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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 27  |  Issue : 4  |  Page : 217-219

Repairment of lateral malleol defects with distal pedicled peroneus brevis muscle flap


1 Department of Plastic, Reconstructive and Aesthetic Surgery, Konya Numune Hospital, Konya, Turkey
2 Department of Plastic, Reconstructive and Aesthetic Surgery, School of the Medicine, Necmettin Erbakan University, Konya, Turkey

Date of Submission29-Nov-2018
Date of Acceptance19-Feb-2019
Date of Web Publication26-Sep-2019

Correspondence Address:
Dr. Zeynep Altuntas
Department of Plastic and Reconstructive and Aesthetic Surgery, School of the Medicine, Necmettin Erbakan University, 42080 Meram, Konya,
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjps.tjps_90_18

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  Abstract 


The availability of local tissue in distal 1/3 of the leg and around the ankle is limited, and the difficulty in re-establishing soft-tissue coverage for these defects continues to challenge surgical procedures. In this study, two cases who had the soft-tissue defects around the lateral malleol reconstructed with the distally pedicled peroneus brevis muscle flap were discussed. The first case was a 30-year-old male patient, who had 4 cm × 2 cm soft-tissue defect with bony exposure, inferior to the lateral malleol after a gunshot injury. The second case was a 26-year-old male patient who had 5 cm × 3 cm soft-tissue defect with exposed metal implant, distal to the lateral malleolus after a traffic accident. Both of the patients were quite satisfied with the esthetic results. The distal pedicled peroneus brevis muscle flap should be kept in mind as a reliable and relatively easy flap option for the reconstruction of the soft-tissue defects around the lateral malleol with good results.

Keywords: Distal pedicled flap, lateral malleol defect, peroneus brevis muscle


How to cite this article:
Yarar S, Kendir MS, Altuntas Z. Repairment of lateral malleol defects with distal pedicled peroneus brevis muscle flap. Turk J Plast Surg 2019;27:217-9

How to cite this URL:
Yarar S, Kendir MS, Altuntas Z. Repairment of lateral malleol defects with distal pedicled peroneus brevis muscle flap. Turk J Plast Surg [serial online] 2019 [cited 2019 Nov 12];27:217-9. Available from: http://www.turkjplastsurg.org/text.asp?2019/27/4/217/267934




  Introduction Top


The lower 1/3 defects of leg and foot have special importance for reconstructive surgeons. As a general principle, reconstruction with free flaps is suitable for the repair of large defects at the distal part of the leg that cannot be covered with the local flaps. Conversely, use of local flaps in the area around the defect in smaller defects requires fewer skills as well as more appropriate in terms of time, labor, and morbidity. Repairment of the defects in these areas is difficult due to the anatomical structure of the region. If the defect around the ankle is not large and the general condition of the patient is unfavorable for a free flap or the patient does not want the free flap option or the free flap option is kept for the next operation in case of failure, the distal pedicled peroneus muscle flap option can be used for reconstruction of small defects around the ankle and leg.[1]

Using the distal pedicled peroneus brevis muscle flap to covering the small-sized defects on the lateral malleolar region, Achilles tendon, and tibial distal tip is the appropriate local flap option for the reconstructive procedure spectrum. In this study; we evaluated the results of repairing lateral malleolar tissue defects with distal pedicled peroneus brevis muscle flap in two cases.


  Case report Top


A 30-year-old male patient had a 4 cm × 2 cm defect after gunshot injury, with a bony exposure on the heel and a 26-year-old male patient had a 5 cm × 3 cm defect distal to the lateral malleolus after a traffic accident. There is bone exposition, and a metal implant on the bone can be seen [Figure 1]. There was no systemic disease in both of the patients. Preoperatively, the presence of peripheral pulses was confirmed to rule out vascular injury and peripheral vascular disease. No angiograms were done. We planned reconstruction with the distal pedicled peroneus muscle flap.
Figure 1: Preoperative appearance, soft tissue defect at lateral malleolar region

