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Free vascularized fascia flap combined with skin grafting for

deep toe ulcer in diabetic patients
1 1
Xuekang Yang, MD, Zhuoqun Fang, MM, Mengdong Liu, MD, Yue
Zhang, MM, Qiaohua Chen, MM, Ke Tao, MD, Juntao Han, MD, and
Dahai Hu, PhD, MD*
Department of Burns and Cutaneous Surgery, Xijing Hospital, Fourth Military Medical University, Xi’an, China

article info abstract

Article history: Background: This study introduces a technique for the reconstruction of deep toe defects in diabetic patients
Received 24 January 2018 using a method that combines free vascularized fascia flap with skin grafting. Methods: In this retrospective
Received in revised form 25 study, conducted between March 2010 and February 2016, 15 diabetic patients with deep toe ulcer received
April 2018 Accepted 24 May surgeries that combined free vascularized fascia flap with skin grafting, including nine anterolateral thigh
2018 Available online xxx fascia lata flaps and six superficial temporal fascia flaps. Their medical records were systematically reviewed
from electronic databases. The donor artery was anastomosed to the dorsalis pedis artery in an end-to-side
manner, and the vein was anastomosed to the accompanying vein in an end-to-end manner.
Keywords:
Free vascularized fascia flap
Skin grafting Results: Thirteen fascia flaps completely survived without any rejection. Partially necrosed grafted skins,
Diabetes which were found in two cases, were healed after routine dressing changes. Patients achieved an esthetic
Toe outcome and acceptable functions without further revisions. Two patients suffered from ischemic necrosis of
Microsurgery the fascia flap and eventually underwent amputation.

Conclusions: The present study demonstrated that vascularized fascia flap combined with skin grafting has
great advantages for correcting deep toe ulcer in diabetic patients characterized by the esthetic outcome,
abundant vascularity, surgical simplicity, and good deformability.
ª 2018 Elsevier Inc. All rights reserved.

Introduction
Diabetic foot ulcer is one of the most common and serious complications
that occurs in diabetic patients. It is particu-larly complicated by problems
such as prolonged angiopathy and sensorial neuropathy. Further
complications, such as numbness, pain, and skin ulcers probably cause
gangrenes, which would lead to amputations or even death if not treated
1
well. Toes are the most common and vulnerable parts of the body for
infections and ulcers that are usually conservatively
treated with debridement and local wound therapy. However, these
treatments are inadequate for patients with deep ulcers as they expose the
underlying bones and tendons and even-tually lead to amputation of the
2
toes. Another method that is used to treat foot ulcers is reconstruction
using reversed dorsalis pedis artery island flap. Although this method has
the advantage that it can be occasionally performed when vascular
conditions of the lower extremity are well conserved, the main problem is
that it would destroy the anatomical structure of acrotarsium vessel. This
would lead to a decrease

* Corresponding author. Department of Burns and Cutaneous Surgery, Xijing Hospital, Fourth Military Medical University, 15 Changle Xi
Road, Xi’an 710038, P.R. China. Tel.: þ86-29-84775298; fax: þ86-29-83251734. E-mail
address: hudahaidoc@163.com (D. Hu).
1
Xuekang Yang and Zhuoqun Fang contributed equally to this work.
0022-4804/$ e see front matter ª 2018 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jss.2018.05.051
168 journalofsurgicalresearch n o v e m b e r 2 0 1 8 ( 2 3 1 ) 1 6 7 e1 7 2

