It has been said that it is the secret dream of any surgeon to leave this world with his or her name attached to at least one instrument. This is what makes craniofacial surgery real fun as Paul Tessier had his name attached to almost all instruments on an average craniofacial surgery instrument tray. So whenever the surgeon grumbles “Now just give me the Tessier” he is sure to get some instrument in his hand …
So I have almost given up the idea of immortality by instruments. However, I’d rather be associated with a procedure. And I have come one step closer. In April’s issue of the Annals of Plastic Surgery our article Ruan HJ, Cai PH, Schleich AR et al. “The Extended Peroneal Artery Perforator Flap for Lower Extremity Reconstruction” Ann. Plast. Surg. 64(4):451, 2010″ was published bringing me one crucial step closer to this objective.
As stated “The peroneal artery perforator flap and its modifications have been widely used for coverage of soft tissue defects of ankle and foot in the past decade. In this article, we report on a series of upper knee, ankle, and foot reconstructions with a proximally or distally based extended peroneal artery perforator (EPAP) flap supplied by distinct perforating branches off the proximal or distal peroneal artery. Total pedicle length obtained ranged from 6 to 12 cm. Twelve patients with soft tissue defects of the lower extremity underwent reconstruction using the EPAP flap. The flaps were designed with the sizes from 10 × 6 cm to 25 × 15 cm. All 12 flaps survived completely without complications. Our experience demonstrates that the EPAP flap is reliable and versatile and can provide a large amount of soft tissue for coverage of defects in the leg anywhere from knee to forefoot obviating the need for free tissue transplantation.”
Theoretically this should be the article to end most of the microsurgery necessary for lower extremity reconstruction substituting a 3.5 hour predictable procedure for an often more than six hour undertaking fraught with sometimes considerable uncertainty. This would imply that some limbs can be salvaged without having to maintain the costly and difficult to acquire microsurgical expertise necessary to do free tissue transplantations.
While the capability to predictably perform free microsurgical tissue transplantation and replantation of amputated parts is still the true Olymp of plastic surgery in my mind and represents a relatively merciless skills test for the surgeon it also implies that certain types of reconstructions could only be performed at highly specialized centers by surgeons dedicating a considerable part of their practice to the upkeep of their rare expertise.
A less involved alternative as we demonstrated in the above article with a higher success rate than microsurgical free tissue transplantation, which has its highest failure rate in the lower extremity even in the hands of Asian microsurgeons (the best of the best in my humble opinion based on having actually trained with them), may be an avenue to improved access to limb salvage procedures.
My main critique of the EPAP procedure is the appearance of the extremity after having to close the donor site in the leg with a skin graft. I contend that a superior appearance is actually possible with microsurgical free tissue transfer techniques and some examples are given in the member’s section of Trinidad Institute of Plastic Surgery website. Also, the patient population in this article were all young and relatively healthy having suffered open fractures and other soft tissue injuries to the leg and/or foot. This is markedly different to what I see in my US practice – generally people with chronic wounds and considerable vascular disease in the lower extremity. Short of amputations a free tissue transfer in those circumstances may be still more promising than using a solution like the EPAP which relies on a well circulation in relatively small vessels.
The future will tell if the EPAP was designed for the “gallery” as just another gimmick or it has the potential we think – the “next Chinese flap” delivering for lower extremity reconstruction as did the radial forearm flap (widely known as the “Chinese flap”) in the upper extremity.