posterior tibial artery-based multilobar combined flap free transfer for repair of complex soft...

POSTERIOR TIBIAL ARTERY-BASED MULTILOBARCOMBINED FLAP FREE TRANSFER FOR REPAIROF COMPLEX SOFT TISSUE DEFECTS

XU ZHANG, M.D., Ph.D.,* XIAOHUA WANG, M.D., SUMIN WEN, M.D., Ph.D., HONGWEI ZHU, M.D., ZHIWEN NING, M.D.,

XU MI, M.D., CHENGLIN LI, M.D., Ph.D., and RUXIA YU, M.D., Ph.D.

In this report, the posterior tibial artery (PTA) based multilobar combined flap is introduced for the repair of complex soft tissue defects.The flap was designed based on the perforatoring branches of PTA in the anterior soleus muscle septum, which supply the skin over themedial side of the calf and the entire soleus muscle. The saphenous nerve was included in one perforator flap of the combined flap forreinnervation. The tibial artery was repaired with a vein graft after harvest of flap. From October 2005 to February 2007, eight patients (6males, 2 females) underwent PTA-based multilobar combined flap transfer for coverage of soft tissue defects involving the foot (threecases), hand (two cases), and calf (three cases). Each combined flap composed of two to three perforator flaps, and the size of the perfo-rator flaps ranged from 4 3 2 cm to 10 3 8 cm. With an average follow-up of 6 months, all flaps survived without complications andinjured extremities showed a good functional recovery with restoration of the partial protective sensation on the flap with reinnervation.This clinical report has shown that a reliable multilobar combined flap can be designed based on the perforators of the posterior tibial ar-tery and used for coverage of the complex wound. VVC 2008 Wiley-Liss, Inc. Microsurgery 28:643–649, 2008.

Reconstruction of complex soft-tissue defects remains a

challenge. A multilobar combined flap that consists of

multiple perforator flaps may provide a tool for this

reconstruction. In design of the multilobar combined flap,

each perforator flap receives its blood supply from a

branch originating from a main vascular pedicle. Hence,

only a single recipient pedicle is required for revasculari-

zation of the entire combined flap.

Several multilobar combined flaps, such as scapular

and lateral circumflex femoral artery-based flaps have

been reported for repair of complex soft tissue defects.1,2

Medial side of the calf with its rich perforatoring

branches from the posterior tibial artery (PTA) can also

be a good candidate for this purpose. In this article, we

first report our successful clinical experience of transfer-

ring multilobular perforator-based flaps from the lower

leg based on PTA in eight patients for complicated

wound reconstruction in hand, foot, and leg.

PATIENTS AND METHODS

From October 2005 to February 2007, eight patients

(6 males, 2 females) with a mean age of 31.75 years

(range from 20 to 40 years) underwent PTA-based multi-

lobar combined flap free transfer for the repair of com-

plex soft tissue defects involving the foot (n 5 3), hand

(n 5 2), and calf (n 5 3). The causes of the injuries

included traffic accidents in five patients and industrial

machinery injuries in three patients. In those cases, the

injury combined two to three soft tissue defects compli-

cated with bone, tendon, and/or nerve exposure and

injury. Details of all patients are summarized in Table 1.

Surgical Technique

Each patient was placed in a supine position under

general anaethesia. An ultrasound probe was used to

evaluate the flow of the main arteries of the donor leg.3–6

The flap was designed in the medial side of the calf,

according to the size and shape of the tissue defects at

the recipient site. Each perforator flap included at least

one perforatoring branch of the tibial artery that came

from the anterior soleus muscle septum, which was

marked after Doppler probe detection.7

The incision was first made from the anterior edge of

the designed flap. After identification of the perforators,

dissection went deep into the muscle septum until the

posterior tibial vessels were found (Fig. 1A).

