a comparative study on the protective effects of … · menjalankan pembedahan flap keatas perokok...
TRANSCRIPT
1
A COMPARATIVE STUDY ON THE PROTECTIVE EFFECTS OF
ASCORBIC ACID AND TUALANG HONEY ON THE SKIN FLAP
OF REVERSE SURAL FASCIOCUTANEOUS FLAP IN A
SMOKING RABBIT MODEL
DR MOHD SHAKIR BATHUSHA BIN MOHD HUSSAIN
DISSERTATION SUBMITTED IN PARTIAL FULFILLMENT OF THE
REQUIREMENTS FOR THE DEGREE OF MASTER OF SURGERY
(PLASTIC SURGERY)
SCHOOL OF MEDICAL SCIENCES
UNIVERSITI SAINS MALAYSIA
2015
2
II ACKNOWLEDGEMENTS
All praise and gratitude to Allah, the Almighty god, the most Beneficent and the most
Merciful. The Lord, who has given me the strength in completing this study and
dissertation. Without His wills and blessings none of this would have been possible.
I would to express my utmost gratitude to my supervisor, Professor Dr Ahmad Sukari
Halim, for his support, guidance and valuable comments in preparing, reviewing and
correcting this dissertation. Apart from that, he has been instrumental in shaping my
career in Plastic Surgery. He also has been the inspiring force for me to present the
findings of this thesis in “ Annual Scientific Meeting 2014, College of Surgeons
Academy of Medicine of Malaysia” which won me the “Ethicon Prize”. I would also
like to thank Dr Abdul Nawfar Bin Sadagatullah and Dr Wan Azman Wan Sulaiman,
for their ideas and inputs in the preparation of the study proposal, obtaining grant and
facilitating conduct of the study from the beginning till the conclusion of this
dissertation.
I am most grateful to Madam Normala Basiron and Mr Mohammad Ali bin Mat Zain,
who are my supervisors in Hospital Kuala Lumpur for their guidance and wisdom.
Their critical comments and intellectual input has been a motivation for me to complete
this dissertation.
I am most grateful to Professor Dr Ahmad Sukari Halim, Madam Normala Basiron and
Mr Mohammad Ali bin Mat Zain for their guidance, knowledge, and inspiration. They
have been important and exemplary figures in journey to acquire knowledge and
surgical skills. Not to forget all the specialists both in Hospital Universiti Sains
3
Malaysia and Hospital Kuala Lumpur for their patience, supervision and constant
source of encouragement.
I would like to express my gratitude to Universiti Sains Malaysia for the short-term
grant PPSG/07(A)/044/(2010)(54) and Federal Agency and Marketing (FAMA) Kedah
for providing the Agromas® Tualang Honey.
I am most grateful to the excellent co-operation given to me by the staff members of
Department of Reconstructive Sciences and Laboratory Animal Research Unit (LARU),
Universiti Sains Malaysia. I would take this opportunity to extend my gratitude to En
Tg Mohd Ikhwan Bin Tg Abu Bakar Sidik from Clinical Research Council Hospital
Kuala Lumpur for assisting in the statistical aspect of this study and Prof Siti Amrah
from Department of Pharmacology, Hospital Universiti Sains Malaysia for her expert
opinion in “Tualang honey”.
Finally, I would like to express my deepest appreciation to my parents, Mohd Hussain
bin Abdullah and Fatimah binti Aurn for their everlasting support, prayers and
encouragement, to my loving wife, Jirsah binti A Bakar Kunchu for her support,
patience and understanding during this challenging four years period, and to my lovely
son, Muhammad Irfan, my source of courage to attain a greater height.
4
III Preface
Trauma involving the lower limb is in the rising trend. Similar trend is also seen in the
number of cigarette smokers. Reconstruction of lower limb soft tissue defect could be a
challenging task especially amongst patient whom are smokers as has been reported in
the literature. We are in an era of promoting limb salvage surgery as compared to
amputation which may be the only option in the past.
