Bone and soft tissue sarcomas, tumors of the skinBone and soft tissue sarcomas, tumors of the skinСаркомы костей, мягких тканей и опухоли кожи2219-46142782-3687Publishing House ABV Press377SOFT TISSUE SARCOMASСАРКОМЫ МЯГКИХ ТКАНЕЙPropeller perforator flaps in distal lower leg: evolution and clinical applicationsПерфорантные лоскуты в хирургическом лечении злокачественных опухолей кожи и мягких тканей голени и стопыAzimovaR. B.АзимоваР. Б.
Russian Federation

Moscow

г.Москва

ranoazimova78@gmail.comSobolevskyV. A.СоболевскийВ. А.
Russian Federation

Moscow

г.Москва

N.N. Blokhin Russian Cancer Research Center Ministry of Health of the Russian FederationФГБУ «РОНЦ им. Н.Н. Блохина» Минздрава России220420168254602201202222012022Copyright ©; 2016, Azimova R.B., Sobolevsky V.A.Copyright ©; 2016, Азимова Р.Б., Соболевский В.А.2016Azimova R.B., Sobolevsky V.A.Азимова Р.Б., Соболевский В.А.https://creativecommons.org/licenses/by/4.0https://sarbon.abvpress.ru/jour/article/view/377

Simple or complex defects in the lower leg, and especially in its distal third, continue to be a challenging task for reconstructive surgeons. A variety of flaps were used in the attempt to achieve excellence in form and function. After a long evolution of the reconstructive methods, including random pattern flaps, axial pattern flaps, musculocutaneous flaps and fasciocutaneous flaps, the reappraisal of the works of Manchot and Salmon by Taylor and Palmer opened the era of perforator flaps. This era began in 1989, when Koshima and Soeda, and separately Kroll and Rosenfield described the first applications of such flaps. Perforator flaps, whether free or pedicled, gained a high popularity due to their main advantages: decreasing donor-site morbidity and improving functional and aesthetic outcome. The use as local perforator flaps in lower leg was possible due to a better understanding of the cutaneous circulation, leg vascular anatomy, angiosome and perforasome concepts, as well as innovations in flaps design. Somebody introduced a new expression «like-by-like». This review will describe the evolution, anatomy, flap design, and technique of the main distally pedicled propeller perforator flaps used in the reconstruction of defects in the distal third of the lower leg and foot and our experience.

Замещение обширных дефектов нижней трети голени и стопы после удаления злокачественных опухолей по-прежнему представляет сложную проблему для реконструктивных хирургов. После долгой эволюции реконструктивных методик, начинавшихся с лоскутов со случайным кровоснабжением, кросс-пластики, использования филатовского стебля, появившихся позже кожно-мышечных и кожно-фасциальных методов, произошла переоценка работ Manchot и Salmon (1983) благодаря Teilor и Palmer (1987), которые открыли эру перфорантных лоскутов. Это направление было популяризировано Koshima и Soeda в 1989 г., а также Kroll и Rosenfeld в 1988 г., которые отдельно описали применение таких лоскутов. Перфорантные лоскуты – основанные на принципе строения ангиосом, свободные и на ножке, стали очень популярны благодаря таким преимуществам, как возможность выделения лоскута нужного размера в продолжение реципиентной зоны и соответственно эстетически малозначимой, относительной простоте данной техники в сравнении с пересадкой микрохирургических лоскутов. Появился термин «замена подобного подобным» – «like-by-like». Использование в качестве ножки перфорантного сосуда стало возможно благодаря лучшему пониманию принципов кровоснабжения кожи, сосудистой анатомии нижних конечностей – концепции ангиосом и перфоросом и нововведений в дизайне лоскутов. В данной статье описывается история развития перфорантных лоскутов, техника выделения основных перфорантных лоскутов, используемых для замещения дефектов дистальной трети голени и стопы, собственный опыт.

