|Year : 2015 | Volume
| Issue : 1 | Page : 1-7
Reconstruction of soft tissue defects in the distal third of the leg, ankle, and foot: A meta-analysis
Samuel Adesina Ademola1, Wasiu Olushola Adebayo1, Olukemi Lawani2
1 Department of Plastic, Reconstructive and Aesthetic Surgery, University College Hospital, Ibadan, Nigeria
2 Department of Orthopaedic Surgery and Trauma, University College Hospital, Ibadan, Nigeria
|Date of Web Publication||8-Oct-2015|
Samuel Adesina Ademola
Department of Plastic, Reconstructive and Aesthetic Surgery, University College Hospital, Ibadan
Source of Support: None, Conflict of Interest: None
Management of soft tissue defects in the distal third of the leg, ankle and foot has evolved over time despite its challenges. No option of coverage is universally recommended for defects in this region of the body. Our objectives were to review and analyze outcomes of reported options of reconstruction of soft tissue defects in this region. We conducted a search of PUBMED and HINARI databases from 2000-2014 to identify reported options of reconstruction of soft tissue defects of the leg, ankle, and foot. Pooled data from suitable articles were analyzed and the success and complication rates as well as the relative risks for failure and complications were computed. One thousand and thirty two articles were retrieved out of which thirty three met the inclusion criteria for analysis. All the 33 articles were uncontrolled cohort and descriptive studies. There were 14 reports on sural artery flap, 6 on perforator-based flaps, and 5 on free flaps. Cross leg flaps, adipofascial, peroneus brevis, and hemisoleus muscle flaps were reported in two studies each while medial plantar, supramalleolar, and skin grafts were reported in one study each. Flap failure was the commonest complication with free flaps while reconstruction with skin grafts had the lowest failure rate. Free flaps were, however, versatile for reconstruction of complex defect. Conclusively, meticulous planning is required in the reconstruction of defects of the lower third of the distal third of the leg, ankle, and foot in order to use the most appropriate method for best outcomes.
Keywords: Ankle, distal third of the leg, foot, meta-analysis, reconstruction, soft tissue defects
|How to cite this article:|
Ademola SA, Adebayo WO, Lawani O. Reconstruction of soft tissue defects in the distal third of the leg, ankle, and foot: A meta-analysis. Nigerian J Plast Surg 2015;11:1-7
|How to cite this URL:|
Ademola SA, Adebayo WO, Lawani O. Reconstruction of soft tissue defects in the distal third of the leg, ankle, and foot: A meta-analysis. Nigerian J Plast Surg [serial online] 2015 [cited 2021 May 9];11:1-7. Available from: https://www.njps.org/text.asp?2015/11/1/1/166851
| Introduction|| |
The lower limbs serve the functions of support and ambulation, making them essential requirements for activities of daily living. Defects involving the distal third of the leg, ankle, and foot are common, their reconstruction are complex and they are frequently associated with bone(s), ankle, joint, tendon(s), and neurovascular structure exposure. The causes of these isolated or composite soft tissue defects vary widely, including trauma; soft tissue infections; diabetic, vascular, and neuropathic ulcers. The decline of blood supply as one proceeds distally along the leg, limited muscle and soft tissue around the ankle, lack of laxity in the skin of the distal third of the leg as well as the propensity for repeated trauma, all contribute to the difficulty in achieving coverage of soft tissue defects in the distal third of the leg. Defects around the ankle joint may leave an exposed joint cavity and the heel being a weight bearing zone, all add to the challenge of providing soft tissue coverage for defects in this region. Despite these challenges, early reconstruction has been shown to provide the best prospect of fastest return of function, increased chances of return to employment, and as such is advocated as the best option. There is, however, a dilemma in achieving this best practice due to difficulties in determining the option of reconstruction that will be most appropriate for a given situation.
The reported options for managing defects of the distal third of the leg include skin grafts and a wide range of flaps, each with its technical challenges and complication profile. Although many of these reconstructive methods are being used, there is need for high-level evidence of outcomes to guide the practice. Randomized control studies are difficult to design for such studies due to ethical issues. A meta-analysis, which is a painstaking and a detailed analysis can, however, produce such reasonable evidence. We, therefore, embarked on an analysis of outcomes of reconstruction of soft tissue defects of the distal third of the leg, ankle, and foot to serve as a guide to reconstruction in the region and to provide insights for future research.
| Materials and Methods|| |
Our hypothesis was that “there is no significant difference in outcomes among the various methods of soft tissue coverage for defects involving the distal third of the leg, ankle, and foot.”