Free tissue transfer would be the better option for reconstruction in area with precarious
blood supply. However this form of reconstruction may be far from reach in many
places. Introduction of reverse sural neurocutaneous flap has open a new dimension for
lower limb reconstruction. It is a relatively easy flap to raise with lesser steep learning
curve. However the complication are similar to any pedicled flap. Smoking is a known
factor for flap failure and it is attributed to vasoconstrictive effect of nicotine and
carbon monoxide found in the mainstream cigarette smoke. Both these agents contribute
to the release of inflammatory mediators and later give rise to ischaemic reperfusion
injury leading to flap loss.
We studied the effect of two anti-oxidant (Ascorbic acid and “Tualang honey”) in
improving the outcome of flap survival using smoking rabbit model. We hope to
establish the beneficial effect of both these agents which later could be extended its use
in our clinical practice among the active smokers in our patient population.
5
IV TABLE OF CONTENTS
Contents Page numbers
I Frontispiece ………………………………………………………… 1
II Acknowledgements ………………………………………………… 2
III Preface ……………………………………………………………….. 4
IV Table of Contents …………………………………………………… 5
V Abbreviations ……………………………………………………….. 9
VI List of Figures ………………………………………………………. 11
VII List of Tables ………………………………………………………. 12
VIII Abstrak ……………………………………………………………… 14
IX Abstract …………………………………………………………….... 17
1.0 INTRODUCTION AND LITERATURE REVIEW
1.1 Research Background 19
1.2 Evolution of flap 20
1.3 Lower limb trauma and reconstruction
Challenges in reconstruction of distal third of leg
21
1.4 23
6
1.5
1.6
1.7
1.8
1.9
1.10
1.11
1.12
1.13
1.14
1.15
Fasciocutaneous concept and sural flap
Vascular anatomy of lower limb
Reverses sural flap and flap circulation
Cigarette smoking and its global health impact
Contents of cigarette
Impact of cigarette smoking on wound healing and flap
surgery
Ascorbic acid ( Vitamin C) Beneficial effect ascorbic acid Honey in medical practice Tualang honey and its properties Rabbit as an animal model for experimental surgery
24
25
26
27
28
29
30
31
32
33
34
2.0
OBJECTIVE AND HYPOTHESIS
2.1 General objective 37
2.2 Specific Objective 37
2.3 Study hypothesis 38
7
3.0 MATERIALS AND METHODOLOGY
3.1 Study design 39
3.2 Study venue 39
3.3 Study population 39
3.4 Inclusion criteria 40
3.5 Exclusion criteria 40
3.6 Sample size 40
3.7 Ethics 41
3.8 Housing and general care of the rabbits used
in the experiment
41
3.9 Handling of rabbits 41
3.10 Identification of study group 42
3.11 Preparation of study group 44
3.12 Flow chart of research methodology 46
3.13 Perioperative care 50
3.14 Anaesthesia 53
3.15 Preoperative preparation 56
3.16 Flap design and operative procedure 59
8
3.17 Post operative care 62
3.18 Flap assessment 62
3.19 Euthanesia 68
3.20 Statistical analysis 68
4.0
RESULTS
4.1 Demographic results
4.1.1 Control group (Smoking) 69
4.1.2 Smoking with ascorbic acid 70
4.1.3 Smoking with “Tualang” honey 70
4.2 Descriptive analysis
4.2.1 Statistical analysis 71
5.0 DISCUSSION 86
6.0 CONCLUSSION 94
7.0 LIMITATION AND RECOMMENDATION 96
8.0 REFERENCES 97
9.0 APPENDIX 105
9
V ABBREVIATIONS
% Percent
α Alpha
BC Before Christ
Cm centimetre
cor Co-relation
2D Two dimension
df Degree of freedom
EDCF Endothelial-derived contracting factor
EDRF Endothelial derived relaxing factor
FAMA The Federal Agriculture Marketing Authority
g gram
IL Interleukin
kg Kilogram
L/min Litre per minute
mm2 millimetre square
mg milligram
n Numbers
10
PVC Polyvinylchloride
pH A measure of the acidity or basicity of a solution. It approximates p[H],
the negative logarithm (base 10) of the molar concentration of dissolved
hydronium ions
p value is the probability of obtaining the same or more extreme data assuming
the null hypothesis of no effect; p-values are generally (but arbitrarily)
