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Comparative Study Between Perforator Based Island Flaps And The Egyptian Journal of Hospital Medicine (January 2020) Vol. 78 (2), Page 257-264 Comparative Study between Perforator Based Island Flaps and Fasciocutaneous Flaps in Reconstruction of Lower Extremities Wael Mohammad Sakr, Wael Mohammad El Shaer, Adel Mayhoub Mahmoud, Gamal Mohammad Ali El Ziady, Omar Mahmoud Nasser* Department of Plastic and Reconstructive Surgery, Faculty of Medicine - Beni-Suef University * Corresponding author: Omar Mahmoud Nasser, Mobile: (+20) 01226664107, E-mail: [email protected] ABSTRACT Background: Open wound of the lower limb is one of the common health problems that have a significant economic and social burden. It has a risk of osteomyelitis of the underlying bone and even necrosis can occur. Objective: To evaluate the difference between the perforator-based island flaps and fasciocutaneous flaps in reconstruction of lower extremities regarding; functional, aesthetic outcome, size of the flap, degree of rotation, technical difficulties, percentage of flaps survival, flap loss, operative time and donor site morbidity. Patients and Methods: The study was conducted on 40 patients with soft tissue defects in lower extremities which were equally distributed into two groups. Group 1 consisted of 20 patients that were treated by perforator based island flap and group 2 that consisted of 20 patients treated by fasciocutaneous flap. Results: The two techniques had similar results when evaluated by the Likert scale. The results of both procedures had no significant statistical differences as regards any of the Likert score components namely, color, texture, appearance, and shape. The main finding of the current study was the comparable postoperative outcome for both techniques. The number of patients that had necrosis was 7 in perforate based island flap and 4 in fasciocutaneous flap which represented 35% and 20% respectively of each studied group and this was statistically insignificant. Conclusion: Any flap can be used as a perforator-based island flap in which the source vessel is completely preserved. Perforator flaps have multiple advantages over Fasciocutaneous flaps as allowing increased diversity and versatility in the design and composition of flaps. Keywords: Perforator Based Island Flaps; Fasciocutaneous Flaps in Reconstruction; Lower Extremities. INTRODUCTION Lower extremity reconstruction is an Fasciocutaneous flaps are tissue flaps that essential part of plastic surgery and focuses on the include skin, subcutaneous tissue, and the underlying treatment of wounds and defects secondary to fascia. Including the deep fascia with its prefascial trauma, cancer, or chronic disease processes. During and subfascial plexus enhances the circulation of the last 25 years, advances in plastic surgical these flaps (5). techniques and improved wound care technologies Perforator flap surgery is a technique used in have revolutionized this field, allowing the salvage reconstructive surgery where skin and/or of limbs that would have otherwise been subcutaneous fat are removed from a distant or amputated(1). adjacent part of the body to reconstruct the excised The goal of lower extremity reconstruction is part. The vessels that supply blood to the flap are the coverage of defects and open wounds of the isolated perforator derived from a deep vascular lower extremity to give patients a healed wound and system through the underlying muscle or to let them resume their life, ambulate, and go back intermuscular septa. Some perforators can have a to work while preventing amputation (2). The mixed septal and intramuscular course before reconstructive ladder guides our efforts in lower reaching the skin (6). extremity reconstruction and describes levels of Microvascular free tissue transfer has increasingly complex management of wounds (3). revolutionized the treatment of high energy lower Closure by secondary intention is the simplest extremity injuries with associated bone, soft tissue, method of reconstruction and focuses on allowing and muscle loss and with exposure of bone and vital the wound to naturally granulate and contract by the structures (7). use of good local wound care (4). The concept of perforator-based island flaps Many wounds can be closed by directly becomes simple, providing more options in the opposing the skin edges as long as there is minimal selection of an appropriate design and resolves the tension on the wound and the skin edges are non- problems that previously required a free flap as by traumatized and have good blood supply (1). using perforator-based island flaps, the source Full-thickness or split-thickness skin grafts vessels can be preserved and the donor site can be can be used for lower extremity reconstruction. Skin closed without the need of a skin graft (6). grafts best used to cover exposed muscle or soft tissue (1). 