Advancement Flap for Recalcitrant Posterior Leg Ulceration Nisha Shah DPM1, Jessica L. Olson DPM2, and Randall C. Thomas Jr. DPM, AACFAS3 1: Resident, PGY-I, Grant Medical Center, Columbus, OH 2: Resident, PGY-II, Grant Medical Center, Columbus, OH 3: Attending, Assistant Director Grant Medical Center Foot & Ankle Surgery Residency, Columbus, OH STATEMENT OF PURPOSE CASE STUDY To present a case study of a patient with surgical correction of a recalcitrant posterior leg ulceration. Posterior ulcerations of the leg are complicated due to the location and neurovascular anatomy. Many methods of reconstruction have been described such as free flaps, skin grafts, and advancement flaps in this area of interest. This case study depicts a surgical technique of an advancement flap in treating a recalcitrant posterior leg ulcer CASE STUDY INTRAOPERATIVE TECHNIQUE RESULTS 70 year old male with a history of Atrial fibrillation, Hypertension, Tobacco Abuse (smoker), and Obesity suffered a slip and fall injury in the winter of 2014 and fell on the curb causing a posterior middle 1/3rd of the lower leg wound. He presented to an outside hospital and was referred to an outside wound care provider. After six months of no improvement in his traumatic wound he was referred to Dr. Thomas at the Grant Medical Center Wound Care Center. He underwent biopsy of the wound and cultures which were benign and no growth respectively. Non invasive vascular studies including arterial duplex and ABIs were performed and within normal limits. Nutrition markers were reviewed and optimized. X-rays and advanced imaging were reviewed with no signs of complication. He underwent three months of local wound care with serial debridements and collagen based products and off loading. Smoking cessation was performed. Compression was utilized for edema control. Minimal improvement in the depth of the wound was achieved. He was not approved for skin substitutes or advanced products. The wound remained recalcitrant and the patient decided he wanted to undergo surgical intervention given nine months of non healing. Patient followed up weekly post op and at three weeks underwent suture removal. At that time was allowed to weight bear in a CAM boot. After another month he transitioned to normal shoe gear and did not require physical therapy. He was last seen for a one year follow up and had no signs of complication, no pain, and returned to ADL without any restrictions. Wound at level of aponeurosis of the Achilles and calf complex junction Full-thickness excisional biopsy of excessive hypergranular tissue at lateral aspect of wound Planned excision of wound measuring 2.5 x 3.5 x 0.7cm depth allowing for 7 mm clearance margins used as a skin island Advancement flap closure at site with planned two arms measuring 7.5cm in length proximally from the borders Flap harvested and raised, care taken to avoid injury to neurovascular structures Flap advanced distally to cover wound defect, secured with vicryl and nylon Capillary refill time immediate, no dusky appearance or concern for dysvascular nature LITERATURE REVIEW Angiosomes were first described by Taylor and Palmer in 1987 in which they defined three-dimensional vascular territories supplied by source arteries and veins to each tissue layer between the skin and bone.6 The leg has arterial supply from the popliteal, posterior tibial, anterior tibial, and peroneal arteries. Most tissues are crossed by two angiosomes and have anastomotic vessels within the tissues. This is an important concept for flaps as anastomotic pathways revascularize tissues when a source artery is sacrificed.4   Several methods of reconstruction have been described in the literature such as free flaps, skin grafts, and advancement flaps. With better understanding of the vascular anatomy and angiosomes, advancement flaps have become a method of choice for moderate-sized defects in the distal leg for numerous reasons. First, advancement flaps have similar pigmentation, pliability, texture, and thickness to the defect which potentially provides a better contour.2 Furthermore, a patient with a long-standing ulceration most likely has co-morbidities preventing healing. This procedure is simple and reliable. It has low complication rates and is quicker which helps avoid long operative times under anesthesia.3 Lastly, in the event the advancement flap fails, one is still left with the option for a more extensive and expensive free flap or skin graft. The technique for the advancement flap should be well designed. Cutaneous nerves supplying the skin can be identified to a degree to preserve some sensation to the operative site.1 In addition, planning the flap around predetermined and predictable perforator vessels allows for greater viability and movement. Flaps are dissected under tourniquet control and sutured with minimum deep sutures to prevent ischemia to the undersurface of the flap.7 Meticulous dissection and hemostasis is critical for survival of the flap. The main goal for any soft tissue coverage is to restore form and as much function as possible. With a recalcitrant ulcer of the posterior leg, coverage must be adequate enough to withstand the forces of gait. Advancement flaps allow for primary repair without tension by use of neighboring tissue that are known to resist these forces.4 With the proper planning and technique, the literature supports that this is a safe and reliable method of choice for treatment for reconstruction of soft tissue defects.5 PREOPERATIVE Surgical Plan Wound irrigation and debridement, Preparation of site Wound biopsy Right posterior leg advancement flap closure Position: prone Anesthesia: General with peripheral nerve block Site Preparation: pre-scrub with chlorhexidine brush, standard sterile betadine prep to knee D E Figure D: intraoperative clinical image of mobilized advancement flap Figure E: intraoperative clinical image of successful advancement flap with primary closure DISCUSSION This case study describes successful surgical management of a recalcitrant posterior leg ulceration utilizing an advancement flap. The review of the literature presented several methods of treatment. With primary focus on advancement flaps and angiosomes, a successful surgical treatment plan was formulated. This case study provides an example of a surgical option for the management of recalcitrant posterior leg ulcerations. B C Figure B: intraoperative clinical image of planned advancement technique Figure C: intraoperative clinical image of dissected advancement flap REFERENCES A Niranjan, N. S., R. D. Price, and P. Govilkar. "Fascial Feeder and Perforator-based V-Y Advancement Flaps in the Reconstruction of Lower Limb Defects." British Journal of Plastic Surgery 53 (2000): 679-89. Parrett, Brian M., Simon G. Talbot, Julian J. Pribaz, and Bernard T. Lee. "A Review of Local and Regional Flaps for Distal Leg Reconstruction." Journal of Reconstructive Microsurgery 25.7 (2009): 445-55. Pennington, A. J., and P. Mallucci. "Closure of Elective Skin Defects in the Leg with a Fasciocutaneous V-Y Flap." British Journal of Plastic Surgery52 (1999): 458-61. Roukis, Thomas, Monica Schweinberger, and Valerie Schade. "V-Y Fasciocutaneous Advancement Flap Coverage of Soft Tissue Defects of the Foot in the Patient at High Risk." The Journal of Foot and Ankle Surgery 49 (2010): 71-74.  Shishehbor MH. Clev Clin J Med. 2014;81:209-216. Taylor, G. Ian, and Wei Ren Pan. "Angiosomes of the Leg: Anatomic Study and Clinical Implications." Plastic and Reconstructive Surgery 102.3 (1998): 599-616.  Zgonis, Thomas, John Stapleton, and Thomas Roukis. "Advanced Plastic Surgery Techniques for Soft Tissue Coverage of the Diabetic Foot." Clinics in Podiatric Medicine and Surgery 24 (2007): 547-68. POSTOPERATIVE Figure A: Preoperative clinical image of wound defect at Achilles calf complex junction Posterior splint with slight plantarflexion to right lower leg for off loading. Strict non-weight bearing to leg for 3 weeks with assistive device for flap to heal and completely take.