D IS T A L L Y BA SED D O R SA L İS P E D IS
A D IP O F A S d A L FLA P F O R R E C O N ST R T JC T I O N O F T H E D İST A L F O O T C O N T R A C T U R E
Dr. Naci Karacaoğlan, Dr. O. Ata Uysal
Oruhkuzınayıs Üniversitesi Tıp Fakültesi Plastik ve Rekonstruhtif Cerrahi Anabilim Dalı, Samsun
SUMMARY
A disialy based dorsalis pedis island adipofascial fla p is described. It has been successfully ıtsed in two patients wüh postburn contracture. A wide skin defect o f the distal portion o f the dorsalfoot ıvhich appear after release o f the contracture was resurfaced with this flap. It has minimal donar area morbid-ity because skin över the adipofascial fla p İs protected and donar area was closed primarly.
Key Words : Adipofascial flap, foot contracture
Dorsal foot contractures as a resul t of bunı injury often result in lıyperextensİon of metatarsophalangeal joints. The defect which appear after the release of contracture is usually resurfaced with a skin graft. If vital tissues like tendon, bone end vessels are exposed and m ore extensive surgery such as tendon lengthening and dorsal MTJ capsulotomy is required to release toe contracture (Yang 1982) then a flap is required1.
Cross-leg flap2’3, free flaps4-5, distally based dorsalis pedis isi and flap6, distally based fır s t web flap'1, adipofascial turn-over flap8 have been used for resurfacing of the dorsal foot.
Adipofascial flap s have been described for resurfacing dorsal hand, dorsal foot and elbow d efects18’9’16. (Ali of these flaps are ran.dom -pattem. This paper deseribes tlıe distally based dorsalis pedis adipofascial flap which was successfully employed in two cases to reconstruct the distal portion of the foot.
ANATOMY
The posterior tibial artery, the anterior tibial
ÖZET
Bu çalışmada distal tabanlı dorsalis pedis adipofasyal ada flebi tanımlanmıştır. Bu fleb yanık kontraktürlü iki h a s ta d a b a ş a r ılı bir ş e k ild e u y g u la n m ıştır.
Ko n t ra k türlerin serbestleştirilm-esinden sonra ortaya çıkan ayak dorsalinin distal kısmındaki defekt tanımlanan bu jleple onarılmıştır.
Bu flebin donar alan morbiditesi minimaldir. Çünkü donör a la n d a k i deri korunm uş ve a la n prim er kapatılmıştır.
Anahtar kelimeler : Adipofasyal flep, ayak kontraktürii
artery and the peroneal artery supply the foot.
Deep plantar, superficial plantar and dorsal arcuate arch are formecl by Communications between tlıese arteries. The anterior tibial artery terminates in the dorsalis pedis artery. The dorsalis pedis artery gives of the deep plantar branch över the proximal third of the first intermetatarsal space to communicate with the lateral plantar artery and forms the plantar arch.
This direct arterial anastomotic system ensures the viability of a distally based dorsalis pedis island cutaneous flap by retrograde arterial flow via the plantar arch, without endangering the blood supply to other portions of the foot. (Ishikawa 1987)6. The distally based dorsalis pedis adipofascial flap is nourislıed by tlris reti'ograde arterial flow via the plantar arch like Ishikawa’s flap.
SURGICAL TECHNIQUE
The pateney of the anterior and posterior tibial artery was identifıed by doppler. Över tlıe
Türk Plast Cer Derg (1995) Cilt: 3, Sayı: 1
dorsal foot, the adipofascial flap was planned as much as the defect size (Fig I). The skin of the dorsal foot was elevated through a zig-zag incision. The skin was undermined deep to the dermiş. Skin undermining was started from the edge of Üre wound and carried out towards the periphery. Proxİmal par t of the dorsalis pedis artery and veiııs were identifîed at distal portion of tlıe external retinaculum and ligated' Adipofascial flap was raised starting from this point. Dissecdon was continued distally down to the level of the deep plantar branclı. The adipofascial flap was then turned-over 180 degrees aronnd on the distal pedicle that was the deep plantar branches of the dorsalis pedis artery and veİns to cover the wound and fixed with interruptecl sutures (Fig 2). The donor site was closed directly. A penrose drain was lef t beneath the flap for drainage. The ou ter surface of the transferred adipofascial flap was covered with a split skin graft (Fig 3). The foot was immobilised by splinting and elevated for two weeks postoperative.