considered significant if p < 0.05
PDGF Platlet derived growth factor
SV Smoking with ascorbic acid
SH Smoking with “Tualang” honey
SD Standard deviation
SPSS Statistical Package for the Social Sciences
TNF Tumour necrosis factor
TGF Transforming growth factor
USM Universiti Sains Malaysia
VEGF Vascular endothelial growth factor
Vs Versus
11
VI LIST OF FIGURES
FIGURE TITLE PAGE
Figure 1 An adult White New Zealand rabbit (Oryctolagus cuniculus) 36
Figure 2 Standard animal housing with water canister and palate
chamber
43
Figure 3 Labeling of each study group (SV – Smoking with Ascorbic
acid)
43
Figure 4 Smoke chamber used in the study 47
Figure 5 Custom-built rabbit smoke chamber and exhaust for the smoke 48
Figure 6 Rabbit placed in smoke chamber 48
Figure 7 Sketch of the rabbit smoke chamber 49
Figure 8 Preoperative workstation 50
Figure 9 Process of shaving rabbit hind limb with an electric shaver 51
Figure 10 Limb preparation after shaving 52
Figure 11 Induction of anaesthesia 53
Figure 12 Maintainence of anaesthesia with inhalation agent 54
Figure 13 Medications ( induction agents, antibiotic and analgesic) used
throughout the study)
55
Figure 14 Intramuscular injection of analgesic (Meloxicam) 55
Figure 15 Operating table with inbuilt warming system 57
12
Figure 16 Rabbit in prone position on operating table with all 4 limbs abducted
57
Figure 17 Heart rate and oxygen saturation monitoring with pulse oxy-meter
58
Figure 18 Flap design with dimension 2.5 x 2.5 cm over posterior calf 60
Figure 19 Process of reverse sural flap elevation 61
Figure 20 Temperature assessment with a digital thermometer 64
Figure 21 Colour of flap and area of congestion 64
Figure 22 Flap complicated with hematoma 65
Figure 23 Progressive chages in the flap appearance 65
Figure 24 Flap assessment and outcome on post operative day 7 66
Figure 25 Example of flap tracing on grid paper for survival calculation 67
Figure 26 Graft representing temperature changes between each group on various post operative day
78
Figure 27 Mean plot of survival between three groups 84
VII LIST OF TABLES
TABLE TITLE PAGE
Table 1 Comparison of research parameters between right and left limb
of smoking rabbit sample
71
Table 2 Comparison of research parameters between right and left limb
of smoking with ascorbic acid rabbit sample
73
Table 3 Comparison of research parameters between right and left limb 75
13
of smoking with Tualang Honey sample
Table 4 Comparison of average in temperature between three groups 76
Table 5 Post hoc comparison of temperature for each pair of group
77
Table 6 Association between groups and flap colour on Day 0 79
Table 7 Association between groups and flap colour on Day 3 79
Table 8 Association between groups and flap colour on Day 7 80
Table 9 Association between groups and infection on Day 3 81
Table 10 Association between groups and infection on Day 7 81
Table 11 Association between groups and hematoma on Day 1 82
Table 12 Association between groups and hematoma on Day 3 82
Table 13 Association between groups and hematoma on Day 7 83
Table 14 Comparison of survival percentage between groups 83
14
VIII ABSTRAK
Trauma anggota badan yang melibatkan kaki sememangnya cabaran yang besar untuk
pakar bedah rekonstruktif. Kerumitan dalam komposisi tisu anggota badan yang lebih
rendah dan kebimbangan mengenai keberkesanan pengaliran darah telah menjadi
cabaran dalam proses rekonstruktif. Pengenalan “ pedicled fasciocutaneous flap”
berdasarkan aliran songsang telah menyediakan alternatif untuk memudahkan proses
rekonstruktif demi menggantikan tisu yang hilang disebabkan oleh trauma. Flap sural
songsang semakin popular dan digunakan secara meluas dalam proses rekonstruktif
melibatkan pembinaan semula tisu melibatkan kaki. Teknik ini lebih mudah jika di
bandingkan dengan penggunaan teknik pemindahan tisu bebas.
