Journal of Plastic, Reconstructive & Aesthetic Surgery
MRI anatomical preoperative evaluation of distally based peroneus brevis muscle flap in reconstructive surgery of the lower limb☆
Introduction
Soft tissue defect reconstruction of the lower limb is very challenging for the plastic surgeon, and a great number of solutions have been proposed.1 Appropriate reconstruction can be accomplished performing either local flaps or free flaps, and the choice of the most appropriate technique remains a crucial point.2, 3 Fasciocutaneous and muscle local flaps are associated with a high rate of complications, donor site morbidity, and the amount of suitable tissue is often insufficient and poorly reliable with a limited distal arch of rotation.3, 4 Thus, free flaps transfer is often the treatment of choice.8 However, free tissue transfer requires microvascular expertise and strict patient selection, and it is time-consuming, with high donor site morbidity.5, 6 Thus, there is a constant search for new safe local flaps.
One valuable reconstructive option is the distally based peroneus brevis muscle flap. First described by Mathes and Nahai7 as a type II muscle flap in 1997, it was reclassified by Taylor and Pan5 as a type IV and successively studied on cadavers by Yang et al.,8 it was used in clinical practice for the first time by Eren et al.9 Surgical preoperative planning is crucial for a successful reconstructive, and one of the most important limiting factor is the length of muscle belly suitable for distal rotation.
Magnetic resonance imaging (MRI), because of its accurate depiction of soft tissues anatomy and pathology without any exposure to ionizing radiations, has been extensively applied in the imaging of the lower extremities.10 Exploiting the natural contrast of MRI because of the different signal intensity of tissue components, it is easy to differentiate fat, muscle, bone marrow, cortical bone, and fascia. Therefore, MRI is considered the optimal technique for displaying the anatomy in the musculo-skeletal district.10, 11 In this study, we continue our previous work12 assessing the capability of preoperative 3D MRI of the leg to evaluate peroneus brevis muscle length in a group of 32 consecutive patients with soft and bony tissue defects of the distal third of the lower limb to help surgical planning and evidence-based patients selection.
Section snippets
Patients' selection and MRI technique
From January 2008 to March 2017, we performed 32 distally pedicled peroneus brevis muscle flaps in 32 consecutive patients (23 males and 9 females, age range: 22–83 years, μ = 50 ± 17.5). We selected patients with small- to moderate-sized defects located in the distal third of the leg, over the ankle and the Achilles tendon. The dimension of the defects varied between 3 and 9 cm in length and 2 and 7 cm in width associated with exposed bone, tendons, or metallic hardware. The patients were
MRI and surgical measurements
For all patients, we could measure the proximal distance and the peroneus brevis muscle belly length on MRI.
MRI measures of the muscle ranged from 9 to 21 cm (μ = 14.44 ± 3.43 cm). The proximal distance on MRI ranged from 6 to 15 cm (μ = 9 ± 2.5 cm).
During surgical reconstruction, we measured the muscle belly length before the elevation of the flap. Intraoperative measures of the peroneus brevis muscle belly ranged from 9 to 20 cm (μ = 14.2 ± 2.3 cm). The proximal surgical distance measures
Surgical considerations
Soft and bony tissue defects of the distal third of the leg are common and challenging clinical situations for a plastic surgeon.
Adipofascial flaps are a simple option for small- to moderate-sized defects of the distal leg.14 Unfortunately, elderly patients or patient with extensive peripheral vascular disease are not good candidates because of the high rate of complications.14
Neurofasciocutaneous flaps, such as the distally based sural flap,15, 16 first described by Masquelet et al.,15 are
Conflict of interest
We have no conflict of interest to declare. None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript.
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Cited by (5)
The esthetic outcome of lower limb reconstruction
2020, Annales de Chirurgie Plastique EsthetiqueCitation Excerpt :In order to reduce donor site morbidity, other local muscle flaps have been proposed as coverage for small-sized defects. Peroneus brevis [131,132], and the extensor digitorum brevis [133,134] are the most commonly used and seem to provide good esthetic results. Kneser et al. compared distally based peroneus brevis and sural flaps for reconstruction of foot, ankle, and distal lower leg.
Distally based peroneus brevis muscle flap: A single centre experience
2019, Chinese Journal of Traumatology - English EditionCitation Excerpt :Abd-Al Moktader21,22 described open book splitting of distally based peroneus brevis muscle flap to cover moderate to large size defects (up to 120 cm2 area. Barbera et al.23 recommend preoperative 3D MRI to assess the size of the peroneus brevis muscle before performing the procedure. Being a muscle flap, it helps in combating against osteomyelitis as reported by Antonini et al.24 The lower portion of the peroneus brevis muscle has been elevated along with the distally based sural artery flap as a distally based sural artery peroneus flap to increase the chances of flap survival.25
Re: MRI anatomical preoperative evaluation of distally based peroneus brevis muscle flap in reconstructive surgery of the lower limb
2018, Journal of Plastic, Reconstructive and Aesthetic SurgeryLimitations of Computed Tomography Angiography in Preoperative Planning of Peroneus Brevis Rotational Flap
2023, Plastic and Reconstructive Surgery - Global OpenOne-Step Approach for Infections After Achilles Tendon Open Repair: The Distally Based Peroneus Brevis Muscle Flap
2022, International Journal of Lower Extremity Wounds
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No financial support or benefits have been received by any author. We have not a relationship from any commercial source, which is related directly or indirectly to the scientific work. The principles outlined in the Declaration of Helsinki have been followed in this study.