Yang 2018

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Free vascularized fascia flap combined with skin grafting for deep toe ulcer in diabetic patients 1

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Xuekang Yang, MD, Zhuoqun Fang, MM, Mengdong Liu, MD, Yue Zhang, MM, Qiaohua Chen, MM, Ke Tao, MD, Juntao Han, MD, and Dahai Hu, PhD, MD* Department of Burns and Cutaneous Surgery, Xijing Hospital, Fourth Military Medical University, Xi’an, China

article info

abstract

Article history:

Background: This study introduces a technique for the reconstruction of deep toe defects in diabetic patients

Received 24 January 2018

using a method that combines free vascularized fascia flap with skin grafting. Methods: In this retrospective

Received in revised form 25

study, conducted between March 2010 and February 2016, 15 diabetic patients with deep toe ulcer received

April 2018 Accepted 24 May

surgeries that combined free vascularized fascia flap with skin grafting, including nine anterolateral thigh

2018 Available online xxx

fascia lata flaps and six superficial temporal fascia flaps. Their medical records were systematically reviewed from electronic databases. The donor artery was anastomosed to the dorsalis pedis artery in an end-to-side manner, and the vein was anastomosed to the accompanying vein in an end-to-end manner.

Keywords: Free vascularized fascia flap Skin grafting

Results: Thirteen fascia flaps completely survived without any rejection. Partially necrosed grafted skins,

Diabetes

which were found in two cases, were healed after routine dressing changes. Patients achieved an esthetic

Toe

outcome and acceptable functions without further revisions. Two patients suffered from ischemic necrosis of

Microsurgery

the fascia flap and eventually underwent amputation. Conclusions: The present study demonstrated that vascularized fascia flap combined with skin grafting has great advantages for correcting deep toe ulcer in diabetic patients characterized by the esthetic outcome, abundant vascularity, surgical simplicity, and good deformability. ª 2018 Elsevier Inc. All rights reserved.

Introduction Diabetic foot ulcer is one of the most common and serious complications that occurs in diabetic patients. It is particu-larly complicated by problems such as prolonged angiopathy and sensorial neuropathy. Further complications, such as numbness, pain, and skin ulcers probably cause gangrenes, which would lead to amputations or even death if not treated 1

well. Toes are the most common and vulnerable parts of the body for infections and ulcers that are usually conservatively

treated with debridement and local wound therapy. However, these treatments are inadequate for patients with deep ulcers as they expose the underlying bones and tendons and even-tually lead to amputation of the 2

toes. Another method that is used to treat foot ulcers is reconstruction using reversed dorsalis pedis artery island flap. Although this method has the advantage that it can be occasionally performed when vascular conditions of the lower extremity are well conserved, the main problem is that it would destroy the anatomical structure of acrotarsium vessel. This would lead to a decrease

* Corresponding author. Department of Burns and Cutaneous Surgery, Xijing Hospital, Fourth Military Medical University, 15 Changle Xi Road, Xi’an 710038, P.R. China. Tel.: þ86-29-84775298; fax: þ86-29-83251734. E-mail address: [email protected] (D. Hu). 1 Xuekang Yang and Zhuoqun Fang contributed equally to this work. 0022-4804/$ e see front matter ª 2018 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jss.2018.05.051

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in the foot blood supply and, therefore, increase the incidence of severe foot ulcer infection. In addition, the blood supply of reversed dorsalis

Method

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pedis artery island flap relies on the deep plantar branch of artery. The angiopathy in diabetic patients may predispose them for small vessel embolization and in-crease the risk of flaps failure. In some medical centers, small free flaps (peroneal ar-tery perforator flap, posterior interosseous artery perfo-rator flap, and so forth) are given priority over repairing and reconstructing toe defects. The artery and vein of the small free flaps are anastomosed to the plantar arch of the foot. However, in diabetic patients who are prone to peripheral small vascular diseases, this would result in skin flap ischemia and anastomotic embolization eventually leading to the failure of small free flaps. Thus, the long vascular pedicle free flap (the anterolateral thigh flap and so forth) may offer a better choice for diabetic patients. The donor arteries of these flaps are anastomosed to the dorsalis pedis artery, which could

Clinical data Fifteen of the 973 diabetic foot patients admitted in our department of Xijing Hospital were enrolled in this study. All of them had consented to this study in accordance with the requirements of the Research Ethics Committee of Xijing Hospital. Although the injured toes of all the 15 patients were accompanied by severe soft tissue defects and bone and tendon exposure, their blood supply was still abundant. The inclusion criteria for this procedure were the presence of se-vere soft tissue defects with bone and/or tendon exposure after debridement without any severe uncontrollable sys-temic disease such as uremia. Each patient’s detailed profile is documented in Table. The research work reported here was also performed in line with the process criteria.