A comprehensive literature search of PUBMED and HINARI databases was conducted to identify publications on the subject matter from 2000 to 2014 using the following key words: Reconstruction; defects; and distal third of the leg, ankle, and foot. The inclusion criteria were as follows: Original articles, prospective and retrospective reports, and case series of all reconstructive methods used to cover defects of the distal third of the leg, ankle, and foot within our specified period of interest. Case reports, review articles, anatomical studies, studies combining reconstruction of soft tissue defects of the distal leg and ankle with those in other parts of the body, and articles that were not written in English were excluded from the study [Figure 1].
The data extracted from articles included title of the paper, type of surgical intervention, the lead author, year of study, number of cases reported in the study, patients' characteristics (inclusive of age, size of defects, and comorbidities), outcomes, and duration of follow-up. The primary outcome measure was flap survival while complications as described in the ensuing pages were the secondary outcome measures.
The strength of each study was graded using a modification of the method of Ebell et al. The following scale was adapted as depicted in [Table 1]. A total score of 3–5 was assigned a strength of 1, score 6–7 a strength of 2, and score greater than 7 a strength of 3. A study with a strength of 3 is, therefore, of higher level of evidence than the one with a score of 1.
Data from included studies were then pooled for analysis. When a study combines several methods of reconstruction in its report, similar methods were pooled together and analyzed. We regarded complete flap necrosis as failed reconstruction. Other complications were graded into major and minor for the ease of analysis. Minor complications were those complications that would not immediately threaten flap survival while the major ones were those that would directly threaten flap survival or if there was some flap necrosis. The pooled outcome: Failures, successes, and complication rates were calculated and expressed as percentages for each reconstructive method and the relative risk for developing complications were also calculated.
Heterogeneity was assessed using the Q-statistic and the I2-statistic. Q- statistic P < 0.05 indicate statistical significance and the corresponding I2percentage indicates the degree of significance. Relative risk was, however, not computed for those reconstructive methods where the complication was not reported.
| Results|| |
One thousand and thirty two articles were identified from PUBMED and HINARI database searches for screening. Of these, 33 articles met our inclusion criteria for analysis. [Figure 1] depicts the attrition pattern of the articles searched and those eventually included in the analysis. All the 33 articles included in the meta-analysis were uncontrolled cohort and are descriptive studies. Fourteen of the reports (42%) had strength of 1 while 16 (49%) had strength of 2. Only three publications (9%) had strength of 3.
Of the 33 articles, 14 reported on sural artery flap and its various modifications, perforator-based flaps were reported in 6 studies, and free flaps were reported in 5 studies. Cross-leg flaps, adipofascial, peroneus brevis, and hemisoleus muscle flaps were all reported in two studies each while medial plantar, supramalleolar, and skin grafts were reported in one study each. [Table 2] presents the data from the 33 studies that were included. It depicts the number of reconstructions in each method, their failure, and pooled complication rates. Various complications were reported in the studies. They included total reconstructive failure (total flap or graft necrosis), partial flap/graft failure that included tip necrosis as well as superficial necrosis. Venous congestion, surgical site infection, wound dehiscence, donor site morbidity, and other (minor) complications (bulky flap, hematoma, and sural hypoesthesia) were also documented.
|Table 2: Distribution of the reported reconstructive methods and their pooled outcome|
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Sural artery flap was the most commonly employed method of reconstruction, and it was used in 31.9% of all reported reconstructions. This was closely followed by free flaps in 23.9% of the reconstructions. Reconstruction with skin graft alone was reported in as high as 5% of the cases. The relative risk of failure and other complications for each method of reconstruction, and the level of significance are presented in [Table 3]. Failure rate was the highest with free flaps (7.9%). This was followed by supramalleolar flap and medial plantar flap with failure rates of 5.9% and 3.3%, respectively. No failure was reported with cross-leg flaps, peroneus brevis muscle flap, hemisoleus muscle flap, adipofascial flaps, neurocutaneous flaps, and skin grafts. Overall pooled complication rate was highest with supramalleolar flap (88.2%) and lowest with skin grafts (1.7%). However, the complications of supramalleolar flaps were almost entirely minor. Others with high overall pooled complication rates were sural artery flap (48.7%), perforator-based flaps (32.8%), peroneus brevis muscle flap (21.6%), and adipofascial flaps (14.2%). No reconstructive method is free from complications.
|Table 3: Relative risk for failure and other complications by method of reconstruction|
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The result of the analysis of relative risk for failure and other complications with each reconstructive method is as shown in [Table 3]. All calculated relative risks were at 95% confidence interval. The relative risk of total necrosis (failure of reconstruction) was highest with free flap (6.5) and lowest with sural artery flap (0.4). Relative risk of failure for perforator-based flap was also quite low (0.8). Relative risk of venous congestion was the highest for supramalleolar flap and sural artery flap.