257 Received:12/09/2019 Accepted:21/10/2019 ejhm.journals.ekb.eg AIM OF THE STUDY applied over the entire limb. Non-viable skin, fat, The aim of this work was to evaluate the muscle and bone are excised, with irrigation of the difference between the perforator-based island flaps wounds with large amounts of saline. Skin margins and fasciocutaneous flaps in reconstruction of lower were excised, with a generous extension of wounds extremities regarding; functional, aesthetic outcome, with exploration through all layers, and excision of size of the flap, degree of rotation, technical damaged muscles. Muscles are assessed for color difficulties, percentage of flaps survival, flap loss, (pink not blue), contraction, consistency (devitalized operative time and donor site morbidity. muscle tears in the forceps during retraction) and capacity to bleed. If the soft tissue damage is difficult PATIENTS AND METHODS to assess. A second look was undertaken 24-48h This study was conducted in the period later. At the time of the first debridement, ampicillin- between February 2017 to February 2019 on 40 sulbactam was administered. patients with soft tissue defects in lower extremities from the outpatient Clinic and Emergency Management of bone fracture: Department of Plastic Surgery, Faculty of Medicine, Suitable exposure of the fracture surfaces was Beni-Suef University. The patients were classified done through wound extensions along the line of a randomly into 2 equal groups each involve 20 fasciotomy incision to preserves the fasciocutaneous patients. Group (A) were various perforator-based perforator vessels that supply angiosomes of skin on island flaps and group (B) with fasciocutaneous medial and lateral sides of the pretibial surface. flaps. Delivery of bone ends through the wound with care taken to avoid further periosteal stripping through Ethics: The study was performed in accordance injudicious use of retractors and clamps. Visible dirt with the Helsinki Declaration. After approval of and particulate debris were removed. Stabilization the Local Ethical Committee of Beni-Suef was achieved through spanning external fixators University Hospital. Written consent was obtained with attempts to preserve access for plastic surgical from all patients. procedures. In open injuries which after debridement, can be closed by simple suture of the Management Protocol: wound (typically Gustilo grades I and II), internal A. History: Admission information was collected fixation can be used safely. concerning the type and the time of injury, magnitude and extent of the injury, time and type of Temporary wound dressings: trauma, history of previous surgical procedures and Following excision of all non-viable tissues, if history of concomitant medical and surgical the soft tissue reconstruction was not performed disorders. immediately, the Negative pressure wound therapy B. Primary Management in the Emergency (NPWT) device was applied with the application of Department: Initial evaluation of the Airway, negative pressure. Dressings were changed every 48 Breathing, and Circulation according to ATLS h with continuous sub-atmospheric pressure at 125 (Advanced Trauma Life Support) principles. mmHg. Antibiotic prophylaxis (ampicillin-sulbactam) and anti-tetanus measures were provided in the Flap Design and Surgical technique: emergency room. Examination of the local condition Before operation, the perforators were of the wound was done to detect whether this limb is identified and marked on the skin using a hand-held salvageable or not. 8 MHz Doppler probe on the medial side of the leg with initial design of the flap. Before rotating the Pre-operative Preparations: flap the defect to be covered should be revised and if . Routine laboratory investigations. possible reduced in size with the aid of split skin . Plain X-ray to detect the presence of grafts. In many of these cases, it may be necessary fractures or osteomyelitis. for conjunction with the orthopedic surgeons to . Arterial Duplex and angiography were used chisel off the bone, remove sequestra and in suspected vascular problems. occasionally insert bone graft. Debridement: Perforator based island flap: After induction of anesthesia, the limb was Firstly the distance between the perforator and cleaned using a soap solution for removal of the distal edge of the defect was measured. This particulate debris on the surface of the limb. The value was then transposed proximally, again limb prepped and draped in the standard manner with measured from the perforator, and one centimeter an antiseptic chlorhexidine skin preparation solution was added forming the proximal limit of the flap. 258 ejhm.journals.ekb.eg The width of the defect
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