Perforated flaps of different tissue composition in open shin injury surgery

Relevance. Despite the successes and achievements of modern traumatology, the  method  of  microsurgical autotransplantation of tissue complexes remains an urgent topic today. Unfortunately, in various situations, for various reasons, it is not possible to perform microsurgical surgery. The best results of the implantation of free autografts are achieved provided that the defect plastic is performed early, in the acute phase of the wound process, when the wound is contaminated but not yet microbially colonized. Often, the general condition of the victim does not allow for autotransplantation, since an open injury to the lower leg may be part of a multiple or combined injury. There is a contradiction between the need to close a soft tissue defect and the very possibility of performing a large reconstructive operation. The aim is to study and analyze currently existing studies on the use of reconstructive plastic surgery using perforant flaps in patients with a traumatological profile. Highlighting the main directions that can be applied in clinical practice, reviewing and delving into the technical aspects of this method of surgical treatment.

Materials and methods. The search for literary sources was carried out using the bibliographic databases of eLibrary.RU, PubMed, Google Scholar and Scopus.

Conclusion. Thanks to the review, the main directions of soft limb transplantation were identified. The search for solutions to the problem of treating soft tissue defects in the lower third of the lower leg is far from complete. An in-depth study of the possibilities of perforant skin fascial flaps will allow us to obtain a tool with which it will be possible to improve the results of surgical treatment of this group of patients.

1. Pshenisnov K.P. Principles of Lower Limb Reconstruction. Selected Issues in Plastic Surgery. 2003;1(9):48. (In Russ).

2. Rumyantsev D.O., Airapetov G.A., Vorotnikov A.A. The current state of the problem of soft tissue defects replacement in the lower extremities in conditions of chronic osteomyelitis. Innovative medicine of Kuban. 2022;(1):69-76. (In Russ). https://doi.org/10/35401|2500-0268-2022-25-1-69-76

3. Jayes P.H. Cross leg flaps: A review of 60 cases. Br J Plast Surg. 1950;3(1):1-5. https://doi.org/10.1016/s0007-1226(50)80002-4

4. Milanov N.O., Trofimov E.I., Adamyan R.T., Karibykov T.S. Microsurgical autotransplantation of tissues – a direction of reconstructive microsurgery. Annals of the Russian Scientific Center of Surgery, Russian Academy of Medical Sciences. 2002;(11):13-19. (In Russ).

5. Milanov N.O. Microsurgery in the country. 30 years of the journey. Medical care. 2003; (6): 9-16. (In Russ).

6. Rodomanova L.A., Polkin A.G. Reconstructive microsurgery of the upper limb. Traumatology and Orthopedics of Russia. 2006;(4):15-19. (In Russ).

7. Startseva O.I., Melnikov D.V., Redin R.R. Features of perforator flaps and their preoperative preparation. Annals of Plastic, Reconstructive and Aesthetic Surgery. 2012;(1):45-53. (In Russ). https://doi.org/10.1016/0007-1226(87)90185-8

8. Verega G., Fegiu L., Iordachescu R., Unguryan T., Ivanov V., Clipa M. Cutaneous tendon flap of the lower leg for plastic surgery of infected combined defects of the Achilles region. Issues of reconstructive and plastic surgery. 2013;16(2):20-28. (In Russ.)]

9. Morris SF, Taug M, Almutairi K. The anatomic basis of perforator flaps. Clin Plast Surg. 2010;37(4):553-570. https://doi.org/10.1016/j.cps2010.06.006

10. Shtutin A.A., Mikhailichenko V.Yu., Shtutin I.A., Samarin S.A. Features of plastic closure of wound defects of the distal parts of the lower limb with a sural flap. Plastic surgery and aesthetic medicine. 2021;(1): 52-57. (In Russ.)] https://doi.org/10.17116/plast.hirurgia202101152

11. Kutyanov D.I., Rodomanova L.A., Kochish A.Yu. Modern approaches to the use of reconstructive plastic microsurgery technologies in the treatment of patients with pathology of large joints and periarticular structures of the extremities. Traumatology and Orthopedics of Russia. 2012;4:33-42. (In Russ).

12. Pontén B. The fasciocutaneos flap: its use in soft tissue defects of the lower leg. Br J Plast Surg. 1981;34(2):215-220. https://doi.org/10.1016/s0007-1226(81)800097-5

13. Lewin M.L. Resurfacing Procedures in Compound Injuries of Lower Extremities. Ann Surg. 1948;128(1):66-79. https://doi.org/10.1097/00000658-194807000-00010

14. Azimova R.B., Sobolevsky V.A. Perforator flaps in surgical treatment of malignant tumors of the skin and soft tissues of the leg and foot. Bone, soft tissue sarcomas and skin tumors. 2016;(2):54-60. (In Russ).

15. Azimova R.B. Soft tissue flaps options for reconstruction of lower limb defects as one of the most complex sections of reconstructive oncosurgery. Literature review. Bone, soft tissue sarcomas and skin tumors. 2018;10(4):40-50. (In Russ).

16. Bui DT, Cordeiro PG., Hu QY, Disa JJ, Pusic A, Mehrara BJ. Free flap reexploration, treatment, and outcomes in 1193 free flaps. Plast Reconstruct Surg. 2007;119(7):2092-2100. https://doi.org/10.1097/01.prs.0000260598.24376.e1

17. Wallace CG, Kao HK, Jeng SF, Wei FC. Free –style flaps: a further step forward for perforator flap surgery. Plast Reconstruct Surg. 2009;124(6 Suppl):e419-e426. https://doi.org/10.1097/PRS06013e3181bcfl89

18. Low OW, Sebastin SJ, Cheah AEJ. A review of pedicled perforator flaps for reconstruction of the soft tissue defects of the leg and foot. Indian J Plast Surg. 2019;52(1):26-36. https://doi.org/10.1055/s-0039-1688103