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13 months in a tertiary care unit. The purpose of this Case 1
study was to present a management protocol for various A 34-year-old male with a crush injury to the right heel
types of soft tissue defects of the distal third of the leg pad and ankle region was referred to our center 3 weeks
and foot with pedicle flaps, by including HBO therapy in following injury. The patient presented with necrosis of the
the treatment regimen with the flap delay. The study was heel pad with multiple lacerations over the ankle on both
approved by the review board of Jubilee Mission Medical the medial and lateral aspects [Figure 1a-c]. The wound
College and Research Institute. was debrided, and HBO therapy sessions were started.
METHODS On postdebridement day 2, an extended reverse sural
flap was elevated with flap delay [Figure 1d], continuing
A total of 23 patients with soft tissue defects of lower the hyperbaric sessions. On postdebridement day 4, flap
third of the leg and foot were treated over a period of inset was completed [Figure 1e]. The donor area was
13 months (December 2012 to December 2013). On the covered with a split-thickness skin graft. HBO therapy
basis of the defects, lateral supramalleolar, reverse sural was administered for an additional 12 sessions. The
and distally-based posterior tibial artery perforator plus postoperative period was uneventful [Figure 1f and g].
flaps were utilized for soft tissue coverage. Of 23 patients,
12 patients were managed by flap delay with HBO therapy Case 2
as an adjunct, and 11 patients were managed by direct A 68-year-old male developed an ulceration on the lateral
flap transfer without HBO therapy. Outcomes following malleolus with exposure of the ankle joint [Figure 2a]. HBO
the different types of management and secondary therapy sessions were started. The wound was debrided,
procedures performed were noted. All involved patients and lateral supramalleolar flap coverage was planned
gave their consent forms. [Figure 2b]. The lateral supramalleolar flap was elevated,
RESULTS and flap delay was performed, with continuation of the
hyperbaric sessions [Figure 2c]. On postdebridement
The mechanism of injury for 20 patients was a road day 4, flap inset was completed, and the donor area was
traffic accident, 1 patient presented with an open wound covered with a split-thickness skin graft [Figure 2d]. HBO
secondary to a diabetic ulcer, 1 defect was due to therapy was administered for 12 additional sessions. The
osteomyelitis and 1 was due to a snake bite injury. Of postoperative period was uneventful [Figure 2e].
23 patients, there were 6 females (26.1%) and 17 males
patients (73.9%). The mean age was 42 years (range: Case 3
13-68 years). A 21-year-old male sustained injury to the lower third of
the right leg with soft tissue loss and exposure of the tibial
In 12 patients, the flap delay was performed, and HBO bone [Figure 3a]. Following debridement, a distally-based
therapy was used as an adjunct. Of these 12 patients, posterior tibial artery perforator plus flap was planned.
2 patients had sustained the defect due to an infectious A distally-based posterior tibial artery perforator plus
source, and 10 cases occurred secondary to a road flap was elevated, and flap delay was performed with
traffic accident. Among these 12 patients, 5 patients had continuation of the hyperbaric sessions [Figure 3b and c].
diabetes mellitus, and 1 patient had soft tissue loss due On postdebridement day 4, flap inset was completed,
to a snake bite injury. Two patients were scheduled for and the donor area was covered with a split-thickness
extended sural artery flap, and 1 patient had varicose skin graft [Figure 3d]. HBO therapy was administered for
veins as a comorbid condition. Five flaps were lateral an additional 6 sessions. The postoperative period was
supramalleolar flaps, 1 was a distally-based posterior uneventful [Figure 3e].
tibial artery perforator flap, and 6 were reverse sural
artery flaps. Among the 6 reverse sural flaps, 2 were Case 4
extended reverse sural flaps. The severity of injury, time A 39-year-old male sustained injury to the right foot
of referral, comorbid conditions, age of the patients, and secondary to a road traffic accident and presented with soft
the extent of the flap were considered to be qualifying tissue loss over the medial malleolar and calcaneal regions
conditions for flap delay with associated HBO therapy. [Figure 4a]. The wound was debrided, and a reverse sural
One patient developed a recurrent abscess at the ankle artery flap was performed [Figure 4b and c]. The patient
joint, which required incision and drainage, and 1 patient developed flap tip necrosis and required a skin graft for
had discoloration of the flap tip which resolved without coverage [Figure 4d].
intervention.
For 11 patients, direct transfer of the flap was performed. DISCUSSION
Of these 11 patients, 1 child had suffered soft tissue loss
secondary to osteomyelitis, and the rest of the defects Soft tissue defects of the lower third of the leg and foot
were due to road traffic accidents. Four flaps were lateral may be covered with skin grafts, local flaps, distally or
supramalleolar flaps and 7 were reverse sural artery flaps. proximally-based island flaps, and distant tissue transfer or
Six patients developed postoperative complications. Five cross leg flaps. In 1983, distally-based fasciocutaneous flaps
patients suffered tip necrosis, which required debridement were introduced, providing flaps with a reliable vascular
and skin grafting, and 1 patient sustained partial loss of supply regardless of their length to width ratio. The
a reverse sural flap, which subsequently required skin reverse sural artery flap, lateral supramalleolar flap, and
grafting [Tables 1-3]. inferiorly-based medial and lateral fasciocutaneous flaps

Plast Aesthet Res || Vol 2 || Issue 3 || May 15, 2015 131