Menjalankan pembedahan flap keatas perokok telah terbukti menghasilkan keputusan
yang kurang memuaskan. Komponen dalam asap rokok memberi kesan negatif kepada
sel endothelium salur darah. Nikotin dan karbon monoksida dalam asap rokok
menghasilkan kerosakan oksidatif dan melepaskan spesies oksigen reaktif yang
mengakibatkan kecederaan iskemia.
Asid askorbik dan madu Tualang adalah dua agen yang telah dikaji secara meluas untuk
fungsi anti oksidatif mereka dan sifat-sifat penyembuhan luka. Kajian sebelum ini
bertujuan untuk mengkaji kesan asap rokok dan asid askorbik pada endothelium salur
darah berkaliber besar seperti karotid dan aorta. Kajian ini telah dijalankan untuk
membandingkan kesan anti oksidatif kedua-dua agen ini dalam meningkatkan kadar
kelangsungan hidup flap sural songsang menggunakan model arnab yang terdedah
kepada asap rokok.
15
Kajian ini adalah bertujuan untuk mengolah sifat antioxida kedua- sebut di kalangan
perokok demi meningkatkan peredaran mikrovaskular dalam flap sural songsang
menggunakan model arnab merokok.
Semua sampel arnab terdedah kepada asap rokok menggunakan kebuk asap untuk
tempoh sejumlah 5 minggu. Sampel kajian telah dibahagikan kepada tiga kumpulan.
Kumpulan kawalan hanya menerima asap rokok manakala dua kumpulan lain menerima
asid askorbik dalam bentuk suntikan intramuskular dan minum madu Tualang selain di
dedahkan kepada asap rokok. Pembedahan Flap sural songsang dilakukan keatas semua
arnab pada hari ke 30 pendedahan kepada asap rokok.
Penilaian sampel dilakukan serta merta selepas pembedahan, hari pertama selepas
pembedahan, hari ketiga dan hari ketujuh. Parameter seperti suhu flap, tempoh isian
semula peredaran kapilari, warna flap, bukti terkumpulnya darah beku dibawah flap
atau bukti kehadiran jangkitan dirakamkan. Kadar kelangsungan hidup flap dikira pada
hari ketujuh. Ketiga tiga kumpulan masih didedahkan kepada asap rokok serta diberi
suntikan asid ascorbic dan madu tualang mengikut kumpulan masing-masing sepanjang
tempoh eksperimen.
Kami mendapati bahawa, kedua-dua kumpulan yang didedahkan dengan asid askorbik
dan madu Tualang menunjukkan peningkatan yang ketara dalam kadar kelangsungan
hidup flap. Analisa statistic menunjukkan peningkatan yang ketara dari aspek suhu,
peningkatan warna dan pengurangan dalam kadar pembentukkan darah beku di bawah
flap. Kadar kelangsungan hidup flap melonjak daripada 62% di lengan merokok kepada
88.9% dan 81.0% dalam kumpulan asid askorbik dan madu tualang. Walau
bagaimanapun analisa menggunakan ANOVA sehala menunjukkan nilai p 0.075 yang
menghampiri nilai yang ketara.
16
Kesimpulannya adalah asid askorbik mempunyai lebih kesan positif berbanding madu
Tualang dalam mengurangkan kesan kerosakan oksidatif yang dihasilkan oleh asap
rokok serta menperbaiki peredaran mikrovaskular flap sural songsang.