in the foot blood supply and, therefore, increase the incidence of severe
foot ulcer infection. In addition, the blood supply of reversed dorsalis
3
pedis artery island flap relies on the deep plantar branch of artery. The
angiopathy in diabetic patients may predispose them for small vessel
embolization and in-crease the risk of flaps failure.
In some medical centers, small free flaps (peroneal ar-tery perforator
flap, posterior interosseous artery perfo-rator flap, and so forth) are given
priority over repairing and reconstructing toe defects. The artery and vein
of the small free flaps are anastomosed to the plantar arch of the foot.
However, in diabetic patients who are prone to peripheral small vascular
diseases, this would result in skin flap ischemia and anastomotic
embolization eventually leading to the failure of small free flaps. Thus,
the long vascular pedicle free flap (the anterolateral thigh flap and so
forth) may offer a better choice for diabetic patients. The donor arteries of
these flaps are anastomosed to the dorsalis pedis artery, which could
4
highly increase the success rate of the surgery. However, for patients with
thick subcu-taneous fat, it is difficult to clip the excess soft tissue and fat
off the small flaps, which causes the recipient toe to appear bulky.
Method
Clinical data
Fifteen of the 973 diabetic foot patients admitted in our department of
Xijing Hospital were enrolled in this study. All of them had consented to
this study in accordance with the requirements of the Research Ethics
Committee of Xijing Hospital. Although the injured toes of all the 15
patients were accompanied by severe soft tissue defects and bone and
tendon exposure, their blood supply was still abundant. The inclusion
criteria for this procedure were the presence of se-vere soft tissue defects
with bone and/or tendon exposure after debridement without any severe
uncontrollable sys-temic disease such as uremia. Each patient’s detailed
profile is documented in Table. The research work reported here was also
performed in line with the process criteria.
Preoperative preparation

Strict blood glucose control (80-110 mg/dL), water-electrolyte balance,

and the absence of any systemic dis-ease were assessed and improved in
Thus, the purpose of this retrospective study was to eval-uate the the perioperative period. Transcutaneous oxygen was measured in
efficacy and feasibility of free vascularized fascia flaps together with skin patients, and improvements were made so that oxygen levels reached
grafts in treating diabetic patients with deep ulcers in their toes. more than 30 mmHg before surgery. Osteomyelitis was

Table e Clinical data and treatment outcomes of patients.

Case Age/gender Injured location Defect Lower PTA Fascia flap Survival Complication
2 extremity therapy choice of flap
size, (cm )
vessels
1 52/M 5th toe 1.9 1.6 Normal No ATFL flap Yes No
2 44/M 3rd toe 2.1 1.7 Normal No STF flap Yes No
3 59/W 4th, 5th toes 3.3 2.2 Normal No ATFL flap Yes Partial skin
grafting necrosis
4 49/M 4th, 5th toes, and 5.9 9.2 Normal No STF flap Yes No
partial dorsum pedis
5 55/W 5th toe 2.0 1.5 PT stenosis Yes ATFL flap Yes No
6 37/M 2nd toe 2.6 1.7 Normal No STF flap Yes No
7 45/M 2nd, 3rd toes 4.5 2.9 P and PT Yes ATFL flap Yes No
stenosis
8 61/M 5th toes 3.1 2.2 AT, PT, and Yes ATFL flap No 5th toes amputation
P stenosis
9 57/W 4th toe 2.2 1.5 AT stenosis Yes ATFL flap Yes No
10 49/M 5th toe and partial 5.6 4.2 Normal No ATFL flap Yes No
dorsum pedis
11 65/M 4th toe 3.1 1.9 AT and P Yes STF flap No No
stenosis
12 76/W 5th toe 2.5 2.1 AT and P No ATFL flap No 4th, 5th toes
stenosis amputation
13 41/M 3rd toe 2.2 2.1 Normal No ATFL flap Yes No
14 51/M 1st toe 4.2 2.6 AT and P Yes STF flap Yes Partial skin
stenosis grafting necrosis
15 48/M 1st, 2nd toes 4.1 4.6 Normal No STF flap Yes No

AT ¼ anterior tibial artery; ATFL flap ¼ anterolateral thigh fascia lata flap; DP ¼ dorsalis pedis artery; P ¼ peroneal artery; PT ¼ posterior tibial artery; STF flap ¼

superficial temporal fascia flap.

