Archives of Plastic Surgery

Korean Society of Plastic and Reconstructive Surgeons (대한성형외과학회)
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"Pure Fat Flap"-Perforator-based Adiposal Layer Only Flap for Lateral Ankle Reconstruction

  • Seok Joon Lee (Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Jeongmok Cho (Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Changsik Pak (Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Hyunsuk Suh (Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Joon Pio Hong (Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine)
  • Received : 2023.09.04
  • Accepted : 2024.01.30
  • Published : 2025.01.15
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Abstract

Lateral ankle soft tissue defects pose challenges, especially in cases due to chronic pressure from cross-legged sitting, which usually present with a large dead space, small skin opening that often accompanies an open joint. Traditional reconstruction methods using fasciocutaneous flaps may result in donor site morbidity such as delayed wound healing or nerve injury. In this article, we present a case of diabetesrelated lateral ankle defect successfully treated using adiposal layer only flap, also known as pure fat flap. The anatomy and the surgical technique of adiposal layer only flap were reviewed. These flaps preserve the subdermal plexus and deep fascia while obliterating dead space and providing a gliding surface for proper ankle movement. A perforator-based adiposal layer only flap was elevated from the peroneal artery and used to cover the defect. Flap perfusion was confirmed using indocyanine green video angiography and color duplex ultrasound. Patient had a successful recovery with minimal donor site morbidity. The technique expands the reconstructive microsurgeon's options for complex ankle coverage, ensuring optimal wound healing and functional outcomes.

Keywords

References

  1. Bhandari PS, Bath AS, Sadhotra LP, Singh M, Mukherjee MK. Management of soft tissue defects of the ankle and foot. Med J Armed Forces India 2005;61(03):253–255 https://doi.org/10.1016/S0377-1237(05)80167-4
  2. Chen H, Yin G, Hou C, Zhao L, Lin H. Repair of a lateral malleolus defect with a composite pedicled second metatarsal flap. J Int Med Res 2018;46(12):5291–5296 https://doi.org/10.1177/0300060518801461
  3. Schaper NC, van Netten JJ, Apelqvist J, et al; IWGDF Editorial Board. Practical guidelines on the prevention and management of diabetes-related foot disease (IWGDF 2023 update). Diabetes Metab Res Rev 2023:e3657 https://doi.org/10.1002/dmrr.3657
  4. Suliman MT. Distally based adipofascial flaps for dorsal foot and ankle soft tissue defects. J Foot Ankle Surg 2007;46(06):464–469 https://doi.org/10.1053/j.jfas.2007.08.002
  5. Cho MJ, Kwon JG, Pak CJ, Suh HP, Hong JP. The role of duplex ultrasound in microsurgical reconstruction: review and technical considerations. J Reconstr Microsurg 2020;36(07):514–521 https://doi.org/10.1055/s-0040-1709479
  6. Attinger CE, Evans KK, Bulan E, Blume P, Cooper P. Angiosomes of the foot and ankle and clinical implications for limb salvage: reconstruction, incisions, and revascularization. Plast Reconstr Surg 2006;117(7 Suppl)261S–293S https://doi.org/10.1097/01.prs.0000222582.84385.54
  7. Lese I, Biedermann R, Constantinescu M, Grobbelaar AO, Olariu R. Predicting risk factors that lead to free flap failure and vascular compromise: a single unit experience with 565 free tissue transfers. J Plast Reconstr Aesthet Surg 2021;74(03):512–522 https://doi.org/10.1016/j.bjps.2020.08.126
  8. Daar DA, Abdou SA, David JA, Kirby DJ, Wilson SC, Saadeh PB. Revisiting the reverse sural artery flap in distal lower extremity reconstruction: a systematic review and risk analysis. Ann Plast Surg 2020;84(04):463–470 https://doi.org/10.1097/SAP.0000000000002041
  9. Mohindra A, Parmar S, Praveen P, Martin T. The fat-fascia paddle only with a composite fibula flap: marked reduction in donor site morbidity. Int J Oral Maxillofac Implants 2016;45(08):964–968 https://doi.org/10.1016/j.ijom.2016.03.014
  10. Lee KJ, Lee SH, Kim MB, Lee YH. Adipofascial fold-down flaps based on the posterior tibial artery perforator to cover the medial foot and ankle defects. J Plast Reconstr Aesthet Surg 2016;69(12):e229–e237 https://doi.org/10.1016/j.bjps.2016.08.019
  11. Nakajima H, Imanishi N, Fukuzumi S, et al. Accompanying arteries of thelesser saphenous vein and sural nerve: anatomic study andits clinical applications. Plast Reconstr Surg 1999;103(01):104–120 https://doi.org/10.1097/00006534-199901000-00018
  12. Bekara F, Herlin C, Mojallal A, et al. A systematic review and meta-analysis of perforator-pedicled propeller flaps in lower extremity defects: identification of risk factors for complications. Plast Reconstr Surg 2016;137(01):314–331 https://doi.org/10.1097/PRS.0000000000001891
  13. Khansa I, Momoh AO, Patel PP, Nguyen JT, Miller MJ, Lee BT. Fat necrosis in autologous abdomen-based breast reconstruction: a systematic review. Plast Reconstr Surg 2013;131(03):443–452 https://doi.org/10.1097/PRS.0b013e31827c6dc2
  14. Kim HB, Han SJ, Kim EK, Eom JS, Han HH. Comparative study of DIEP and PAP flaps in breast reconstruction: reconstructive outcomes and fat necrosis. J Reconstr Microsurg 2023;39(08):627–632 https://doi.org/10.1055/a-2040-1368
  15. Bouloumié A, Galitzky J. Angiogenesis in adipose tissue. In: Bastard J-P, Fève B, eds. Physiology and Physiopathology of Adipose Tissue. Paris: Springer; 2013:27–38
  16. Corvera S, Solivan-Rivera J, Yang Loureiro Z. Angiogenesis in adipose tissue and obesity. Angiogenesis 2022;25(04):439–453 https://doi.org/10.1007/s10456-022-09848-3
  17. Larsen OA, Lassen NA, Quaade F. Blood flow through human adipose tissue determined with radioactive xenon. Acta Physiol Scand 1966;66(03):337–345 https://doi.org/10.1111/j.1748-1716.1966.tb03208.x
  18. Lempesis IG, Goossens GH, Manolopoulos KN. Measurement of human abdominal and femoral intravascular adipose tissue blood flow using percutaneous Doppler ultrasound. Adipocyte 2021;10(01):119–123 https://doi.org/10.1080/21623945.2021.1888471
  19. Li K, Zhang Z, Nicoli F, et al. Application of indocyanine green in flap surgery: a systematic review. J Reconstr Microsurg 2018;34(02):77–86 https://doi.org/10.1055/s-0037-1606536
  20. Onode E, Takamatsu K, Kazuki K, Nakamura H. Bipedicled digital artery perforator volar adiposal turned-over flap for reconstruction of transverse fingertip amputation. JPRAS Open 2022;32:111–115 https://doi.org/10.1016/j.jpra.2022.02.006