Repair Of Skin And Soft Tissue Defect In Proximal Two Third Of Lower Leg By Surgical Flaps

Objective:To investigate each sort of flap's characteristic and choose the best of all to repair different wounds, we summarized clinical experiences for 6 sorts of flaps repairing skin and soft tissue defect in proximal 2/3 of lower leg.Methods:We did retrospective research and analysis on clinical cases from October 2003 to February 2009,146 cases did flaps restoration in proximal 2/3 of lower leg's skin and soft tissue defect.The anterior board of the gastrocnemius myocutaneous flap was extended from the medial margin of the tibiae to the crista anterior tibiae, and anterior border located in medial border of defects,which we called modified medial gastrocnemius myocutaneous flap. The anterior border of the lateral gastrocnemius myocutaneous flap was extended from the overlying of fibula to the crista anterior tibiae, and anterior border located in lateral border of defects,which we called the modified lateral gastrocnemius myocutaneous flap.66 cases(22 the modified and 44 the non-modified) were treated with medial gastrocnemius myocutaneous flaps,with 53 cases in upper 2/3 segment of the cnemis,13 cases in middle 1/3 segment extend to distal 1/3 segment of the cnemis; 9 flaps'inferior margin were lower than 5cm above medial malleolus,and the lowest was 2cm above medial malleolus,and 1 of that posterior margin exceeded 2cm of the midline of cnemis;the anterior border of all the modified medial gastrocnemius myocutaneous flaps exceeded the medial margin of the tibiae, and that of 2 flaps reached to the crista anterior tibiae, that of 2 cases' inferior margin were lower than 5cm above medial malleolus, The width of flap on anteromedial surface of the tibiae ranged from 1.Ocm to 3.0cm, averagely 1.4 cm; the 66 flaps' area measured from 8cm×4cm～34cm×11cm.34 cases(23 the modified and 45 the non-modified) were treated with lateral gastrocnemius myocutaneous flaps,with 8 cases in upper 1/3 segment of the cnemis,8 in anteriomedialis of middle 1/3 segment of the cnemis (all of that were the modified), and 18 in anteriolateral of middle 1/3 segment of the cnemis; 10 flaps' inferior margin were lower than 10cm above lateral malleolus,and the lowest was 2cm above lateral malleolus;the anterior border of all the modified lateral gastrocnemius myocutaneous flaps exceeded crista anterior fibulae, and that of 2 flaps reached to the crista anterior tibiae,and there were 9 flaps'inferior margin were lower than 10cm above lateral malleolus, the width of flap on anterial compartment of the cnemis ranged from 1.0cm to 7.0cm, averagely 5.0 cm.The 34 flaps'area measured from 12cm×5cm～35cm×12cm.10 cases of cross-leg flap were performed and the area of which measured from 13cmx5cm to 24.5cm×13cm.Free flap includes totally 15 cases, the area of which measured from 17cm×8.5cm to 41cm×16cm. Also,9 cases of saphenous artery island flap and 12 fasciocutaneous flaps were performed. We made statistical analysis of the average area and the ratio of distal partial necrosis between the modified and the non-modified medial gastrocnemius myocutaneous flaps,the same methods of statistical analysis of the lateral gastrocnemius myocutaneous flaps. Statistics analytical methods:for enumeration data we use chi-square test, and t-test for measurement data.Results:Among the 66 medial gastrocnemius myocutaneous flaps, 57 cases survived,and 9 with marginal necrosis of distal end and the ratio of that was13.6%(9/66);18 cases of 22 modified medial gastrocnemius myocutaneous flaps survived and 2 cases whose anterior border reached to the crista anterior tibiae included,but there were still 3 flaps with marginal necrosis of distal end and the ratio of that was 13.6%(3/22);6 cases of the non-modified medial gastrocnemius myocutaneous flaps appeared marginal necrosis of distal end and the ratio of that was 13.6%(6/44);The flaps with marginal necrosis of distal end were healed after the second stage flaps. Among the 34 lateral gastrocnemius myocutaneous flaps,29 cases survived,4 with marginal necrosis of distal end and healed after the second stage flaps, the ratio of marginal necrosis of distal end was 11.8%(4/34),1 with distal superficial necrosis healed after dressing change;20 cases of 23 modified lateral gastrocnemius myocutaneous flaps survived and 2 cases whose anterior border reached to the crista anterior tibiae included,3 flaps whose inferior margin were 5cm,5cm and 3 cm above lateral malleolus respectively with marginal necrosis of distal end and healed after the second stage flaps, the ratio of marginal necrosis of distal end was 13.0% (3/23),1 with distal superficial necrosis healed after dressing change;the cases' number those wound area extended to the anteriomedialis of middle 1/3 segment of the cnemis were 8 totally,and all of them were the modified lateral gastrocnemius myocutaneous flaps,and 6 of them survived,2 with marginal necrosis of distal end; 10 flaps of 11 non-modified lateral gastrocnemius myocutaneous flaps survived,and 1 cases suffered from marginal necrosis of distal end and the ratio of that was 9.1%(1/11).All the 9 saphenous artery island flaps survived.1 case of 10 cross-leg flaps suffered from distal partial necrosis.13 cases of 15 free flaps survived,and 2 with marginal necrosis of distal end.only 1 case of 12 fasciocutaneous flaps had distal partial necrosis.Through 2 weeks to 4 years follow up, the 146 flaps survived well and had satisfied appearance. The modified lateral gastrocnemius myocutaneous flaps' average area is larger than those of non-modified lateral gastrocnemius myocutaneous flaps(p<0.05),and the ratio of distal partial necrosis had no statistically significant between the modified and the non-modified lateral gastrocnemius myocutaneous flaps (p>0.05). None of the average area and the ratio of distal partial necrosis had statistically significant between the modified and the non-modified medial gastrocnemius myocutaneous flaps (p>0.05).Conclusions:①The modified lateral gastrocnemius myocutaneous flap maked the design and operation simple,quickly and reliable,and With the extension of the effective width and length, the modified lateral gastrocnemius myocutaneous flaps could repar anteriomedialis of middle 1/3 segment of the cnemis, besides the upper 1/3 segment and the anterolateral of middle 1/3 segment of the cnemis.②The medial gastrocnemius myocutaneous flap could repair the upper of distal 1/3 segment of the cnemis, besides upper 2/3 segment of the cnemis,the modified medial gastrocnemius myocutaneous flap had advantage of simple,quickly and reliable.③chosen the best of all to repair different wounds of upper 2/3 segment of the cnemis according to specific conditions.