 y a n g e t a l f a s c i a fl a p s f o r r e p a i r i n g d e e p t o e u l c e r
diagnosed, by analyzing clinical, radiological, and motor function
outcomes, in 2 of 15 patients. Doppler ultrasound examination was
performed for all patients to assess the vascular status of their lower
extremities. Varying degrees of peripheral vascular stenosis was observed
in 13 patients at the anterior tibial artery, the posterior tibial artery, and the
dorsal artery. Ten patients had undergone lower ex-tremity angiography,
and six patients in the study had a balloon therapy to remove the
inflammatory granulation tissue, subcutaneous tissue, denatured tendon,
or even necrotic bone as far as possible. One to three debridements, in
combination with timely dressing changes, were per-formed until the
infection was controlled (level of bacteria <105 cells/g of tissue) and
wound bed.
Surgical procedure
The reconstructive surgery is divided into four steps. The first step was
the preparation of the recipient area which involved debriding the wound
of the recipient toe region and then exploring the recipient vessel (dorsalis
pedis artery and accompanying vein) for their patency and blood flow
veloc-ity. The second step was the flap harvesting of the donor site in
which the anterolateral thigh fascia lata flap (ATFL flap) and the
superficial temporal fascia flap (STF flap) were designed and harvested
according to the area size of recip-ient site, similar to that reported in
5
previous publications. The third step was vascular anastomosis. Before
perform-ing the anastomosis, the fascia flap was transferred and fixed to
the recipient site. The donor artery was anastomosed to the dorsalis pedis
artery in an end-to-side manner, and the vein was anastomosed to the
accompanying vein in an end-to-end manner under the microscope. When
the operations aforementioned were completed, we carefully checked and
ensured that the anastomosis was unobstructed, and the fascia flap blood
circulation was good. The fourth step was the grafting of the skin which
involved harvesting the thin split skin and transplanting and fixing it on
the surface of the fascia flap. A bandage with observation holes was
applied with moderate pressure to the skin. Finally, the affected limbs
6 healed by dressing change. Transcutaneous oxygen was 36 mmHg. The
were immobilized, in functional positions, with gyp-sum or braces.
Postoperative management
The affected limb was elevated and kept warm after the pro-cedure and
other medical treatments were provided if necessary. Medication for flaps,
which included vasodilator, antispasmodic, and anticoagulant drugs, was
used systemi-cally. The Doppler ultrasound was applied to check the
patency of anastomosis after the operation, and the dressing was changed
in a timely manner. The blood status was observed every 4-6 h until the
7th-d postoperation. Edema was nearly resolved 14 d after the procedure.
Orthopedic shoes were used to prevent the recurrence of ulcerations.
Gradual walking and systemic rehabilitation exercises were recom-
mended for the patients until they could bear full weights 4 wk after
surgery. The follow-up period of the study was varying from 6 to 18 mo
according to the disease recovery of these patients.
169
Results
Free vascularized fascia flaps surgeries were performed in 15 patients.
Flaps used included nine ATFL flap and six STF flap. Patients age ranged
from 37 to 76 y (average of 56.4 y). The average hospital stay was 15.4 d
(range, 9-27 d). The number of surgical procedures ranged from 1 to 4
(mean of 2.5), which included dressing changes, debridement surgery, and
fascia flap transfer.
Fascia flap completely survived in nine patients with normal lower
limb blood vessel status, which was ascertained before surgery. One case
of skin necrosis, caused by local in-fections, was healed by regrafting and
conventional dressing therapy. Two cases of fascia flap completely
survived in pa-tients with normal arteriae tibialis anterior status although
they had an abnormal posterior tibial artery or a peroneal artery. Four
cases with anterior tibial artery stenosis and abnormal dorsalis pedis pulse
improved significantly by balloon dilatation, of which two patients
suffered from avas-cular necrosis of the fascia flap and eventually
underwent amputation. All patients were able to stand and ambulate with
full weight-bearing during the follow-up period. All pa-tients were able to
wear shoes, and they unanimously accepted the esthetic outcome. There
were no complications, such as ulceration and necrosis, related to the
donor site.
Typical case 1: superficial temporal fascia free flap
This case involved a 49-year-old male diabetic patient with uncontrolled
blood glucose levels for 11 y. Random blood glucose check of the patient
showed that he had a blood glucose value of 324 mg/dL when he was sent
to our depart-ment. The patient had neglected prior disease treatments
which had resulted in diabetic ketoacidosis twice before. The ulceration
had begun spontaneously 2mo before our study. It was located in the
partial dorsum of the left foot between the fourth and fifth toe and had not
fourth and fifth toe tendons were exposed as a result of a previous surgical
debridement. Blood glucose was controlled strictly with a week-long
endocrinological treatment in the preoperative period. Wounds, with
tendons exposed, were ascertained to be untreatable by simple
conventional dressing therapy or skin grafting. This patient had a wound
size of about 5.9 9.2 cm (Fig. 1A). To treat this, we designed and obtained
an STF flap that would fit the wound size and esthetically sutured the
incision of the donor site (Fig. 1B-D). After that, we performed a vascular
anastomosis, fascia flap trans-plantation, and thin split-skin grafting (Fig.
1E). The fascia flaps and grafted skin survived well after surgery (Fig.
1F). After a follow-up period of 12 mo, the patient wore orthopedic shoes
regularly. His functional recovery was satisfactory (Fig. 1G). The scars at
the donor site were not obviously visible and were free of any ulceration
(Fig. 1H).
Typical case 2: tensor fascia lata flap
This case involved a 57-year-old female, who had been a diabetic patient
for 16 y, with an intrinsic muscle imbalance
170 journalofsurgicalresearch n o v e m b e r 2 0 1 8 ( 2 3 1 ) 1 6 7 e1 7 2

