Open-book Splitting of a Distally Based Peroneus Brevis Muscle Flap to Cover Large Leg and Ankle Defects

Autor: Magdy Ahmed Abd-Al Moktader
Rok vydání: 2015
Předmět:
Zdroj: Plastic and Reconstructive Surgery Global Open
ISSN: 2169-7574
DOI: 10.1097/gox.0000000000000560
Popis: Large defects in the lower leg and ankle are challenging for a plastic and reconstructive surgeon. A variety of useful methods for lower leg reconstruction are now available, including the use of local cutaneous flaps, fascial or fasciocutaneous flaps, muscle flaps and free flaps, the distally based sural island flap,1 lateral supramalleolar island flap,2 reverse adipofascial flap,3 and free tissue transfer.4 Reconstruction of the distal third of the leg is associated with the highest complication rate for local procedures because of the paucity of reliable local flaps, which is because of the limited amount of available local tissue. In addition, local flaps are not always suitable for covering defects in the lower leg because of the small radius of extension in the distal direction.5 Thus, free tissue transfer is often recommended as the treatment of choice for large defects. However, microvascular flaps require microsurgical expertise, which is a relatively complex and time-consuming procedure.6 Moreover, not all patients are willing or healthy enough to undergo free tissue transplantations. The peroneus brevis muscle flap has been proven to be a sufficient local flap for small defects.7, 8 These muscles were first described by Pers and Medgyesi,9 and this flap has become an established workhorse in reconstructive procedures of the lower leg. This flap was originally described as a proximally based flap for pretibial defects.10 Barr11 and Saydam12 reported on the reliability of distally based peroneus brevis muscle flaps. Anatomical Consideration The peroneus brevis muscle is located deep to the peroneus longus in the lateral compartment of the leg. The extensor digitorum longus is found anterior to the peroneus brevis in the anterior compartment, and the flexor hallucis longus is posterior to it in the deep posterior compartment. The peroneus brevis muscle originates from the mid shaft of the lateral fibula, passing posterior to the lateral malleolus and inserting at the tuberosity of the fifth metatarsal bone. It remains muscular distal to the lateral malleolus, beyond which it is entirely tendinous. Motor supply to the peroneus muscles is from the superficial peroneal nerve, which is located superficially in the lateral compartment.13 Originally, the peroneus brevis was a type II muscle flap, but it was reclassified by Mathes and Nahai14 as type IV with a dominant pedicle or pedicles from the peroneal artery, located proximally, entering the muscle from its deep surface, and distal minor pedicles from the peroneal or anterior tibial vessels. When the flap is based distally, it is recommended that 3 fingerbreadths be left intact from the distal tip of the lateral malleolus.15 Yang et al16 described the vascular pattern of the peroneus muscle. Six cadaveric specimens were dissected to determine the location of the distal pedicles and flap type. This flap was identified as a type IV flap, and the location of the distal pedicle was found within 6 cm of the fibula tip. McHenry17 reported that the peroneus brevis muscle had an average of 3.5 vascular pedicles (range, 2–6). The average distance of the distal pedicle from the tip of the lateral malleolus was 6.7 cm (range, 3.5–12.0 cm). Villarreal et al18 described 2 principal source arteries: the anterior tibial artery and peroneal artery, which supply the muscles. The anterior tibial artery is the dominant artery and supplies the proximal and middle thirds of these muscles. The peroneal artery is considered to be a supplementary vascular source and supplies the distal third of these muscles. On the basis of these surgical anatomies, this muscle is circumpennate, with an internal axial blood supply from 2 arteries corresponding to nearly its total length, and the blood supply enters through its deep surface. The muscle splitting through its superficial surface described here allows for the coverage of larger defects than has been previously described in the literature. Surgical Technique Under tourniquet control, refreshment of the edge of the defect was performed first, followed by flap elevation. An incision was made over the peroneus muscle bellies, from below the neck of the fibula to the proximal edge of the defect. Using loupe magnification, the peroneus brevis muscle was separated from the peroneus longus muscle. The origin of the brevis muscle was detached from the fibula, keeping the periosteum attached to this muscle, and care was taken not to injure the epimysium of the muscle. Dissection proceeded distally with ligation of the proximal branches of the peroneal and anterior tibial arteries to the muscle and cutting the motor branch to the peroneus brevis from the superficial peroneal nerve. Dissection proceeded up to 6 cm above the lateral malleolus, preserving the most distal segmental branches of the peroneal and anterior tibial arteries, which feed the distal portion of the peroneus brevis. The tourniquet was then released, and hemostasis was achieved. The proximal portion of the muscle belly was then split from the outer external surface, leaving the deep part of the muscle intact with its attached epimysium and periosteum (Figs. ​(Figs.1,1, ​,2,2, and ​and4B4B and C). The muscle was then turned over and gently sutured into the defect using fine 4/0 absorbable sutures (Figs. ​(Figs.3C3C and D). The split thickness skin graft was immediately applied (Fig. ​(Fig.4E),4E), suction drainage was inserted, the donor site was closed, and the leg was dressed and secured using a posterior splint. Fig. 1. Schematic diagram representing peroneus brevis before and after splitting. A, The lower limit of dissection of the muscle 6 cm above lateral malleolus; B, defect in the leg; C, incision for muscle approach; D, the muscle before splitting; E, the muscle ... Fig. 2. Schematic diagram of transverse section of peroneus brevis before and after splitting. Fig. 3. A, Preoperative large ulcer on the lateral aspect of the leg; B, preoperative design of the flap and diameter of the defect before refreshment of the edge of approximately 8 × 9 cm; C, intraoperative after edge refreshment and split muscle sutured ... Fig. 4. A, Preoperative chronic leg ulcer, defect diameter, and flap design; B, intraoperative before muscle splitting; C, intraoperative after muscle splitting; D, intraoperative after muscle split and turned to cover the defect; E, intraoperative after graft ...
Databáze: OpenAIRE
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