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Following the sterilization, flap dissection was initiated under the tourniquet. The leg was held at 60°–70° of flexion by the assistant to relax peroneus muscles and allow easy access to peroneus brevis muscle, which is lying deep to the peroneus longus. The incision was made just posterior of the fibula and deepened through deep fascia to expose the peroneal compartment. When the skin flaps were harvested, attention was taken to protect the superficial branch of the peroneal nerve that protruded about 15 cm above the lateral malleolus. After the peroneus brevis muscle has seen in the lateral compartment, muscle dissection was performed from superior to inferior and from anterior to posterior. The peroneus brevis was isolated from the anterior intermuscular septum which is on the anterior surface of the fibula. The muscle was pulled out of the periosteum at proximal 2/3 of the fibula, and its proximal was relaxed. During dissection, the vascular branches entering the muscle are knotted while the flap was harvested. Flap rotation should be measured step by step to make it appropriate for the defect. When it reached the level where the defect could be closed, the dissection was terminated. At least 6 cm of intact tissue from the lateral malleolus should be left at the distal site to provide flap circulation. Thus, the distal segmental branches of the peroneal and anterior tibial arteries are preserved. After the tourniquet was opened and bleeding control is performed, the flap was passed through the tunneled area and covered to the defect [Figure 2]. A split thickness skin graft was applied over the muscle flap. A drain was inserted into the flap donor area and the skin is primarily closed. To immobilize the foot, short leg splint is applied to the foot in the neutral position, and the operation is terminated.
Figure 2: Perioperative appearance, peroneus brevis muscle flap harvestment

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Postoperative results were pretty esthetic, and high levels of patient satisfaction were observed [Figure 3].
Figure 3: Postoperative appearance - 2nd month

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  Discussion Top


The availability of local tissue in distal 1/3 of the leg and around the ankle is limited, and the difficulty in re-establishing soft-tissue coverage for these defects continues to challenge surgical procedures. Reconstruction with free flap has good results in closing large defects in the distal third of the leg, due to its three-dimensional design and sufficient tissue volume. However, reconstruction with free flap procedure restricted because of the need for expertise in microsurgical techniques, longer operative time, the use of large vascular structure in the tibial region, donor site morbidity, and high cost.[2],[3] Distal-based peroneus brevis muscle flap is useful for small- and medium-sized defects in the lateral of the leg and the ankle due to its simple flap design, faster obtaining, and lesser morbidity in the donor area. This perforator-based flap can provide excellent solutions for recipient field alignment because of its flap texture and thicknesses. Many studies have examined the clinical use of this muscle and have reported that the results are good, reliable, and reproducible when it is used as a flap.[4],[5],[6]

The average length of the peroneus muscle is 25 cm. Yang et al. in their study reported that the distal pedicle was located within 6 cm of the distal end of the fibula and emphasized that this region was not included in the flap. As a result, up to 19 cm of muscle can be obtained as the flap. However, the dissection should be discontinued when the muscle is sufficient to cover the defective area to protect as many distal pedicles as possible.[4] The most common postop complication is distal flap necrosis.[6] When we look at the blood supply of the muscle, we see a dominant pedicle originating from the peroneal artery that enters proximally to the muscle at the deep side of it, and segmental minor pedicles that originate from the peroneal and the anterior tibial arteries at the distal side. Although in the former classification peroneus brevis muscle was classified as a type 2 muscle flap due to a dominant pedicle in the proximal part of the muscle originating from the peroneal artery and minor pedicles in the distal part, it was reclassified as type 4 by Mathes and Nahai because of the segmental vascular pedicles that could limit the motion of the flap. An anatomical study by Villarreal et al. reported that two main source arteries feeding the muscle are anterior tibial artery and peroneal artery, and the anterior tibial artery is the dominant artery, as opposed to the other information, both of the proximal and middle thirds of the muscle are fed by this artery. According to this study, the peroneal artery is considered as an auxiliary vascular source and provides circulation of a distal third of these muscle.[7] Very good results have been reported in the literature about the reconstruction of appropriate cases with distal pedicled peroneus muscle flap.[8],[9],[10],[11] Additional advantages of the peroneus brevis muscles include the ability to be harvested as a composite flap containing a vascularized fibular bone segment. There is also an option to use it as a free flap, which is creating very low donor site morbidity.[11]