17
IX ABSTRACT
Lower limb traumas impose a great challenge for reconstructive surgeons. Complexity
in the tissue constituent of lower limb and the concern regarding vascularity has been
the barrier in the process of reconstruction. Introduction of pedicled fasciocutaneous
flap based on reverse flow has provided an alternative to free flap reconstruction.
Reverse sural fasciocutaneous flap is gaining popularity and widely being used in the
reconstruction of distal third of lower limb due to its ease of elevation compared to free
flap.
Performing flap surgery in smokers has been proven to yield poor outcome.
Components in cigarette smoke have an established negative impact on the vascular
endothelium of blood vessels. Nicotine and carbon monoxide in cigarette smoke
produce oxidative damage and release reactive oxygen species resulting in ischaemic
injury.
Ascorbic acid and “Tualang honey” are two agents which have been extensively studied
for their anti oxidative and wound healing properties. Previous studies were aimed at
studying the impact of cigarette smoke and ascorbic acid on the endothelium of large
calibre vessel like carotid and aorta. The present study was undertaken to compare the
anti oxidative properties of both these agents in improving the outcome in flap survival
using a smoking rabbit model. This study is aimed at assessing the beneficial anti
oxidative property to improve microvascular circulation in a reverse sural
fasciocutaneous flap in a smoking rabbit model.
18
All samples were exposed to cigarette smoke using a smoke chamber for a total of 5
weeks. Study sample was divided into three groups. Control group only received
cigarette smoke while the other two groups each received ascorbic acid in the form of
intramuscular injection and oral “Tualang honey” on top of exposure to cigarette smoke.
Reverse sural fasciocutaneous flap was raised in all the rabbits at day 30 of exposure to
cigarette smoke.
Samples were evaluated on immediate post operative period, post operative day 1, 3 and
7. Parameters documented throughout the study were temperature, capillary refill time,
colour of flap, presence hematoma or infection, and on post operative day 7 the flap
survival was calculated. Intervention with smoking, ascorbic acid and “Tualang honey”
were continued throughout the period of experiment.
We found that, both group intervened with ascorbic acid and “Tualang honey” showed
marked improvement in the flap survival. Statistically significant improvement were
documented with regard to temperature, improvement in colour of flap and reduction in
hematoma. Flap survival improved from 62% in the smoking arm to 88.9% and 81.0%
in the ascorbic acid and “Tualang honey” arm. However oneway ANOVA test showed
p value of 0.075 which was near to significant value.
In conclusion both ascorbic acid and “Tualang honey” improved the survival of reverse
sural fasciocutaneous flap in smoking rabbit model. However ascorbic acid is superior
compared to “Tualang honey” in improving the oxidative damages produced by
cigarette smoke and microvascular circulation of the reverse sural fasciocutaneous flap.
19
A comparative study of the effects of ascorbic acid and Tualang Honey
on the skin flap of the reverse sural fasciocutaneouss flaps in a
smoking rabbit model.
1.0 INTRODUCTION AND LITERATURE REVIEW
1.1 Research background
Injuries following motor vehicle accident are common in accident and emergency
department practice. Lower limb trauma is a common injury sustained in these
accidents. Besides that diabetic patient with diabetic foot ulcer is increasing in number
in our clinical setting. Injuries and soft tissue defect to lower third of lower limb pose a
difficult challenge to both orthopaedic and reconstructive plastic surgeon. They present
as a complex wound and soft tissue defect over distal third of the leg, ankle and foot
thus it remains as difficult problem to solve (Hassanpour et al., 2008). Despite free
tissue transfer being the choice of treatment, technical difficulty and lack of expertise
lead to choosing a less complicated option in the reconstructive ladder to address the
soft tissue defect in those areas mentioned above (Tharayil and Patil, 2012).
Masquelet et al in 1992 described neuroskin island flap which form the basis of reverse
sural flap (Masquelet et al., 1992b). Reverse sural flap have been extensively studied
for its application in the reconstruction of distal leg and heel defects. However the issue
of skin viability has remained a concern in this type of flap due to its dependence to the
reverse blood flow following the transaction of its axial blood supply or underlying
microangiopathy. It is also a poor choice of reconstruction in situation with extensive
20
injury taking place 5 to 13 cm proximal to the lateral malleolus as most fasciocutaneous
perforators emerge along this area. However various modifications has been described
to overcome those shortfalls (Almeida et al., 2002; Tharayil and Patil, 2012).