The PTA was dissected proximally to obtain required

length. The entire flap consisting of perforator flaps was

then elevated. Each perforator flap included at least one

perforatoring branch. The saphenous nerve that innervates

skin over the medial calf region and follows the path of

the greater saphenous vein was dissected and included in

one perforator flap for reinnervation of the flap (Fig. 1B).

Once the recipient area was debrided and suitable re-

cipient vessels were identified, the pedicle of the flap was

transected and the combined flap was harvested. The flap

was inset to cover the defects and then the microneuro-

vascular repairs were performed. At the donor site, the

defect of the PTA was reconstructed using a piece of

Department of Microsurgery, The Second Hospital of Qinhuangdao,Chengde Medical College, Hebei, People’s Republic of China

*Correspondence to: Xu Zhang, M.D., Ph.D., Department of Microsurgery,The Second Hospital of Qinhuangdao, Changli, Qinhuangdao, Hebei066600, P.R. China. E-mail: [email protected]

Received 13 November 2007; Accepted 22 April 2008

Published online 8 October 2008 in Wiley InterScience (www.interscience.wiley.com). DOI 10.1002/micr.20529

VVC 2008 Wiley-Liss, Inc.

great saphenous vein that was harvested from the same

leg (Fig. 1C).

In our series, each combined flap composed of two to

three perforator flaps. The sizes of the perforator flaps

ranged from 4 3 2 cm to 10 3 8 cm. The saphenous

nerve in one of the perforator flaps was coapted to a

cutaneous nerve at the recipient site. The PTA was anasto-

mosed to the recipient artery in the fashion of end-to-end

in seven cases and side-to-side in one case. The mean

length of the harvested PTAs was 6.38 cm (range form

5–8 cm). The donor sites were closed directly in six

cases and covered by skin grafts in two cases (Table 1).

The follow-up period ranged from 4 to 8 months with

an average of 6 months. The reconstructed feet and legs

were assessed in terms of pain, range of motion (ROM)

of the knee and ankle joints, and walking. The recon-

structed hands were assessed in terms of pain, ROM of

the metacarpophalangeal (MCP) joints, motion functions

and esthetics that were according to Michigan Hand Out-

comes Questionnaire (MHQ).8 The donor leg morbidity

was evaluated with pain, loss of sensitivity, ROM of the

knee and ankle joints, and walking. The method used to

measure sensation of the flaps and donor sites was the

Semmes-Weinstein (SW) monofilament test.9

RESULTS

All flaps completely survived without complications

during the postoperative course. Venous congestion in

flap was not observed in this series of patients. Wound

healing of the defects was achieved and satisfactory

results were obtained in all cases.

Patients were assessed postoperatively with an aver-

age follow-up of 6 months. All recipient sites showed a

good appearance without swelling and pain. Debulking

was not required in all of the cases. Partial protective

Table

1.Patients

Demongraphic

andSurgicalDetails

Case

Age/Sex

Locationof

injury/side

Cause

Sizeofwound

(cm

3cm)

Flap

type/side

Number

ofPF

Flapdim

entio

n

(cm

3cm)