The relative risk of partial necrosis was highest for supramalleolar flap and lowest for skin graft. When the overall complications were pooled, the relative risk was highest for supramalleolar flap (11.7), lowest for perforator-based flaps (0.1) while free flaps showed a modest relative risk of (0.6). Of all reconstructive methods where donor site morbidity was reported, sural artery flap had the highest relative risk (2.6). For other forms of morbidity reported (which included hematoma, excessive bulk, and hypoesthesia among others), supramalleolar flap had the highest relative risk (24.5) and free flaps had the lowest relative risk (0.1). Other studies did not include morbidity in this category for cross-leg, peroneus brevis muscle, adipofascial, hemisoleus, medial plantar, and neurocutaneous flaps as well as skin grafts.
| Discussion|| |
The results of this meta-analysis highlight the difficulty often encountered when a surgeon is confronted with a soft tissue defect in the distal third of the leg, ankle, and foot. The multiplicity of possibilities for soft tissue coverage and the dilemma of making a choice are reflected in the complication profile noted in this study. Sural artery flap was the most commonly raised and had the least failure rate but it is not adequate for all defects, especially when they are composite defects. Conversely, free tissue transfers were more versatile but the risk of total failure was high. Perforator-based flaps, however, had lower risk of total failure and comparable risk of other complications when compared with other flaps in addition to being versatile in coverage of soft tissue defects. From these findings, it would appear that flap versatility and complication profile are important considerations in decision-making for the closure of soft tissue defects in the lower third of the leg and foot.
Injuries to the leg and foot are common and are accompanied by soft tissue and bony defects of varying complexities. Proper soft tissue coverage of injured tissues should restore the integrity of these tissues and return the limb to functionality but the defects can be challenging to reconstruct due to paucity of soft tissues in the lower third of the leg, reduction in the robustness of blood supply, and prominence of distal parts of the long bones that are disposed subcutaneously. Where the defects are the result of trauma, the extent of soft tissue damage also contributes to the difficulties encountered in reconstruction.
Over the years, advances in reconstructive surgical techniques have greatly influenced the management of soft tissue defects in the distal third of the leg and around the ankle joint, resulting in greatly enhanced ability for limb salvage. There are several of these reconstructive methods that have been reported. This work did not dwell on the selection criteria for choice of reconstructive technique or primary ablation and the limitations of such criteria as several works have been done and reported on this.,, We, however, focused on the outcomes of reported methods of reconstructing these defects.
A successful reconstruction should provide a sensate and durable soft tissue cover preferably with tissues that are comparable with the one that was lost. This is, however, seldom achievable. Thus, the choice of reconstructive method will consider the location and characteristics of the soft tissue defect, the status of surrounding local and regional soft tissue as well as the status of local and regional vasculature.
Reconstructive methods can be attended by success, failure, or other complications. The difficulty in finding appropriate tissue for reconstruction as earlier stated makes the outcome more significant.
We undertook a calculation of the risk of failure or other complications from analysis of pooled data from several studies to evaluate the utility of the individual methods of reconstruction with the hope that this will serve as a guide to practice in specific situations.
Meta-analysis is a well-known statistical technique used to combine results of data from several independent studies. It can provide an objective assessment of the effects of treatment interventions. It has an advantage of increasing the power of the report due to the increase in sample size afforded by pooling of data from different sources. It should then be a useful tool in situ ations where high level of evidence is required for decision-making but studies that can provide such evidence are difficult to design due to ethical issue. It is such a scenario that is presented in this report.