“Plastic surgery is a constant battle between blood supply and beauty” (Gillies and
Millard 1957). Plastic surgery practise is a constant battle between blood supply and
wound healing. It is a well accepted assumption that cigarette smoking leads to necrosis
of cutaneous skin flaps (Thomas Lawrence et al., 1984). Smoking is becoming a trend
among Asian male and female. Performing surgeries in patients with cigarette smoking
habit is inevitable and impose a challenge towards optimal wound healing. Our aim in
this study was to evaluate the method to improve the survivability of the skin flap in
smoking patient using a rabbit model to test our hypothesis.
1.2 Evolution of flap
“ Flap “ originated in the 16th century from the Dutch word “ flappe ” which carries the
meaning of something that hung broad and loose and fastened only by one side. Flap
surgery dates as far as 600 BC described in a famous Indian surgical encyclopaedia by
Sushruta Samita who described nasal reconstruction using a cheek flap. Various
scriptures, historical and scientific literature have described the evolution of flap
surgery over time. The surgical procedures described during the early years involved the
use of pivotal flaps, which transport skin to an adjacent area while rotating the skin
about its pedicle (blood supply). The French were the first to describe advancement
flaps, which transfer skin from an adjacent area without rotation. Distant pedicle flaps,
The French were the first to describe advancement flaps, which transfer skin from an
21
adjacent area without rotation. Distant pedicle flaps, which transfer tissue to a remote
site, also were reported in Italian literature during the Renaissance period.
Subsequent surgical flap evolution occurred in phases. During the First and Second
World Wars, pedicled flaps were used extensively. The next period occurred in the
1950’s and 1960’s, when surgeons reported using axial pattern flaps (flaps with named
blood supplies). In the 1970’s, a distinction was made between axial and random flaps
(unnamed blood supply) and muscle and musculocutaneous (muscle and skin) flaps.
In the 1980’s, the number of different tissue types used increased significantly with the
development of fasciocutaneous (fascia and skin) flaps (which are less bulky than
muscle flaps), osseous (bone) flaps, and osseocutaneous (bone and skin) flaps.
Fasciocutaneous flap are still of relevance and widely used in the armamentarium of
reconstruction. Various efforts have been taken to improve the outcome of this flap
either by improvising the flap design, delay of flap, in-cooperation of superficial vein
into the flap or microvascular anastomosis of proximal vein to superficial vein around
the recipient bed to create a flow through pattern (Suzuki et al., 2008; Kececi and Sir,
2012; Tsai et al., 2013)
1.3 Lower limb trauma and reconstruction
Motor vehicle accident contributes to a major portion of cases seen in a day to day
emergency department practice. According to the report from the Department of
Statistics Malaysia, in the year 2011 the total number of accidents in Malaysia was
449040 and 18693 patients were injured and 6877 patient succumbed to death.
Motorcycle rider and the pillion rider contributed the most to the figures above
22
amounting 18693 and 6877 patients each.(Malaysia, 2012) In another prospective study
done in three major health facilities reported that motorcyclist are the most vulnerable
group in a road traffic accident. Lower limb trauma contributes 58.3% of the cases
seeking treatment in the accident and emergency department and from the figure above
35% involves injuries around ankle (Lateef, 2002; Malaysia, 2012).
Spectrum of lower limb trauma is variable from the mildest abrasion wound to complex
tissue loss requiring soft tissue and bony reconstruction. The principles guiding lower
limb reconstruction following trauma have been described 300 years ago. Amputation
rates dropped from 70% during the pre modern era to 1.8% in the modern era. Such leap
in the outcome is attributed to the development of greater understanding and
development of modern medicine practice (Wagels et al., 2013). Reconstructive options
for lower limb are described based on the location of injury. They are classified as
upper, middle and lower third of leg reconstruction. Various reconstructive options and
techniques have been described and it’s used judiciously according to the needs of
reconstruction.
