Objective To report operative techniques and clinical results of free sural cutaneoadipofascial flap containing the neurovascular axis based on a dominant peroneal perforating artery (DPPA,with a caliber≥0.8 mm) and its concomitant veins for reconstruction of dorsal forefoot soft tissue defects.Methods The flap was applied in 32 cases with middle to large soft tissue defects in the dorsal forefoot from Aug.2009 to Dec.2014.DPPAs arising from the posterolateral intermuscular septum was located and assessed preoperatively with color Doppler flow image and computed tomography angiography.According to the location,size,and shape of the defects,one of these DPPAs was chosen for flap planning.The flap was harvested from the posterolateral aspect of the leg.The neighboring neurovascular axis (one or more of that of the sural nerve,the medial cutaneous nerve,the lateral cutaneous nerve of calf and the sural communicating nerve) was included to ensure vascular supply.According to skin laxity of the donor site,the width of the full harvesting part which should be able to cover the region of the recipient site where pressure and friction force were prominent while wearing shores was decided;the rest was harvested as an adipofascial flap (without skin) to get enough size.After transfer to recipient site,the flap was revascularized by anastomosing the perforating artery and its venae comitantes with appropriate recipient vessels,and reinnervated (antegrade or retrograded methods).Skin grafting was performed on the adipofascial surface of the flap primarily or secondarily.The defects in donor site of the leg was closed directly.Results All flaps (ranged from 7.5 cm × 5.0 cm to 23.0 cm × 13.0 cm) were transplanted successfully,and no vascular or donor site problems occurred.All primary skin grafts (19 cases) was partially lost,but only 2 of them need a second grafting.Adipose necrosis occurred in 4 of 13 cases receiving secondary grafting but only needed wound care before surgery.Following up for 11-26 months showed both satisfactory functional and cosmetic results without problems of shoe wearing.Flap sensibility restored at least to the degree of S3.Conclusions The cutaneoadipofascial flap combines the advantages of perforator,neurocutaneous axis,free and adipofascial flaps leaving only suture scar in the donor leg,and is a satisfactory method for free-style and acute coverage of dorsal forefoot defects.%目的 探讨应用游离腓动脉穿支小腿后外侧皮神经营养血管筋膜皮瓣,修复足背远端皮肤软组织缺损的手术方法和临床效果.方法 术前应用彩色多普勒血流成像仪及CT血管造影定位双小腿腓动脉穿支,根据创面位置、面积及形状选择1条穿深筋膜点口径≥0.8 mm者为供血血管.筋膜皮瓣中纳入邻近的皮神经及其营养血管链.按皮肤松弛程度确定全厚切取部分的宽度,令其可覆盖穿鞋摩擦部位,其余部分仅切取深筋膜和皮下组织.切取筋膜皮瓣移植到受区后,吻合穿支动、静脉建立皮瓣循环,吻合皮神经建立感觉,皮下筋膜表面一期或二期植皮,供区直接拉拢缝合.筋膜皮瓣切取面积7.5 cm×5.0 cm ～23.0 cm×13.0 cm.结果 2009年8月至2014年12月临床应用32例,全层切取部分均成活,术后未观察到缺血或淤血,供区仅遗留线状瘢痕.19例一期植皮者发生不同程度皮片坏死,除2例再次植皮外,其余经换药后均愈合;13例二期植皮者中9例成活良好,4例发生筋膜瓣表面脂肪组织局限性表浅坏死,清创后打包加压植皮成活.经随访11 ～26个月,修复外形无臃肿,植皮区与原有皮肤厚度基本一致,皮下滑动性良好,可正常穿鞋行走;感觉功能均达到S3级以上.结论 该筋膜皮瓣结合了穿支皮瓣、皮神经营养血管皮瓣、游离皮瓣及筋膜瓣各自优点,供区遗留瘢痕少,可自由、准确修复累及足背远端的创面.
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