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highly increase the success rate of the surgery. However, for patients with thick subcu-taneous fat, it is difficult to clip the excess soft tissue and fat off the small flaps, which causes the recipient toe to appear bulky.

Preoperative preparation

Thus, the purpose of this retrospective study was to eval-uate the efficacy and feasibility of free vascularized fascia flaps together with skin grafts in treating diabetic patients with deep ulcers in their toes.

Table e Clinical data and treatment outcomes of patients. Case Age/gender Injured location Defect 2 size, (cm )

Strict blood glucose control (80-110 mg/dL), water-electrolyte balance, and the absence of any systemic dis-ease were assessed and improved in the perioperative period. Transcutaneous oxygen was measured in patients, and improvements were made so that oxygen levels reached more than 30 mmHg before surgery. Osteomyelitis was

Lower extremity vessels

PTA therapy

Fascia flap choice

Survival of flap

Complication

No

1

52/M

5th toe

1.9 1.6

Normal

No

ATFL flap

Yes

2

44/M

3rd toe

2.1 1.7

Normal

No

STF flap

Yes

No

3

59/W

4th, 5th toes

3.3 2.2

Normal

No

ATFL flap

Yes

Partial skin

4

49/M

4th, 5th toes, and

5.9 9.2

Normal

No

STF flap

Yes

grafting necrosis No

5

55/W

partial dorsum pedis 5th toe

2.0 1.5

PT stenosis

Yes

ATFL flap

Yes

No

6

37/M

2nd toe

2.6 1.7

Normal

No

STF flap

Yes

No

7

45/M

2nd, 3rd toes

4.5 2.9

P and PT

Yes

ATFL flap

Yes

No

3.1 2.2

stenosis AT, PT, and

Yes

ATFL flap

No

5th toes amputation

Yes

ATFL flap

Yes

No

8

61/M

5th toes

9

57/W

4th toe

2.2 1.5

P stenosis AT stenosis

10

49/M

5th toe and partial

5.6 4.2

Normal

No

ATFL flap

Yes

No

11

65/M

dorsum pedis 4th toe

3.1 1.9

AT and P

Yes

STF flap

No

No

12

76/W

5th toe

2.5 2.1

stenosis AT and P

No

ATFL flap

No

4th, 5th toes

No

ATFL flap

Yes

amputation No

Yes

STF flap

Yes

Partial skin

Yes

grafting necrosis No

13

41/M

3rd toe

2.2 2.1

stenosis Normal

14

51/M

1st toe

4.2 2.6

AT and P

4.1 4.6

stenosis Normal

15

48/M

1st, 2nd toes

No

STF flap

AT ¼ anterior tibial artery; ATFL flap ¼ anterolateral thigh fascia lata flap; DP ¼ dorsalis pedis artery; P ¼ peroneal artery; PT ¼ posterior tibial artery; STF flap ¼ superficial temporal fascia flap.

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diagnosed, by analyzing clinical, radiological, and motor function outcomes, in 2 of 15 patients. Doppler ultrasound examination was performed for all patients to assess the vascular status of their lower extremities. Varying degrees of peripheral vascular stenosis was observed in 13 patients at the anterior tibial artery, the posterior tibial artery, and the dorsal artery. Ten patients had undergone lower ex-tremity angiography, and six patients in the study had a balloon therapy to remove the inflammatory granulation tissue, subcutaneous tissue, denatured tendon, or even necrotic bone as far as possible. One to three debridements, in combination with timely dressing changes, were per-formed until the infection was controlled (level of bacteria <105 cells/g of tissue) and wound bed.