Reconstructive option for lower limb defect ranges from skin graft, local flap, muscle
flap, fasciocutaneous flap or free tissue transfer (Baechler et al., 2010; Wagels et al.,
2013). Among the commonly used muscle to reconstruct soft tissue defect include
gastrocnemius, soleus, extensor hallucis longus, tibialis anterior, peronues brevis and
extensor digitorum longus. Free tissue transfer uses either latissimus dorsi, serratus
anterior or gracilis. Fasciocutaneous is also a favourite option of reconstruction which
are based either on medial or posterolateral perforator of the leg. Lower third
reconstruction using fasciocutaneous flap are usually distally based, reverse flow
23
perfused by septocutanoeus perforators either from anterior tibial, posterior tibial or
peroneal perforators.
1.4 Challenges in reconstruction of distal third of leg
Traumas to the leg are divided into upper, middle and distal third for the ease of
describing the management options. Trauma of the distal third leg, tendo- Achiles and
heel trauma poses a great challenge to both orthopaedic and plastic surgeon. Injuries in
functional important areas like the heel require meticulous reconstruction. Choice of
tissue to replace the like with like is rather challenging. The uniqueness of the skin of
the plantar aspect is rather indispensible. Heel pad is an important structure
withstanding the axial load of the body and facilitates the biomechanics of the lower
limb and significantly contribute to the gait cycle.
Extend of injury will determine the options available for reconstruction. Among the
available options are local flaps, advancement flap or free tissue transfer. Defect to
ankle and foot region requires more meticulous choice of tissue used in reconstruction.
Replicating the functional aspect of the heel area requires tissue which can withstand
sheering pressure and does not contract with time (Zgonis et al., 2007; Ahmed et al.,
2008; Haddock et al., 2010; Hamdi et al., 2012).
Lower limb trauma presents as defect with multitude of soft tissue and vascular defect.
Free tissue transfer is the current choice for large soft tissue defect of the distal
extremities; however the availability of resources and technical expertise limits its use.
Fasciocutaneous flap emerged as a preferred alternative option in coverage of skin
defect of the lower leg since it was first described by Masquelet et al in early 1990’s. It
24
is based on sural neurocutaneous perfusion and reverse flow from the posterior tibial
and peroneal artery (Masquelet, 1991; Masquelet et al., 1991; Ahmad, 2011).
1.5 Fasciocutaneous Concept and Sural flap
Fasciocutaneous flap was first described by Ponten in 1981. It was described for soft
tissue reconstruction of lower leg. Inclusion of the fascia in the process of raising the
flap has allowed expansion of the width to length ratio from 1:1 to 1:3. Raising this type
of flap is relatively easy, safe and reproducible by younger surgeons (Ponten, 1981b;
Kan, 1988). Previously deep fascia which lies between muscle and skin was regarded as
an isolated layer of dense and avascular fibrous tissue. Dissection in this plane results in
minimal bleeding thus this layers was not frequently studied of their blood supply and
previously it was thought this layer was insufficient to perfuse a flap (Kan, 1988).
“Fascial plexus ” is the confluence of subfascial, intrafascial, and suprafascial vascular
plexuses within the dermal, subdermal, superficial adipofascial (above Scarpa’s fascia),
and deep adipofascial layers. These plexuses represent a confluence of a large array of
interconnected vessels. Thus this is the reason behind the success of a fasciocutaneous
flap. A fasciocutaneous flap compose of any or all of the tissue layers found between
the skin and deep fascia. Cormack and Lamberty further classify all skin flaps into a
tripartite system that included direct cutaneous, musculocutaneous, and fasciocutaneous
flaps. Besides Cormack and Lamberty other authors like Mathes and Nahai and
Nakajima have also described their classification of fasciocutaneous flap expanding on
the various subtypes of fasciocutaneous flap.