soft tissue sarcomalegperforator flapsсаркома мягких тканейголеньстопаперфорантные лоскуты1. Almeida M.F., da Costa P.R., Okawa R.Y. Reverse-flow island sural flap. Plast. Reconstr. Surg. 2002, v. 109, p. 583-591.Almeida M.F., da Costa P.R., Okawa R.Y. Reverse-flow island sural flap. Plast. Reconstr. Surg. 2002, v. 109, p. 583-591.2. McGregor I.A., Jackson I.T. The groin flap. Br. J. Plast. Surg. 1972, v. 25, p. 3-16.McGregor I.A., Jackson I.T. The groin flap. Br. J. Plast. Surg. 1972, v. 25, p. 3-16.3. Ger R. The operative treatment of the advanced stasis ulcer. A preliminary communication. Am. J. Surg. 1966, v. 111, p. 659-663.Ger R. The operative treatment of the advanced stasis ulcer. A preliminary communication. Am. J. Surg. 1966, v. 111, p. 659-663.4. Orticochea M. The musculo-cutaneous flap method: an immediate and heroic substitute for the method of delay. Br. J. Plast. Surg. 1972, v. 25, p. 106-110.Orticochea M. The musculo-cutaneous flap method: an immediate and heroic substitute for the method of delay. Br. J. Plast. Surg. 1972, v. 25, p. 106-110.5. Ger R. The technique of muscle transposition in the operative treatment of traumatic and ulcerative lesions of the leg. J. Trauma. 1971, v. 11, p. 502-510.Ger R. The technique of muscle transposition in the operative treatment of traumatic and ulcerative lesions of the leg. J. Trauma. 1971, v. 11, p. 502-510.6. Quaba O., Quaba A.A. Pedicled perforator flaps for the lower limb. Semin. Plast. Surg. 2006, v. 20, p. 103-111.Quaba O., Quaba A.A. Pedicled perforator flaps for the lower limb. Semin. Plast. Surg. 2006, v. 20, p. 103-111.7. Jakubietz R.G., Jakubietz M.G., Gruenert J.G. et al. The 180-degree perforator-based propeller flap for soft tissue coverage of the distal, lower extremity: a new method to achieve reliable coverage of the distal lower extremity with a local, fasciocutaneous perforator flap. Ann. Plast. Surg. 2007, v. 59, p. 667-671.Jakubietz R.G., Jakubietz M.G., Gruenert J.G. et al. The 180-degree perforator-based propeller flap for soft tissue coverage of the distal, lower extremity: a new method to achieve reliable coverage of the distal lower extremity with a local, fasciocutaneous perforator flap. Ann. Plast. Surg. 2007, v. 59, p. 667-671.8. Ponten B. The fasciocutaneous flap: its use in soft tissue defects of the lower leg. Br. J. Plast. Surg. 1981, v. 34, p. 215-220.Ponten B. The fasciocutaneous flap: its use in soft tissue defects of the lower leg. Br. J. Plast. Surg. 1981, v. 34, p. 215-220.9. Manchot C. The cutaneous arteries of the human body. New York: Springer-Verlag. 1983.Manchot C. The cutaneous arteries of the human body. New York: Springer-Verlag. 1983.10. Salmon M., Taylor G.I., Tempest M. Arteries of the skin. London: Churchill Livingstone. 1988.Salmon M., Taylor G.I., Tempest M. Arteries of the skin. London: Churchill Livingstone. 1988.11. Taylor G.I., Palmer J.H. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br. J. Plast. Surg. 1987, v. 40, p. 113-141.Taylor G.I., Palmer J.H. