Repair Of Skin And Soft Tissue Defect In Distal One Third Of Lower Leg By Surgical Flap

Objective: To investigate each sort of flap's characteristic and choose the best of all to repair different wounds, we summarized clinical experiences for 9 sorts of flaps repairing skin and soft tissue defect in distal 1/3 of lower leg.Method: We did retrospective research and analysis on clinical case from August, 2008 to April, 2009, 119 cases did flaps restoration in distal 1/3 of lower leg's skin and soft tissue defect. 56 cases did distally based sural neurofasciocutaneous flaps transferring, among which 18 cases had wound on anterolateral part of distal 1/3 lower leg, others included 10 cases on anteromedial part of distal 1/3 of lower legs and 28 cases on Achilles'stendon. All flaps measured from 6cm×5cm～22cm×10cm in area. Also, we had 15 cases doing fasciocutaneous flaps pedicled with the septocutaneous perforators of the posterior tibial artery, among which 11 cases' wounds located in anteromedial of distal 1/3 of lower legs, 4 cases' wound on anterolateral surface. The 15 flaps' area measured from 7cm×4cm～17.5cm×10cm. We also had 13 cases doing anterolateral island flaps of the lower leg, among which 12 had wounds on anteromedial surface, 1 on anterolateral side. 11 proximal and 4 double pedicle based flaps were performed. Free flaps includes totally 17 cases, the area of which measured from 19cm×7cm to 22cm×16cm. We had 5 cases of reversed island flaps pedicled with the posterior tibial artery, including 3 cross-leg cases. Also, 4 bi-pedicled gastrocnemius myocutabeous flaps were performed. 5 local fasciocutaneous flaps were transferred and 7 cases of cross-leg flaps were performed. We did statistical analysis on the staple flap sorts recovering skin and soft tissue defect in distal 1/3 of lower legs. Statistics analytical methods: for enumeration data we use chi-square test, and t-test for measurement data.Result: Among the 56 distally based sural neurofasciocutaneous flaps, 48 cases survived; 5 with distal superficial necrosis, healed after dressing change.; 3 with distal partial necrosis, we gave dressing change to1, 2 were healed after skin-grafting.. 14 survived in the 15 fasciocutaneous flaps pedicled with the septocutaneous perforators of the posterior tibial artery. One of the 15 have distal superficial necrosis and healed after the second satge of skin-grafting. 15 survived in 17 free flaps, 1 with distal superficial necrosis and healed after dressing change, 1 of the 17 had distal partial necrosis and healed after the second stage flaps. 13 anterolateral island flaps of the lower leg,5 reversed island flaps pedicled with the posterior tibial artery and 4 bi-pedicled gastrocnemius myocutaneous flaps and 5 local fasciocutaneous flaps totally survived. Additionally, 7 cross-leg flaps survived. After operation, we followed up the cases by regular visits for 2 weeks to 50 months and found out the the impairment all healed and without infectious relapse.To repair the skin and parenchyma impairment of distal 1/3 of lower legs, distally based sural neurofasciocutaneous flaps'average pedicle length and average flap length plus pedicle length were all larger than those of the fasciocutaneous flaps pedicled with the septocutaneous perforators of the posterior tibial artery (P<0.05); free flaps' average area, length and width were all larger than those of distally based sural neurofasciocutaneous flaps and fasciocutaneous flaps pedicled with the septocutaneous perforators of the posterior tibial artery(P<0.05).Conclusion: (1) Distally based sural neurofasciocutaneous flaps had large whirling scale and have wide sphere of application. It could repair most of small and medial area of skin and soft tissue defect in distal 1/3 lower leg.(2) Fasciocutaneous flaps pedicled with the septocutaneous perforators of the posterior tibial artery have advantage of repairing without damaging main vessels, it is suitable for small and medial wound in the anteromedial surface of distal 1/3 of the lower leg, reversed island flaps pedicled with the posterior tibial artery has flexible pivot point and could have large scale's incision. It is suitable for repairing the large- area wounds in distal 1/3 of lower leg.(3)Anterolateral island flap of the lower leg is adjacent to the wound, it has advantage of convenient design and operation, reliable survival, and it is suitable for the restoration of meidal and small wounds in the distal 1/3 of lower leg. (4)When repairing the large wound in the distal 1/3 of lower leg, it is not applicable to choose pedicle flaps but free flaps could be used.