Surgical procedure The reconstructive surgery is divided into four steps. The first step was the preparation of the recipient area which involved debriding the wound of the recipient toe region and then exploring the recipient vessel (dorsalis pedis artery and accompanying vein) for their patency and blood flow veloc-ity. The second step was the flap harvesting of the donor site in which the anterolateral thigh fascia lata flap (ATFL flap) and the superficial temporal fascia flap (STF flap) were designed and harvested according to the area size of recip-ient site, similar to that reported in

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Results Free vascularized fascia flaps surgeries were performed in 15 patients. Flaps used included nine ATFL flap and six STF flap. Patients age ranged from 37 to 76 y (average of 56.4 y). The average hospital stay was 15.4 d (range, 9-27 d). The number of surgical procedures ranged from 1 to 4 (mean of 2.5), which included dressing changes, debridement surgery, and fascia flap transfer. Fascia flap completely survived in nine patients with normal lower limb blood vessel status, which was ascertained before surgery. One case of skin necrosis, caused by local in-fections, was healed by regrafting and conventional dressing therapy. Two cases of fascia flap completely survived in pa-tients with normal arteriae tibialis anterior status although they had an abnormal posterior tibial artery or a peroneal artery. Four cases with anterior tibial artery stenosis and abnormal dorsalis pedis pulse improved significantly by balloon dilatation, of which two patients suffered from avas-cular necrosis of the fascia flap and eventually underwent amputation. All patients were able to stand and ambulate with full weight-bearing during the follow-up period. All pa-tients were able to wear shoes, and they unanimously accepted the esthetic outcome. There were no complications, such as ulceration and necrosis, related to the donor site.

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previous publications. The third step was vascular anastomosis. Before perform-ing the anastomosis, the fascia flap was transferred and fixed to the recipient site. The donor artery was anastomosed to the dorsalis pedis artery in an end-to-side manner, and the vein was anastomosed to the accompanying vein in an end-to-end manner under the microscope. When the operations aforementioned were completed, we carefully checked and ensured that the anastomosis was unobstructed, and the fascia flap blood circulation was good. The fourth step was the grafting of the skin which involved harvesting the thin split skin and transplanting and fixing it on the surface of the fascia flap. A bandage with observation holes was applied with moderate pressure to the skin. Finally, the affected limbs were immobilized, in functional positions, with gyp-sum or braces.

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Postoperative management The affected limb was elevated and kept warm after the pro-cedure and other medical treatments were provided if necessary. Medication for flaps, which included vasodilator, antispasmodic, and anticoagulant drugs, was used systemi-cally. The Doppler ultrasound was applied to check the patency of anastomosis after the operation, and the dressing was changed in a timely manner. The blood status was observed every 4-6 h until the 7th-d postoperation. Edema was nearly resolved 14 d after the procedure. Orthopedic shoes were used to prevent the recurrence of ulcerations. Gradual walking and systemic rehabilitation exercises were recommended for the patients until they could bear full weights 4 wk after surgery. The follow-up period of the study was varying from 6 to 18 mo according to the disease recovery of these patients.

Typical case 1: superficial temporal fascia free flap This case involved a 49-year-old male diabetic patient with uncontrolled blood glucose levels for 11 y. Random blood glucose check of the patient showed that he had a blood glucose value of 324 mg/dL when he was sent to our depart-ment. The patient had neglected prior disease treatments which had resulted in diabetic ketoacidosis twice before. The ulceration had begun spontaneously 2mo before our study. It was located in the partial dorsum of the left foot between the fourth and fifth toe and had not healed by dressing change. Transcutaneous oxygen was 36 mmHg. The fourth and fifth toe tendons were exposed as a result of a previous surgical debridement. Blood glucose was controlled strictly with a week-long endocrinological treatment in the preoperative period. Wounds, with tendons exposed, were ascertained to be untreatable by simple conventional dressing therapy or skin grafting. This patient had a wound size of about 5.9 9.2 cm (Fig. 1A). To treat this, we designed and obtained an STF flap that would fit the wound size and esthetically sutured the incision of the donor site (Fig. 1B-D). After that, we performed a vascular anastomosis, fascia flap trans-plantation, and thin split-skin grafting (Fig. 1E). The fascia flaps and grafted skin survived well after surgery (Fig. 1F). After a follow-up period of 12 mo, the patient wore orthopedic shoes regularly. His functional recovery was satisfactory (Fig. 1G). The scars at the donor site were not obviously visible and were free of any ulceration (Fig. 1H).