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br. J. Plast. Surg. 1987, v. 40, p. 113-141.12. Koshima I., Soeda S. Inferior epigastric artery skin flaps without rectus abdominis muscle. Br. J. Plast. Surg. 1989, v. 42, p. 645-648.Koshima I., Soeda S. Inferior epigastric artery skin flaps without rectus abdominis muscle. Br. J. Plast. Surg. 1989, v. 42, p. 645-648.13. Kroll S.S., Rosenfield L. Perforator-based flaps for low posterior midline defects. Plast. Reconstr. Surg. 1988, v. 81, p. 561-566.Kroll S.S., Rosenfield L. Perforator-based flaps for low posterior midline defects. Plast. Reconstr. Surg. 1988, v. 81, p. 561-566.14. Geddes C.R., Tang M., Yang D. et al. Anatomy of the integument of the lower extremity. In: Blondeel P.N., Morris S.F., Hallock G.G. et al., editors. Perforator flaps: anatomy, technique & clinical applications. St. Louis: Quality Medical Publishing, Inc. 2006, p. 541-578.Geddes C.R., Tang M., Yang D. et al. Anatomy of the integument of the lower extremity. In: Blondeel P.N., Morris S.F., Hallock G.G. et al., editors. Perforator flaps: anatomy, technique & clinical applications. St. Louis: Quality Medical Publishing, Inc. 2006, p. 541-578.15. Teo T.C. Perforator local flaps in lower limb reconstruction. Cir. Plast. Iberlatinamer. 2006, v. 32, p. 15-16.Teo T.C. Perforator local flaps in lower limb reconstruction. Cir. Plast. Iberlatinamer. 2006, v. 32, p. 15-16.16. El-Sabbagh A.H. Skin perforator flaps: an algorithm for leg reconstruction. J. Reconstr. Microsurg. 2011, v. 27, p. 511-523.El-Sabbagh A.H. Skin perforator flaps: an algorithm for leg reconstruction. J. Reconstr. Microsurg. 2011, v. 27, p. 511-523.17. Hyakusoku H., Yamamoto T., Fumiiri M. The propeller flap method. Br. J. Plast. Surg. 1991, v. 44, p. 53-54.Hyakusoku H., Yamamoto T., Fumiiri M. The propeller flap method. Br. J. Plast. Surg. 1991, v. 44, p. 53-54.18. Hallock G.G. The propeller flap version of the adductor muscle perforator flap for coverage of ischial or trochanteric pressure sores. Ann. Plast. Surg. 2006, v. 56, p. 540-542.Hallock G.G. The propeller flap version of the adductor muscle perforator flap for coverage of ischial or trochanteric pressure sores. Ann. Plast. Surg. 2006, v. 56, p. 540-542.19. Pignatti M., Ogawa R., Hallock G.G. et al. The «Tokyo» consensus on propeller flaps. Plast. Reconstr. Surg. 2011, v. 127, p. 716-722.Pignatti M., Ogawa R., Hallock G.G. et al. The «Tokyo» consensus on propeller flaps. Plast. Reconstr. Surg. 2011, v. 127, p. 716-722.20. Teo T.C. Perforator local flaps in lower limb reconstruction. Cir. Plast. Iberlatinamer. 2006, v. 32, p. 15-16.Teo T.C. Perforator local flaps in lower limb reconstruction. Cir. Plast. Iberlatinamer. 2006, v. 32, p. 15-16.21. Koshima I., Moriguchi T., Ohta S. et al. The vasculature and clinical application of the posterior tibial perforator-based flap. Plast. Reconstr. Surg. 1992, v. 90, p. 643-649.Koshima I., Moriguchi T., Ohta S. et al. The vasculature and clinical application of the posterior tibial perforator-based flap. Plast. Reconstr. Surg. 1992, v. 90, p. 643-649.22. Masia J., Moscatiello F., Pons G. et al. Our experience in lower limb reconstruction with perforator flaps. Ann. Plast. Surg. 2007, v. 58, p. 507-512.Masia J., Moscatiello F., Pons G. et al. Our experience in lower limb reconstruction with perforator flaps. Ann. Plast. Surg. 2007, v. 58, p. 507-512.23. Tos P., InnocentiM., Artiaco S. et al. Perforator-based propeller flaps treating loss of substance in the lower limb. J. Orthop. Traumatol. 2011, v. 12, p. 93-99.Tos P., InnocentiM., Artiaco S. et al. Perforator-based propeller flaps treating loss of substance in the lower limb. J. Orthop. Traumatol. 2011, v. 12, p. 93-99.24. Pignatti M., Pasqualini M., Governa M. et al. Propeller flaps for leg reconstruction. J. Plast. Reconstr. Aesthet. Surg. 2008, v. 61, p. 777-783.Pignatti M., Pasqualini M., Governa M. et al. Propeller flaps for leg reconstruction. J. Plast. Reconstr. Aesthet. Surg. 2008, v. 61, p. 777-783.