Preoperatively patency of the anterior and posterior tibial vessels was identified by doppler. After release of the burn contracture, dorsal capsulotomy and extensor tendon lengthening was undertaken to release the MTPJ deformity in the toe. The defect whiclı appears after the release of contracture was covered by distally based dorsalis pedis adipofascial flap, 6x8 cm in size. Donor area was closed diretly and a split thickness skin graft was used to cover tlıe tumed-over flap. The toe was K-wired in a corrected position for 6 weeks thereby overcoming the MTPJ hyperextension.
The result of flap coverage for the distal foot wound was successful. The flap and skin graft were stable at 20 montlıs follow-up (Fig 4).
Case 2 : A 19 year-old woman sustained dorsal foot contracture caused by a burn injury.
The burn c o n tra c tu re re su lte d in m etatarsophalangeal jo in t hyperextension particularly in second and fifth toes. After identification of posterior and anterior tibial artery flow, burn contracture was released.
Fig 3 ; Donor area was closed directly and the outer surface of the transferred flap was covered vvith a skin graft.
CASE REPORTS
Case 1: A 12 year-old child sustained contracture över the distal foot and toe caused by burn injury. Metatarsophalangeal joint (M T PJ) h y p e re x te n sio n was n o ted .
Second and fifth toes were K-wirecL in a corrected position. An 8x9 cm (in size) distally based dorsalis pedis adipofascial flap was elevated and placed as tum-over on the defect.
Donor area was closed directly and flap was 11
D ÖRS ALIŞ PEDIS AD1POFASCIAL FLAP
Fig 4a: Preoperative view of the contracture. b: Preoperalive view of the contracîure. c; Defecî which appear after release of the contracîure covered by distally based dorsalis pedis adipofascial flap. d: Donor area covered directly and a spliMhickness skin graft used to cover the flap.
Türk Plast Cer Derg (1995) Cilt: 3, Sayı: 1
Fig 4e: Postoperaîive view. f: Postoperative view.
Fig 5:a: Preoperative view o( Ihe foot contracture. b: Defect appear after release of the contracture.
13
DORSAIJS PEDIS ADTPOFASCIAL FLAP
e: Postoperativeview. f: Preoperative view.
Türk Plast Cer Derg (1995) Güt: 3, Sayı: 1
Fig 5gı Preoperative view, h: Postoperative view after 6 months.
ı: Postoperative view after 6 months.
resurfaced with split skin graft. Discoloration and superficial desquamation of the donor site skin was seen. But it healed vvithout any problem. The flap and the skin graft were stable at six months fflow-up (Fig 5).
DISCUSSION
Reconstruction of the burned distal foot remains a complex and often challenging problem despite the recent developrnent in fasciocutaneous, musculocutaneous and free flaps.
After release of the contracture of the dorsal distal foot, in the presence of remaining subcutaneous tissue skin grafting is usally sufficient. But whetı bone, tendons and vessels are exposed, then flap coverage is required11.
Flap coverage to tlhs area ınust provide, a thin, pliable tissue that permits mobility of the underlying bony and tendinous structures.
There are few flaps available on the dorsum of the foot and tlıose recognized in the literatüre are cross-leg flap2 3, free flaps4’5, de-epitelized turn-over flap12, distaîly based first web flap^, distally based dorsalis pedis island flap6 and adipofascial turn-over8.
Cross-leg flaps require a two stage operation forcing the patient to be iımnobilised in an unnatural position. Gornpound skin and muscle free flaps teııd to be too bulky foı*
reconstruction of the dorsum of the foot13. But free fascial flaps such as superficial temporal fascial flaps can be used14. This requires a long surgıcal procedure, trainiug in the technique and two trained teams.
The de-epitelized tum-over flap can be used to resurface the dorsal defect of the foot12. But, the flap donor site skin is sacrificed, therefore a larger amount of skin graft İs required to resurface the wound and there is a risk of demıoid cyst fonıration8.