Recipient

vessel/side

Donor

neve

r/side

Recipient

nerve/side

Donor

siteclosure

128ye

ar/M

Foot/L

Trafficaccident

93

4;73

4;33

2C/C/M

/R3

103

5;83

4;43

2Dorsalpedal/L

SN/R

MDCN/L

Direct

236ye

ar/M

Hand/R

Mach

ine

53

4;53

5C/L

263

5;63

6Ulnar/R

SN/L

SRN/L

Direct

340ye

ar/M

Calf/R

Trafficaccident

93

7;43

5C/L

2103

8;53

6Posteriortibial/R

SN/L

LSCN/R

Skingraft

435ye

ar/F

Foot/R

Trafficaccident

63

5;43

5C/L

273

6;53

6Dorsalpedal/R

SN/L

MDCN/R

Direct

522ye

ar/M

Calf/L

Trafficaccident

83

7;73

5C/R

293

8;83

6Posteriortibial/L

SN/R

LSCN/L

Skingraft

634ye

ar/M

Foot/L

Mach

ine

63

4;43

4;43

3C/C/M

/R3

73

5;53

5;53

4Posteriortibial/L

SN/R

MDCN/L

Direct

726ye

ar/F

Calf/R

Trafficaccident

73

6;63

6C/L

283

6;73

7Posteriortibial/R

SN/L

LSCN/R

Direct

833ye

ar/M

Hand/R

Mach

ine

43

3;63

5C/L

253

4;63

6Radial/R

SN/L

SRN/R

Direct

PTA,posteriortibialartery;C,cutaneousflap;M,muscle

flap.SN,saphenousnerve;PF,

perforatorflap.MDCN,medialdorsalcutaneousnerve;LSCN,lateralsuralcutaneousnerve;SRN,superficialradial

nerve.

Figure 1. A: Surgical anatomy of the multilobar combined flap and

the anterior soleus muscle space. B: The vessels had been trans-

ected. C: Reconstruction of the PTA defect.

644 Zhang et al.

Microsurgery DOI 10.1002/micr

sensations were found in all of the perforator flaps with

reinnervation. Three patients with foot reconstruction and

three patients with leg reconstruction were able to walk

without assistance of crutch with full active ROM of the

knee and ankle joints after the rehabilitation therapy.

Active ROM of the metacarpophalangeal joints of the

two hands was measured in 55–90 degrees (mean 70

degrees). According to MHQ, function recovery of the

hands in activities and esthetics with a mean score of 80

and 85 points (range from 78 to 82 and 81 to 89), respec-

tively, based on a 100-point scale.

There was no functional impairment to the donor

legs. The loss of sensitivity was limited in the medial

side of the calves. The donor site scars were painless. All

patients were able to walk normally.

A summary of the main results of reconstruction is

shown in Table 2.

CASE REPORT

A 28-year-old man suffered a penetrating injury in

the left foot, which resulted in complex tissue defects on

both dorsal and plantar sides of the foot. The tendons

and bones were exposed. The initial surgery included de-

bridement and fixation of the fractures. Flap transfer was

performed 20 days after injury. Because of the presence

of lesions and bruises on the rest of foot and lower leg,

local flaps were not available for coverage of the wounds.

Therefore, a PTA-based multilobar combined flap was

chosen for reconstruction.

After the wounds were thoroughly debrided, the sizes

of tissue defects were measured 9 3 4 cm on the dorsal

and 7 3 4 cm on the plantar of foot, respectively (see

Fig. 2). The flap was designed in the medial side of the

right calf (Fig. 3A). The proximal (10 3 5 cm) and distal

(8 3 4 cm) perforator fasciocutaneous flaps were har-

vested, which were nourished by the first and third cuta-

neous perforatoring branches originating from the PTA,

respectively (Fig. 3B). The saphenous nerve was included

in the perforator flap with the third cutaneous branch.

The soleus muscle flap (4 3 2 3 2 cm) that supplied by

the second muscle branch of the PTA was also raised.

The posterior tibial vein was used for venous drainage of

the perforator flaps. The great saphenous vein was also

included to provide an additional venous drainage for the

perforator flap supplied by the first cutaneous branch

(Fig. 3C).

The perforator flap supplied the third perforatoring

branch which was tunneled through the penetrating

wound and attached to the plantar defect. The muscle

flap was inset into the penetrating wound. The perforator

flap supplied by the first perforatoring branch was

attached to the dorsal defect (Fig. 4).