Typical case 2: tensor fascia lata flap This case involved a 57-year-old female, who had been a diabetic patient for 16 y, with an intrinsic muscle imbalance

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Fig. 1 e The reconstruction of fourth and fifth toes and partial dorsum pedis deep defects using free vascularized superficial temporal fascia flap with skin grafting. (A) After surgical debridement, partial tendon exposure were observed in fourth and fifth toes; (B-D) designing and harvesting of superficial temporal fascia flap; (E) vascular anastomosis was performed after transferring and fixing the fascia flap to the recipient site; (F) the fascia flap and grafted skin survived well at 8th d after operation; (G) at 6 mo follow-up, the appearance of recipient site was even and without dysfunction; and (H) the scars at the donor site were not obvious. (Color version of figure is available online.)

in her right foot for 3 mo. This had resulted in a local infec-tion and a severe soft tissue defect of her fourth toe (Fig. 2A). Transcutaneous oxygen was 32 mmHg. Doppler ultrasound examination and lower extremity angiography showed se-vere vascular stenosis of the distal anterior tibial artery, and

the patient underwent a balloon therapy before reconstruc-tion. After surgical debridement, the wound size was about 2.2 1.5 cm and accompanied by the exposure of her fourth and fifth toe tendons (Fig. 2B). Osteomyelitis was suggested by analyzing the clinical and radiological outcomes. We

Fig. 2 e The reconstruction of fourth toe deep defects using free vascularized anterolateral thigh fascia lata flap with skin

grafting. (A) Preoperative wound characteristics; (B) after surgical debridement, articular capsule destruction and bone exposure were observed; (C and D) designing and harvesting of anterolateral thigh fascia lata flap; (E) vascular anastomosis was performed after transferring and fixing the fascia flap to the recipient site; (F) skin grafting was

performed; (G) the fascia flap and grafted skin survived well at 1 wk after operation; and (H) at 4 mo follow-up, the appearance of recipient site was even and without dysfunction. (Color version of figure is available online.)

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designed and harvested an ATFL flap according to the size of the recipient site (Fig. 2C and D). Then, we transferred and fixed the fascia flap to the wound and performed the vascular anastomosis and skin grafting (Fig. 2E and F). The fascia flap and the grafted skin survived well after the surgery (Fig. 2G). After 8 mo of follow-up, the functional recovery and appearance of the toe were acceptable with special footwear, without any recurrence of the disease (Fig. 2H).

Discussion It is obvious that limb loss would have profound negative impacts not only on individuals’ daily activities but also on their physical and mental health status. Diabetic foot, espe-cially ulcer of the toes, is one of the most common compli-cations in diabetic patients. Deep toe defects usually result in tendon or bone exposure, which may eventually lead to osteomyelitis. Flap transplantation is frequently an alterna-tive method to treat deep toe defects when patients refuse to have their toes amputated. Microsurgery reconstruction had been regarded as one of the main contraindications in di-abetics with lower limb ulcerations as peripheral 7,8

arterial diseases may increase the risk of flap avascular necrosis However, in recent years, mounting evidence had shown the advantages of free flaps for reconstruction in the diabetic foot. Free flaps cover the wound defects and simultaneously improve the blood circulation in the affected feet. Meta-analysis of a systematic review conducted by Oh et al. demonstrated that the 5-year survival rate of diabetic patients who had had skin flap transplantation for limb salvage was as high as 84.9%, thereby improving the quality of life for pa-tients suffering from diabetic foot ulcers.

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Several classic free flaps were often selected for covering the defects that span a large area of the lower limbs. However, the use of small free flaps for reconstructing small-size toe defects significantly increased the difficulty of the procedure along with increasing the incidence of postoperative compli-cations. This is because harvesting the small-size flaps and anastomosing small vessels both require sophisticated sur-gical procedures. Also, small vessel anastomosis increased the risk for skin flap ischemia and anastomotic embolization in diabetic patients. In addition, according to our previous study, many flap revisions, after reestablishment, were performed because when we tried to repair the toe defects with multiple small-size free flaps (anterolateral thigh flaps, medial upper arm flaps, groin flaps, and so forth), they had a bloated appearance and functional shortage.