Although there was not any flap loss in our cases when the literature was examined, it was seen that if the patient has a systemic disease or flap area was affected by major trauma, this may cause partial or complete flap necrosis. In the case of the peroneal artery is obstructed, it is suggested that refer to another option.[12] These factors can be considered as the factors that may limit the usage of this flap.

As a result, distal-based peroneus brevis muscle flap should be kept in mind as a reliable, economical and relatively easy flap option for reconstruction of the medium- and small-sized defects of the distal leg and lateral malleolar region.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ng YH, Chong KW, Tan GM, Rao M. Distally pedicled peroneus brevis muscle flap: A versatile lower leg and foot flap. Singapore Med J 2010;51:339-42.  Back to cited text no. 1
    
2.
Wettstein R, Schürch R, Banic A, Erni D, Harder Y. Review of 197 consecutive free flap reconstructions in the lower extremity. J Plast Reconstr Aesthet Surg 2008;61:772-6.  Back to cited text no. 2
    
3.
Thornton BP, Rosenblum WJ, Pu LL. Reconstruction of limited soft-tissue defect with open tibial fracture in the distal third of the leg: A cost and outcome study. Ann Plast Surg 2005;54:276-80.  Back to cited text no. 3
    
4.
Yang YL, Lin TM, Lee SS, Chang KP, Lai CS. The distally pedicled peroneus brevis muscle flap anatomic studies and clinical applications. J Foot Ankle Surg 2005;44:259-64.  Back to cited text no. 4
    
5.
Bach AD, Leffler M, Kneser U, Kopp J, Horch RE. The versatility of the distally based peroneus brevis muscle flap in reconstructive surgery of the foot and lower leg. Ann Plast Surg 2007;58:397-404.  Back to cited text no. 5
    
6.
Barr ST, Rowley JM, O'Neill PJ, Barillo DJ, Paulsen SM. How reliable is the distally based peroneus brevis muscle flap? Plast Reconstr Surg 2002;110:360-2.  Back to cited text no. 6
    
7.
Villarreal PM, Monje F, Gañán Y, Junquera LM, Morillo AJ. Vascularization of the peroneal muscles. Critical evaluation in fibular free flap harvesting. Int J Oral Maxillofac Surg 2004;33:792-7.  Back to cited text no. 7
    
8.
Bajantri B, Bharathi R, Ramkumar S, Latheef L, Dhane S, Sabapathy SR, et al. Experience with peroneus brevis muscle flaps for reconstruction of distal leg and ankle defects. Indian J Plast Surg 2013;46:48-54.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Troisi L, Wright T, Khan U, Emam AT, Chapman TW. The distally based peroneus brevis flap: The 5-step technique. Ann Plast Surg 2018;80:272-6.  Back to cited text no. 9
    
10.
Lorenzetti F, Lazzeri D, Bonini L, Giannotti G, Piolanti N, Lisanti M, et al. Distally based peroneus brevis muscle flap in reconstructive surgery of the lower leg: Postoperative ankle function and stability evaluation. J Plast Reconstr Aesthet Surg 2010;63:1523-33.  Back to cited text no. 10
    
11.
Schmidt AB, Giessler GA. The muscular and the new osteomuscular composite peroneus brevis flap: Experiences from 109 cases. Plast Reconstr Surg 2010;126:924-32.  Back to cited text no. 11
    
12.
Akan M, Avcı G, Aköz T. Repairment of defects at the lower end of leg with distally based peroneus brevis muscle flap. Turk J Plast Surg 2004;12:170-2.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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