From our results, sural artery flap was the most commonly raised flap for reconstruction of defects of the lower third of the leg and foot. Of all reconstructive methods that had failures, sural artery flap had the least failure rate (total flap loss) of 1.6% but the overall risk of developing postoperative complications was highest with this method. The complications were, however, often minor ones such as wound dehiscence or complications related to the skin grafted donor site. The most commonly reported complication of this flap method was hypoesthesia and this was reported in 63% of the patients in one of the studies in this review but there was no functional impairment. Sural artery flap was found to have the highest relative risk for donor site morbidity. This is perhaps because in all the cases where sural artery flap was used, the secondary defect was covered with split-thickness skin graft. A very common cause of failure of sural artery flap was venous congestion. This could have contributed significantly to the cause of failures in the few cases of failed reconstructions. As a reverse flow flap, venous congestion is a common morbidity of this flap and is frequently responsible for flap necrosis rather than arterial insufficiency, the venous drainage being by the gradual adaptation of accompanying venae comitantes. Sural artery flap combines simplicity in its dissection and reliability with a shorter learning curve. It had been suggested that it should be one of the first options to be considered for defect in this region of the body. However, it would not be sufficient when composite tissue is required for reconstruction.
Microvascular free tissue transfers (free flaps) were the next most frequently employed method of reconstruction in our analysis.
Free flaps offer almost limitless reconstructive possibilities and afford the opportunity of successful composite tissue transfer. The use of free muscle flap better conforms to three-dimensional defects, obliterates dead spaces, and decreases the risk of infection  in a region with poor local muscle mass. From our analysis, the risk of developing complications related to the raised flap was low when total flap failure was excluded. Most of these complications are related to the donor site. In spite of this, the pooled complication rate of free flaps was less than that of other flaps with lesser versatility and usefulness. The drawbacks of free tissue transfer reconstruction include the need to have expertise in microsurgical techniques, need for expensive equipment, longer operating time, a steep learning curve, and higher risk of total failure. Availability of healthy recipient vessels and microsurgical expertise are expedient for success.
In our meta-analysis, we found a pooled failure rate of 7.9% and a relative risk of total necrosis of 6.7, both being the highest in the study. This is perhaps due to problems related to arterial and venous anastomoses (vascular complications) as these are the most common causes of free flap failure. The pooled overall complication rate for free flap in our analysis was 20%. This is comparable to the complication rates reported in other literature that ranged from 10% to 38%.,,, It is, however, important to note that there was a lack of uniformity in the definition of what constituted complication in the reviewed articles on free tissue transfer. For example, some authors did not report vascular thrombosis as complications while others did; the same situation was obtained in the reporting of problems relating to skin graft on the secondary defect as a complication. Free flaps are useful in complex reconstruction, especially those that may require composite tissue transfer. They may also be reserved for those defects in which the use of pedicled local and regional flaps is not feasible and may be one of the last options to consider in resource-constrained settings.
Perforator-based flaps were the third most frequently used reconstructive option in this review. In our analysis, we found that perforator-based flaps had the lowest relative risk for complications and also had low incidence of total flap necrosis (flap failure). Their use was associated with low relative risk for total necrosis (0.8), partial necrosis (1.0), venous congestion (1.5), and overall complication (0.1). Thus, the perforator-based flaps were versatile and safe for the reconstruction of soft tissue defects in this region. This method of reconstruction also combines the advantage of not sacrificing any major blood vessel in the leg  with relatively short operating time.,, The risk of surgical site infection was, however, higher. This may be due to the proximity of many perforator-based flaps to the primary defect that they are designed to cover. Many perforator-based flaps can be designed as propeller flaps and this often allows for the donor site to be closed directly. This method of donor site management, coupled with the fact that many of the flaps spare major vessels could explain the low donor site morbidity in this category of flaps.
With improvement in expertise for free tissue transfer and better understanding of the basis for perforator-based flaps, the cross-leg flap would appear to be less useful in the reconstruction of the lower limb. It may, however, find use in circumstances where all ipsilateral locoregional flaps are not available and there is no expertise or infrastructure for free flap surgery. It is easy to perform and not time-consuming. Its disadvantages include difficulty in postoperative management of the patient, its requirement for immobilization of both the lower limbs with the attendant risk of knee stiffness and deep vein thrombosis, and the need for a second-stage operation. Despite these drawbacks, its success rate has been reported to be very high. This is corroborated by our analysis where the success rate (flap survival) was 100%. This high flap survival rate could be as a result of the favorable length-to-breadth ratio that is required in raising the flap. Also, the risk of partial necrosis and other complications was low in our result (relative risk of 0.5 for partial necrosis and 0.2 for overall complications). While this is gratifying when one considers all the disadvantage of this flap, the low figures may be a result of the type of complications reported by the authors. The focus of their report was complication directly related to the flap. The complication profile may have been altered if those related to the knee and deep vein thrombosis were included.