Fascia flaps, especially the ATFL flap and STF flap, are widely used in the reconstruction of tissue defects because of their advantages, including flexibility, toughness, thin flaps, and abundant blood. The ATFL flap is mainly clinically applied in the repair of abdominal wall and Achilles tendon,

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is characterized by an invariable anatomical relationship with relatively simple harvesting procedures. (2) Esthetic outcome: toe wounds repaired by conventional free flaps always engender adverse consequences like bloated appearance, which needs further revision. Although the ATFL flaps and STF flaps are thin enough, the vascularized fascia flaps, combined with skin grafting, are thinner than them. (3) Better deformability: both of these two fascia flaps show soft textures and abundant blood supply. They can be easily clipped for covering multiple toe defect wounds (in case 2). Moreover, they are flexible enough to be folded to fill the lacuna of a wound. (4) Rich blood supply: abundant blood supply of fascia flaps could in-crease the regional blood flow at the donor site, which could also provide a better infection control against wounds such as osteomyelitis (as in case 2). Besides, the vessels of both the ATFL flap and STF flap have a wide diameter. It is equivalent of reconstructing another major blood vessel in the dorsum of the foot after the end-to-side anastomosis to the dorsalis pedis artery. This method will greatly improve the foot blood supply and reduce the incidence of foot ulcers. (5) For reconstruction of joint capsule: owing to their reliable toughness, fascia flaps are helpful in reconstructing the joint capsule and improving toe function for patients with joint capsule defect and articular cavity exposure.

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It is important to establish the presence of a peripheral vascular disease to assess the recipient site vessel conditions before the patient is recommended to undergo the surgery. Routine physical examinations (checking arterial pulsation, evaluating toe capillaries filling reaction, and so forth) and ultrasonic Doppler should be performed for all patients to assess the vascular status of their lower extremities. If the vascular status is uncertain, CT-angiography, MRA, or even invasive angiography should be recommended. All of those preoperative examinations are very beneficial to improve the success rate of operation. For those patients with lower limb vascular occlusion or stenosis, interventional surgery (balloon dilatation, and so forth) for vascular recanalization should be performed timely. Microsurgery is not recommended for pa-tients for whom balloon dilatation failed to not effectively recanalize the vasculature. In the cases that we dealt with, flaps in nine patients who suffered from normal lower limb vascular status survived completely. Six patients who un-derwent balloon dilatation had improved lower limb blood supply. However, two patients suffered from partial skin grafting ischemic necrosis of fascia flaps and eventually un-derwent amputation. Based on the analysis of 15 cases, we consider it quite safe and efficient for patients with normal lower limb vascularity to receive fascia flap transplantation. However, for those with abnormal lower limb vascular status, especially with anterior tibial artery abnormality, high risks of ischemic necrosis still existed even when the vascular recanalization was performed. In addition, we reviewed our experience with perioperative comprehensive therapy in diabetes patients, and it is very important to work closely with internal medicine, such as glycemic control and other basic diseases treatment.

whereas the STF flaps showed their merits in reestablishing the 11

head, face, and other parts of the body’s soft tissue defects. In this article, the free vascularized fascia flaps combined with skin grafting were effectively applied in treating diabetic patients with deep toe ulcers. Their advantages are as follows: (1) a relatively simple operation: It is not difficult to harvest the ATFL flaps compared with the small anterolateral thigh flaps. The STF flap

Although our method provides several advantages, it still has the following limitations: (1) postoperative observation of the blood circulation of the fascia flaps is difficult. After free transplantation of the STF flaps followed by thin split-

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skin grafting, gauze was wrapped around the operational area which made it difficult to observe the blood circulation of the fascia flaps with the naked eye. We propose that this can be circumvented by using an ultrasonic doppler exami-nation. (2) A traditional pressure dressing after skin grafting was also not suitable for the operation area in the cases that we studied as it would have affected the survival rate of the skin grafts.

Conclusion This study provides a useful method for repairing deep toe ulcer in diabetic patients using free vascularized fascia flap combined with skin grafting. This method offers the advan-tages of an accepted esthetic outcome, abundant vascularity, simple operation, and good deformability that deserve further research and extension. However, it is important to assess the peripheral vascular status comprehensively before perform-ing the surgery as poor peripheral vascular status would lead to a failure of the transplantation.

Acknowledgment The authors confirm that none of the authors have any con-flict of interest. Author’s contributions: X.Y. and Z.F. contributed equally to this work and should be considered as co-first authors. X.Y., Z.F., and D.H. contributed to the study conception and design. Z.F., M.L., and Y.Z. contributed to the acquisition of data and drafting of the article. Q.C., K.T., and J.H. contributed to the analysis and interpretation of data, literature review, and critical revision. The Department of Burns and Cutaneous Surgery, Xijing Hospital, Fourth Military Medical University was acknowledged for proving unrestricted grants.

Disclosure The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in this article.

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