Table

2.Results

oftheFlapTransfer

Case

Locationof

injury/side

Flap

type/side

Flap

survival

Follow-up

(months)

Recipientsiterecove

ryDonorlegmorbidity

Pain

Joint/extension-

flexion(degrees)

SW

testof

reinnervatedPF

Sca

rpain

Lossofsensitivity

(cm

3cm)

ROM

ofknee

andankle

Walking

1Foot/L

C/C/M

/RComplete

40

Ankle/Full

2.36

0SW(10g)5

73

3Full

Norm

al

2Hand/R

C/L

Complete

60

MCPs/15-80

3.61

0SW(10g)5

53

3Full

Norm

al

3Calf/R

C/L

Complete

50

Ankle/Full

3.61

0SW(10g)5

73

2Full

Norm

al

4Foot/R

C/L

Complete

60

Ankle/Full

2.36

0SW(10g)5

63

2Full

Norm

al

5Calf/L

C/R

Complete

70

Ankle/Full

3.61

0SW(10g)5

73

3Full

Norm

al

6Foot/L

C/C/M

/RComplete

50

Ankle/Full

2.36

0SW(10g)5

93

2Full

Norm

al

7Calf/R

C/L

Complete

80

Ankle/Full

3.61

0SW(10g)5

73

3Full

Norm

al

8Hand/R

C/L

Complete

70

MCPs/10-85

2.36

0SW(10g)5

63

2Full

Norm

al

Mean

60

016.75

C,cutaneousflap;M,muscle

flap;PF,

perforatorflap;ROM,Rangeofmotion;MCP,

metacarpophalangealjoint;SW,Semmes-W

einstein

monofilamenttest;g,gramme.

Multilobar Combined Flap Free Transfer 645


An end-to-end anastomosis was completed between

the PTA pedicle and the left dorsalis pedis artery. The

saphenous venous pedicle of the flap was anastomosed to

the saphenous vein of the recipient. The posterior tibial

venous pedicle was anastomosed to the recipeint dorsal

vein. After arterial and venous flow was established, the

Figure 2. Dorsal and plantar defects and a penetrating wound in the left foot.

Figure 3. A: Outline of the distal (d) and proximal (p) perforator flaps. B: The posterior tibial vessels and their perforatoring branches in

the anterior soleus muscle space were exposed. C: The arrow, n, and s indicate the pedicle, the saphenous nerve, and the great saphe-

nous vein, respectively.

646 Zhang et al.


saphenous nerve of the flap was coaptated to the proxi-

mal end of the medial dorsal cutaneous nerve. The

wounds were then closed.

At the donor leg, PTA was reconstructed using a seg-

ment of great saphenous vein from the same leg after the

flap was harvested. (Fig. 5A) The donor site was primar-

ily closed (Fig. 5B).

The postoperative course was uneventful and the flap

survived completely without complication. Four months

postoperatively, partial protective sensation was recovered

at the transferred perforator flap for plantar coverage and

the patient could walk without assistance of crutch (Figs.

6A,B).

DISCUSSION

In our series, all patients presented with complex soft

tissue defects along with tendon and bone exposure. The

poor condition of soft tissue around wounds limited use

of local flaps for wound repair, such as the pedicled sural

nerve nutrient vessel flap.10 A mutilobar combined flap

Figure 4. Coverage of the defects was completed.

Figure 5. A: The reconstructed PTA of the donor leg (arrow). B:

The donor site wound was closed. Figure 6. A and B: Appearance 1 month later. C: The branches

originating from the posterior tibial vessels.



could be an alternative method for single-stage coverage

of defects in this particular circumstance.

Since clinic application of the dorsalis pedis artery-

based mutilobar combined flap was reported in 1995,11,12

other combined flaps from areas of scapular,1,13 postauricu-

lar,14 abdominal,15 groin,16 and lateral circumflex femoral2

have also been introduced for reconstructive surgery.

Zhang first reported PTA flap transfer in 1984.17 The

flap was designed based on the perforators of the PTA,

which supply the skin over the medial side of the calf.18

Tanaka and Wei et al. found that there were 4–5 cutane-

ous perforatoring branches originating from the PTA in

the anterior soleus muscle septum19 and an equal number

of branches to the soleus muscle.20,21 Based on these

findings, the PTA-based flap can be designed in a mutilo-

bar style that includes perforator flaps and muscle island

flaps (Fig. 6C).