Adipofascial turn-over flap have been used to resurface the foot but it is limite d to the large defccts8.
Distally based first web flap have been used to resurface the distal foot defectC But it is limite d to the large defect of the distal foot and morbidity of the donor site is anotlıer disadvaııtage since the donor area of this flap is covered by skin graft.
The distally based dorsalis pedis island flap is of sufficient size to resurface a large defect of the distal foot6. The disadvantage of this flap is related to donor site morbidity such as ulcer form ation, skin breakdown and tendon exposure seen in classical dorsalis pedis flap.
15
DORSALİS PEDİS ADİPOFASCİAL FLAP
To eliminate those disadvantages, tlıe authors describe a distally based dorsalis pedis adipofascial flap.
The authors have not seen any skin loss but observed d iscoloration and superficial desquamation of the doııor site skin in Case 2.
For this reason the skin must. be carefully dissected along the subdermal layer to avoid skin necrosis.
In the dorsalis pedis myofascial flap technique, in which the dissection of the donor area skin İs tlıe sam e to authors skin loss has not be en mentioned15. In additioıı, it has been reported that the adipofascial flap techinique possessed the advantage of reducing the donor area morbidity. (Nothing has been mentioned about donor area skin 1oss49J 0,iü.) it is for this reason the authors think that the complications rate will not rise from skin loss although they have done yet only two cases.
One of the advantages of distally based dorsalis pedis adipofascial flap is that it provides good tendon gliding. Compared with other local flaps, otlıer advantages of this flap are (1) a one stage operation, (2) has minimal donor area morbidity because donor site is covered using the original skin, (3) transposed easily and there is no dog ear with a rotation flap, (4) it provides durable coverage of the exp osed vital stru ctu res and offeı*
subcutaneous fat that tendon s caıi glide through, (5) it is a thin flap, for this reason tlıe us e of normal footvvear will not be difficult, (6) it provides better wound coverage than the horizontal transposition flap because of the ISO - degree tum-over placeınent.
Dr. Naci Karacaoğlu
Ondohuznıayıs Üniversitesi Tıp Fak.
Plast. ve Rekonst Cer. Analnlim Dalı Samsun
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York : Springer-Verlag and Slıangiıai. Scientifİc and Technical Publishers. 1982-
2. Barclay, T.L., Sharp e, D.T., Chisholnı, E.M.
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3. Uhm, K., Shin, K.S., Lew, J . Crane principle of the cross-leg fasciocutaneous flap : Aesthetically pleasing technigue for damaged dorsum o f foot.
Ann. Plast. Surg. 15: 257, 1985.
4. May, J.W ., Rohrich, R.J. Eoot reconstruction using free microvascular musde flaps wit.h skin grafts. Clin. Plast. Surg. 13: 681,1986.
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6. Ishikawa K., Isshİki N., Susuki, S. and Shimaınııra, S. Distally based dorsalis pedis island flap for coverage o f the distal portion of the foot. Br. j Plast. Surg. 40: 521, 1987.
7. Early, M J., Milner, R.H. A distally based fırst web flab in the foot. Br. J Plast. Surg. 42: 507, 1989.
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Adipofascial tum-over flap for reconstruction of the dorsum of the foot. Br. J. Plast. Surg. 44:
170, 1991.
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The adipofascial turnover flap for elbow coverage. Ann. Plast. Surg. 28: 190, 1992-
11. Kucan, J.O ., Bash, D. Reconstruction o f the bumed foot. Clınics İn Plastıc Surgery. 19: 705, 1992.
12. Thatte, R.L., Dhami, L.D. and Patil, U.A.
De-epithelialised turn-over flaps for "salvage"
operations. Br. J . Plast. Surg. 36: 178, 1983.
13. Hidalga, DA. and Shaw, W.W. Reconstruction o f foot. injuries. Glinics in Plastic Surgery. 13: 633, 1986.
14. Brent, B., Upton, J. and Acland, R.D. Experience with tlıe temporal parietal fascial free flap. Plast.
Reconstr. Surg. 76: 177, 1985.
15. İsmail T.A. The dorsalis pedis myofascial flap.
Plast Reconts. Surg. 86: 573, 1990.
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