الفهرس 
AnatomyOnly 14 pages are availabe for public view
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Abstract
Summary
Since flap failure creates a larger defect in an already difficult reconstructive area, it is critically important to minimize the risk of flap failure by optimizing operative techniques.
Both the Free flap and the Perforator Propeller flap are complex microsurgical techniques that need expertise, facilities, and close-monitoring follow up. They have overall similar failure results, with the Perforator Propeller flap having the advantage of not requiring microvascular anastomosis and having a shorter operating time.
Despite the high success rate of the Free flaps, complications, when occurred, cause significant patient morbidity and expense to the healthcare system. Perforator-Plus Flaps, on the other hand, appear to be an excellent first-choice option for treating lower-limb wounds, while Free flaps are reserved for secondary procedures if Perforator-Plus Flaps fail.
In this study, we combined concepts of the Free-Style Flap concept with the Perforator-Plus flap’s Intact skin/adipofascial bridge to achieve complex defect reconstruction in difficult regions (Lower two-thirds leg, Achilles tendon and Ankle).
Free-style(15-16) is per se, not a flap, but it is an approach with certain guidelines, aiming to overcome the anatomical variation of perforators and random nature of defects-occurring. The Free-style approach provides design flexibility and can be used with any flap, local or distant, according to the available matching donor-site, either island or with an intact base. However, if it needed pedicle dissection, it would become a complex procedure with the risk of pedicle injury. Furthermore, the identification of a suitable perforator is also a problem. Finally, the dynamic nature of perforasomes makes predicting flap viability impossible with ordinary measures. As a result, another backup plane-B should always be available.
The Full-thickness skin/adipofascial bridge of the Perforator-Plus flap made the procedure easier, quicker, and safer. This bridge protects the pedicle from damage by eliminating the need for further perforator dissection. It also protects the pedicle from twisting, or compression, providing safe handling of the flap during its transfer. And more importantly, the bridge serves as a backup drainage route in the event that the venae comitantes were injured, insufficient, or absent, with potential random arterial supply through the subdermal and subcutaneous plexi.
In view of the coverage failure, the most critical factor in determining the flap successful surgery, we successfully achieved the mission (defect coverage) in 100% of cases using Free-Style, Perforator-Plus concepts. In view of the ideal reconstruction flap in the lower limb we were able to replace like with like tissue, minimize the morbidity of the donor- site, preserve the main vascular axis, and reduce operating and hospitalization time, without the need for microvascular anastomosis.
“As specialization increases and the advance of knowledge further outstrips the capacity of the mind to keep pace with it, the threads of science gradually become tangled and disconnected” (G. Ian Taylor, 1994). The concept of raising long flaps in the leg is undoubtedly not new. We just tried to collect the tangled and disconnected threads of the available science, refocus on and re-crystallize the anatomical and physiologic facts that have led to the evolution of “Free-Style, Perforator-Plus” flaps.
Conclusion:
The Free-Style, Perforator-Plus Flap is versatile, reliable with relative efficiency, and has a modest rate of failure and need for secondary surgery. Capable to reconstruct small to relatively large, complex defects (exposed bone or hardware and chronic osteomyelitis) in the distal Leg two-thirds, Tendo-Achilles, and Ankle regions. The Flap has a higher degree arc of rotation, replaces like with like, with less donor-site morbidity, and satisfying aesthetic appearance. The procedure, on the other hand, is relatively easy with minimal need for perforator dissection, and no need for microvascular anastomosis or special facilities. Besides, the smooth post-operative follow-up, the less need for general anaesthesia, and the relatively short operation and hospital stay make the procedure being cost-effective.