J Reconstr Microsurg 2009; 25(2): 105-109
DOI: 10.1055/s-0028-1090616
© Thieme Medical Publishers

The Posterior Tibial Artery Perforator Flap: An Alternative to Free-Flap Closure in the Comorbid Patient

Brian M. Parrett1 , Jonathan M. Winograd2 , Samuel J. Lin1 , Loren J. Borud1 , Amir Taghinia1 , Bernard T. Lee1
  • 1Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
  • 2Division of Plastic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
Further Information

Publication History

Publication Date:
15 October 2008 (online)

ABSTRACT

Wounds of the distal third of the leg with exposed bone traditionally require free flaps for coverage. Although this often provides good results, patients with multiple comorbidities cannot undergo the long operating times and multiple surgical sites required for these complex procedures. We reviewed the use of posterior tibial (PT) perforator flaps as an alternative to free flaps for distal leg wound coverage in ill patients. Six patients (mean age, 53 years) with multiple comorbidities that precluded free-flap closures were treated with PT perforator flaps to cover complex distal leg wounds. The most common comorbidity was cardiac disease. Five patients had Gustilo grade IIIB open tibial fractures and one had a chronic wound. Mean flap size was 8 × 5.5 cm with a mean of one perforator per flap. Mean operating room time was 103 minutes. Four flaps were done without general anesthesia. There were no perioperative cardiopulmonary events. With a mean follow-up of 15 months, all flaps survived and all patients were ambulatory. There were no cases of malunion, nonunion, infection, wound breakdown, or partial flap loss. The PT perforator flap is a reliable choice for patients with open leg wounds and comorbidities precluding free-flap closure.

REFERENCES

  • 1 Godina M. Early microsurgical reconstruction of complex trauma of the extremities.  Plast Reconstr Surg. 1986;  78 285-292
  • 2 Aldea P A, Shaw W W. The evolution of the surgical management of severe lower extremity trauma.  Clin Plast Surg. 1986;  13 549-569
  • 3 Heller L, Levin L S. Lower extremity microsurgical reconstruction.  Plast Reconstr Surg. 2001;  108 1029-1041
  • 4 Yazar S, Lin C H, Lin Y T, Ulusal A E, Wei F C. Outcome comparison between free muscle and free fasciocutaneous flaps for reconstruction of distal third and ankle traumatic open tibial fractures.  Plast Reconstr Surg. 2006;  117 2468-2475
  • 5 Jones N F, Jarrahy R, Song J I, Kaufman M R, Markowitz B. Postoperative medical complications—not microsurgical complications—negatively influence the morbidity, mortality, and true costs after microsurgical reconstruction for head and neck cancer.  Plast Reconstr Surg. 2007;  119 2053-2060
  • 6 Chiang S, Cohen B, Blackwell K. Myocardial infarction after microvascular head and neck reconstruction.  Laryngoscope. 2002;  112 1849-1852
  • 7 Ozkan O, Ozgentas H E, Islamoglu K. Experiences with microsurgical tissue transfers in elderly patients.  Microsurgery. 2005;  25 390-395
  • 8 Boruk M, Chernobilsky B, Rosenfeld R M, Har-El G. Age as a prognostic factor for complications of major head and neck surgery.  Arch Otolaryngol Head Neck Surg. 2005;  131 605-609
  • 9 Singh B, Cordeiro P G, Santamaria E, Shaha A R, Pfister D G, Shah J P. Factors associated with complications in microvascular reconstruction of head and neck defects.  Plast Reconstr Surg. 1999;  103 403-411
  • 10 Masia J, Moscatiello F, Pons G, Fernandez M, Lopez S, Serret P. Our experience in lower limb reconstruction with perforator flaps.  Ann Plast Surg. 2007;  58 507-512
  • 11 Amarante J, Costa H, Reis J, Soares R. A new distally based fasciocutaneous flap of the leg.  Br J Plast Surg. 1986;  39 338-340
  • 12 Koshima I, Moriguchi T, Ohta S, Hamanaka T, Inoue T, Ikeda A. The vasculature and clinical application of the posterior tibial perforator-based flap.  Plast Reconstr Surg. 1992;  90 643-649
  • 13 Ozdemir R, Kocer U, Sahin B, Oruc M, Kilinc H, Tekdemir I. Examination of the skin perforators of the posterior tibial artery on the leg and the ankle region and their clinical use.  Plast Reconstr Surg. 2006;  117 1619-1630
  • 14 Erdmann M W, Court-Brown C M, Quaba A A. A five year review of islanded distally based fasciocutaneous flaps on the lower limb.  Br J Plast Surg. 1997;  50 421-427
  • 15 Koshima I, Ozaki T, Gonda K, Okazaki M, Asato H. Posterior tibial adiposal flap for repair of wide, full-thickness defect of the Achilles tendon.  J Reconstr Microsurg. 2005;  21 551-554
  • 16 Cavadas P C, Landin L. Reconstruction of chronic Achilles tendon defects with posterior tibial perforator flap and soleus tendon graft: clinical series.  Plast Reconstr Surg. 2006;  117 266-271
  • 17 Gulur P, Nishimori M, Ballantyne J C. Regional anaesthesia versus general anaesthesia, morbidity and mortality.  Best Pract Res Clin Anaesthesiol. 2006;  20 249-263
  • 18 Kuo Y R, Jeng S F, Lin K M et al.. Microsurgical tissue transfers for head and neck reconstruction in patients with alcohol-induced mental disorder.  Ann Surg Oncol. 2008;  15 371-377
  • 19 Fix R J, Vasconez L O. Fasciocutaneous flaps in reconstruction of the lower extremity.  Clin Plast Surg. 1991;  18 571-582
  • 20 Parrett B M, Matros E, Pribaz J J, Orgill D. Lower extremity trauma: trends in the management of soft-tissue reconstruction of open tibia-fibula fractures.  Plast Reconstr Surg. 2006;  117 1315-22

Bernard T LeeM.D. 

Beth Israel Deaconess Medical Center, 110 Francis St.

Suite 5A, Boston, MA 02215

Email: blee3@bidmc.harvard.edu

    >