Other regional muscle flaps that were reported in the reviewed studies are good options for providing bulk that can conform to three-dimensional defects. However, quite often there are limited local muscles available for this purpose. One muscle that is useful for reconstruction of soft tissue defects of the distal third of the leg is soleus muscle. The distally based medial hemisoleus flap, supplied by perforators from the posterior tibial arteries can be so used with split-thickness skin graft applied over it. Pu  in his series reported a flap survival rate of 100% with satisfactory outcome in all cases and a total complication rate of 0.14%. The distal reach of this muscle flap can be enhanced by dissecting and freeing the first perforator thereby increasing its arc of rotation. Although high failure rates have been reported for soleus muscle flaps in other studies (greater than 21%),, our analysis showed no flap failure in all 23 patients who had the distally based medial hemisoleus flap. Partial flap necrosis, the most common complication was seen in 13.1% of the cases with a relative risk of 1.8 and overall relative risk of complication being 0.3.
Since its description in 1979, the medial plantar sensory flap has continued to provide a durable and sensate cover for the heel. Kalam et al. in their work “Reconstruction of the heel: Options and strategies", reported that “of all the options for reconstructing the heel, the medial plantar island flap was the best one in terms of tissue type, texture, and function.” It is based on the medial plantar vessels and nerve, thus providing a sensate, nonhirsute fasciocutaneous flap with glabrous skin, identical in quality and function to the native tissue of the heel region. In our analysis, the medial plantar flap had a failure rate of 3.3%, with the relative risks for total necrosis, partial necrosis, and overall complication being 1.1, 2.5, and 1.0, respectively.
Skin grafts are sometimes employed in the reconstruction of soft tissue defects in the distal third of the leg and around the ankle joint when the defects are partial thickness leaving a well-vascularized bed after wound debridement or following the application of muscle flaps. For this purpose, split-thickness skin grafts are more frequently used than full-thickness skin grafts as the requirements for survival are less stringent in the former than in the latter. The success rate is high and the hospital stay is comparably shorter but the durability of the reconstruction limits its use, particularly around the ankle joint and the heel. From our analysis, we found 100% success rate with skin graft use, with relative risks for partial loss and overall complication being 0.2 each.
| Conclusion|| |
All the methods of reconstruction analyzed in this study tend to provide good reconstructive option for defects in this region of the body. The perforator-based flaps, however, had the least relative risk of overall complications and should be preferentially considered whenever feasible. Although free flaps had the highest failure rates, their overall complication rate and relative risks were comparable with that of other flaps and should be considered without hesitation when there are obvious indications. Overall, reconstruction of soft tissue defects in this region should be individualized to each patient and the injury profile.
The search was limited to HINARI and PUBMED databases and we excluded studies that were reported in languages other than English. As a result, a sizable number of publications were excluded. We also found a wide variation in the methods of reporting the outcomes of reconstruction employed by different authors. It was, therefore, difficult to standardize the categorization of complications. We overcame some of these limitations by adapting well-known reporting styles. There was insufficient data to evaluate the effects of comorbidity and timing of surgery on the outcome of the various reconstructive options. Most of the studies included in our analysis were retrospective and descriptive in nature.
There is a need to standardize the language of reporting of flap outcomes and complications to facilitate easy comparison and discussion across the legion of flaps available. We suggest a simple system such as the one we utilized. We also recommend large prospective multicenter randomized studies to better evaluate the methods of reconstruction of soft tissue defects in this region of the body.
We thank Professor O.M. Oluwatosin, Dr. O.A. Olawoye, Dr. A.O. Iyun, and Dr. A.I. Michael for technical advice. The assistance of Mrs. A. Ehifun in providing statistical analysis was invaluable.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ifesanya AO, Omololu AB, Ogunlade SO, Alonge TO. The burden of open fractures of the tibia in a developing economy. Niger J Plast Surg 2010;6:32-9.
Francel TJ. Improving reemployment rate after limb salvage of acute severe tibial fracture by microvascular soft-tissue reconstruction. Plast Reconstr Surg 1994;93:1028-34.
Ebell MH, Siwek J, Weiss BD, Woolf SH, Susman J, Ewigman B, et al
. Strength of recommendation taxonomy (SORT): A patient-centered approach to grading evidence in the medical literature. Am Fam Physician 2004;69:548-56.
Griffin JR and Thornton JF. Lower extremity reconstruction. Selected Readings in Plastic Surgery 2003;9:1-44.