We first report the clinic use of the PTA-based muti-

lobar combined flap in eight patients. Our experience has

shown that this flap has adequate length of pedicle for

transfer. Considering an additional 6 cm in length of

each perforatoring branch, the length of the pedicle can

be isolated as long as 10 cm.22 If it is necessary, the cu-

taneous nerve, tendon, or muscle can be included in the

combined perforator flaps. Almost the entire soleus mus-

cle can be harvested as the muscle island flap.23 Since

the flap can be designed from the medial edge of the

tibia to the posterior midline of the calf between knee

and ankle,13 the flap can provide sufficient coverage for

various sizes of complex tissue defects. The wound of

donor site is usually less than 5 cm in width and can be

closed directly. Comparisons of anatomic characteristics

of different combined flaps in literature are shown in

Table 3.

Our experience from this series showed that all

wounds healed after flap transfers and the repaired

extremities regained satisfactory functional restoration.

Donor-site morbidity was minimal.

In conclusion, the medial calf region is a good donor

site for design of a mutilobar combined flap owing to its

rich branches originating from the PTA.18,19,23–25

Although the flap may not be the first choice in many

cases, it may be considered when other options are not

available. It is a reliable and useful procedure for cover-

age of the complex wound.

REFERENCES

1. Zhang Y, Qian Y, Wang D. Combined scapular/parascapular bilobarflaps for reconstruction of severe neck contracture. Zhongguo XiuFu Chong Jian Wai Ke Za Zhi 2006;20:890–892.

2. Huiren L, Ruiguo L, Lei C, Yanmao Z, Shunhong G, Yan W. Thedesign and clinical application of ramified musculocutaneous flappedicled with the descending branch of lateral circumflex femoralartery. Chinese J Microsurg 2006;1:10–13.

3. Prantl L, Pfister K, Kubale R, Schmitt S, Stockhammer V, Jung W,Zorger N, Herold T, Nerlich M, Stehr A, Jung EM. Value of highresolution ultrasound and contrast enhanced US pulse inversionimaging for the evaluation of the vascular integrity of free-flapgrafts. Clin Hemorheol Microcirc 2007;36:203–216.

4. Queral LA, Lucas PR, Badder EM, Wilkerson RJ. Lower extremityrevascularization based on intraoperative arteriography. Ann VascSurg 2007;21:284–288.

5. Haerle M, Hafner HM, Dietz K, Schaller HE, Brunelli F. Vasculardominance in the forearm. Plast Reconstr Surg 2003;111:1891–1898.

6. Xu Z, Chenglin L, Zhiwen N, Sumin W, Ruxia Y, Xinming M,Xinming M, Fucheng Z. Use of flap based on posterior tibial arteryfor free transfer. J Reconstr Microsurg 2007;23:362–365.

7. Miller JR, Potparic Z, Colen LB, Sorrell K, Carraway JH. The accu-racy of duplex ultrasonography in the planning of flaps in the lowerextremity. Plast Reconstr Surg 1995;95:1221–1227.

8. Chung KC, Hamill JB, Walters MR, Hayward RA. The MichiganHand Outcomes Questionnaire (MHQ): Assessment of responsive-ness to clinical change. Ann Plast Surg 1999;42:619–622.

9. Mary VR, Catherine A, Trombly L. Hand Impairments. OccupationalTherapy for Physical Dysfunction, 6th ed., New York: LippincottWilliams & Wilkins; 2007; pp 1133–1138.

10. Xie Y, Li Z, Zheng B, Li P. Application of fibular nerve nutritionvessel flap. Med J Shantou University 2006;22:15–16.

