforator that was proximal to the defect. The skin was incised in zig-zag fashion proximal to the defect, and the skin flap was elevated from the donor site in the subdermal plane. The adipofasical flap was then elevated from proximal to distal in a U-shape until the distal perforator to be retained was identified as the flap pedicle. The flap was then folded down to cover the defect, with the adipose side facing deep, and the fascial side superficial. The flap was sutured to the defect and donor site closed with skin suture with a suction drain left in situ. The flap was inspected after 48 to 72 hours, and skin graft harvested from thigh or groin was used to cover the flap at one to two weeks postoperatively.
Results: All of the flaps and subsequent skin grafts survived. All patients recovered with normal ambulation without assistive devices. All could fit into normal shoes due to the thin flap size. The circumference of the limbs on average was 2.6 cm larger on the operative side versus the healthy side. Complications included an extension contracture associated with hypertrophic scar formation, which was resolved with contracture release and skin grafting. Four patients experienced partial skin necrosis of the donor site, which resolved spontaneously without treatment.
Conclusions: Various flaps have been described to cover defects in the lower leg, including free fasciocutaneous flaps, free muscle flaps and fasciocutaneous sural flaps. The advantages of this technique over others are that it is not as technically difficult, the donor site morbidity is minimal and little monitoring of the flap is required. Advantages over a muscle flap include no muscle weakness since the flap does not consist of muscle, and thinner and wider flap coverage. The flap is malleable, the fat does not adhere to underlying structures, such as tendons, bone or hardware, and the fascial tissue accepts skin grafts well. It works well for postoperative wounds, trauma and burns and is thin enough for use of normal shoe gear. Folding down the flap minimizes the risk of blood flow disturbance seen in rotational flaps. This article concludes that the described flap adds another option for coverage of small- to medium-sized defects in the medial foot and ankle.