Hansen ST Jr. The type-IIIC tibial fracture. Salvage or amputation. J Bone Joint Surg Am 1987;69:799-800.
Johansen K, Daines M, Howey T, Helfet D, Hansen ST Jr. Objective criteria accurately predict amputation following lower extremity trauma. J Trauma 1990;30:568-73.
Bosse MJ, McCarthy ML, Jones AL, Webb LX, Sims SH, Sanders RW, et al
.; Lower Extremity Assessment Project (LEAP) Study Group. The insensate foot following severe lower extremity trauma: An indication for amputation? J Bone Joint Surg Am 2005;87:2601-8.
Saddawi-Konefka D, Kim HM, Chung KC. A systematic review of outcomes and complications of reconstruction and amputation for type IIIB and IIIC fractures of the tibia. Plast Reconstr Surg 2008;122:1796-805.
Dhamangaonkar AC, Patankar HS. Reverse sural fasciocutaneous flap with a cutaneous pedicle to cover distal lower limb soft tissue defects: Experience with 109 clinical cases. J Orthop Traumatol 2014;15:225-9.
Follmar KE, Baccarani A, Baumeister SP, Levin LS, Erdmann D. The distally based sural flap. Plast Reconstr Surg 2007;119:138-48e.
Olawoye OA, Ademola SA, Iyun K, Michael A, Oluwatosin OM. The reverse sural artery flap for the reconstruction of distal third of the leg and foot. Int Wound J 2014;11:210-4.
Pinsolle V, Reau AF, Pelissier P, Martin D, Baudet J. Soft-tissue reconstruction of the distal lower leg: Are free flaps the only choice? Review of 215 cases. J Plast Reconstr Aesthet Surg 2006;59:912-8.
Guzman-Stein G, Fix RJ, Vasconez LO. Muscle flap coverage for the lower extremity. Clin Plast Surg 1991;18:545-52.
Demir A, Kucuker I, Keles MK, Demirtas Y. The effect of learning curve on flap selection, re-exploration, and salvage rates in free flaps; A retrospective analysis of 155 cases. Microsurgery 2013;33:519-26.
Suominen S, Asko-Seljavaara S. Free flap failures. Microsurgery 1995;16:396-9.
Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986;78:285-92.
Khouri RK, Shaw WW. Reconstruction of the lower extremity with microvascular free flaps: A 10-year experience with 304 cases. J Trauma 1989;29:1086-94.
Small JO, Mollan RA. Management of the soft tissues in open tibial fractures. Br J Plast Surg 1992;45:571-7.
Byrd HS, Spicer TE, Cierney G 3rd
. Management of open tibial fractures. Plast Reconstr Surg 1985;76:719-30.
Francel TJ, Vander Kolk CA, Hoopes JE, Manson PN, Yaremchuk MJ. Microvascular soft-tissue transplantation for reconstruction of acute open tibial fractures: Timing of coverage and long-term functional results. Plast Reconstr Surg 1992;89:478-89.
Manjunath P, Ranganth VS, Ramesh KT, Shakarappa M. Propeller flaps for lower leg reconstruction: Results of a tertiary care centre. Int J Pharm Med Biol Sci 2014;3:10-16.
Parett BM, Talbot SG, Pribaz JJ, Lee BT. A review of local and regional flaps for distal leg reconstruction. J Reconstr Microsurg 2009;25:445-55.
Lecours C, Saint-Cyr M, Wong C, Bernier C, Mailhot E, Tardif M, et al
. Freestyle pedicle perforator flaps: Clinical results and vascular anatomy. Plast Reconstr Surg 2010;126:1589-603.
Lee BT, Lin SJ, Bar-Meir ED, Borud LJ, Upton J. Pedicled perforator flaps: A new principle in reconstructive surgery. Plast Reconstr Surg 2010;125:201-8.
Kalam MA, Faruquee SR, Rahman SA, Uddin HN. Reconstruction of the heel: Options and strategies. Bangladesh J Plast Surg 2010;1:14-8.
Pu LL. Further experience with the medial Hemisoleus muscle flap for soft-tissue coverage of a tibial wound in the distal third of the leg. Plast Reconstr Surg 2008;121:2024-8.
Magee WP Jr, Gilbert DA, McInnis WD. Extended muscle and musculocutaneous flaps. Clin Plast Surg 1980;7:57-70.
McCraw JB. Selection of alternative flap in the leg and foot. Clin Plast Surg 1979;6:227-46.
[Table 1], [Table 2], [Table 3]