11. Terry Canale S. Microsurgery. Campbell’s Operative Orthopaedics,Vol. 4. Singapore: Harcourt Publishers Limited; 2001; pp 3178–3181.

12. Yajun X, Kuishui S, Quanrong Z, Yang Q, Jianjun G, Qun Y. Ana-tomical study and clinical application of vascular pedicled trifoliatedflap from the dorsum of the foot. Chin J Hand Surg 1998;14:178–180.

13. Jianjun H, Weiyang G, Zhijie L, Xinglong C, Yonglong C. Clinicalapplication of the free ramified scapular flap. Chin J Orthop 2007;12:21–23.

14. Khemani S, Rannard F, Kenyon G. Bi-lobar post-auricular skin flapfor reconstruction of the earlobe. J Laryngol Otol 2007;11:1094–1095.

15. Li Z, Wang Y, Zhu W, Li Z, Guo X. Application of abdomen loba-reted flap in treating multiply degroved digital injury. Guizhou MedJ 2000;24:543–544.

Table 3. PTA-based Multilobar Flap Has Many Beneficial Factors or Combination of Factors

PTA-based

multilobar flap

Scapular

flap

Dorsal

pedal flap

Groin

flap

Lateral circumflex

femoral artery flap

Diameter of artery (mm) 2.34 3.3 2.3 0.8–1.0 2.5

Number of large vein 3 2 3 1 2

Pedicle length (cm) >10 4.9 >8 3–7 8–15

Numble of PF >6 2 >3 2 <3

Nerve of flap Yes None Yes None Yes

Extension of the flap Large Large Small Large Large

Distance between two of PFs Long Long Short Long Short

PF, Perforator flap.

648 Zhang et al.


16. Liang X, Zhijie L. Clinical application of ilioinguinal abdominalbilobate flap in repairing of skin defect of hand-A report of 30 cases.J Pract Orthoped 2004;10:332–333.

17. Zhang SC. Clinical use of island turnover grafts with a posterior-tib-ial vascular pedicle. Zhonghua Wai Ke Za Zhi 1984;22:685–687.

18. Mardini S, Salgado CJ, Chen HC, Yazar S, Ozkan O, Sassu P. Pos-terior tibial artery flap in poliomyelitis patients with lower extremityparalysis. Plast Reconstr Surg 2006;117:640–645.

19. Wei ZR, Wang YM, Wang DL, Qi JP, Han WJ, Zeng XQ. Anatomi-cal study and clinical applications of the posterior tibial artery inter-muscular septum branches island flaps. Zhongguo Xiu Fu ChongJian Wai Ke Za Zhi 2007;23:293–294.

20. Tanaka K, Matsumura H, Miyaki T, Watanabe K. An anatomicstudy of the intermuscular septum of the lower leg; branches fromthe posterior tibial artery and potential for reconstruction of the

lower leg and the heel. J Plast Reconstr Aesthetic Surg 2006;59:835–838.

21. Li S, Ling X, Du D, Tian L. Value of color doppler ultrasound inthe design of posterior tibial arterial skin flaps. J Trauma Surg2007;8:256–257.

22. Lu K, Han Y, Guo S. Application and development of free compos-ite tissue flap in plastic surgery. Zhongguo Xiu Fu Chong Jian WaiKe Za Zhi 2007;21:940–944.

23. Gao X, Zhou F. Medial lower leg tibial periosteum skin flap freetransfer. Qinghai Med J 1998;28:24–25.

24. Gao X, Zhou F, Zhang Q. Transplantation of medial lower leg tibialperiosteum skin flap to treat opposite tibia exposure. J YoujiangMed Colleg Nation 1999;1:481–482.

25. Hou C. Fasciotaneous Flap and Fascia Flaps. Shanghai: ShanghaiScience and Technology Publishing Company; 2002. pp 153–155.



posterior tibial artery-based multilobar combined flap free transfer for repair of complex soft...

Documents