Fig. 1 e The reconstruction of fourth and fifth toes and partial dorsum pedis deep defects using free vascularized superficial temporal fascia flap with
skin grafting. (A) After surgical debridement, partial tendon exposure were observed in fourth and fifth toes; (B-D) designing and harvesting of
superficial temporal fascia flap; (E) vascular anastomosis was performed after transferring and fixing the fascia flap to the recipient site; (F) the fascia
flap and grafted skin survived well at 8th d after operation; (G) at 6 mo follow-up, the appearance of recipient site was even and without dysfunction; and
(H) the scars at the donor site were not obvious. (Color version of figure is available online.)

in her right foot for 3 mo. This had resulted in a local infec-tion and a
severe soft tissue defect of her fourth toe (Fig. 2A). Transcutaneous
oxygen was 32 mmHg. Doppler ultrasound examination and lower
extremity angiography showed se-vere vascular stenosis of the distal
anterior tibial artery, and
the patient underwent a balloon therapy before reconstruc-tion. After
surgical debridement, the wound size was about 2.2 1.5 cm and
accompanied by the exposure of her fourth and fifth toe tendons (Fig. 2B).
Osteomyelitis was suggested by analyzing the clinical and radiological
outcomes. We

Fig. 2 e The reconstruction of fourth toe deep defects using free vascularized anterolateral thigh fascia lata flap with skin
grafting. (A) Preoperative wound characteristics; (B) after surgical debridement, articular capsule destruction and bone
exposure were observed; (C and D) designing and harvesting of anterolateral thigh fascia lata flap; (E) vascular
anastomosis was performed after transferring and fixing the fascia flap to the recipient site; (F) skin grafting was
performed; (G) the fascia flap and grafted skin survived well at 1 wk after operation; and (H) at 4 mo follow-up, the
appearance of recipient site was even and without dysfunction. (Color version of figure is available online.)
 y a n g e t a l f a s c i a fl a p s f o r r e p a i r i n g d e e p t o e u l c e r
designed and harvested an ATFL flap according to the size of the recipient
site (Fig. 2C and D). Then, we transferred and fixed the fascia flap to the
wound and performed the vascular anastomosis and skin grafting (Fig. 2E
and F). The fascia flap and the grafted skin survived well after the surgery
(Fig. 2G). After 8 mo of follow-up, the functional recovery and
appearance of the toe were acceptable with special footwear, without any
recurrence of the disease (Fig. 2H).
Discussion
It is obvious that limb loss would have profound negative impacts not
only on individuals’ daily activities but also on their physical and mental
health status. Diabetic foot, espe-cially ulcer of the toes, is one of the most
common compli-cations in diabetic patients. Deep toe defects usually
result in tendon or bone exposure, which may eventually lead to
osteomyelitis. Flap transplantation is frequently an alterna-tive method to
treat deep toe defects when patients refuse to have their toes amputated.
Microsurgery reconstruction had been regarded as one of the main
contraindications in di-abetics with lower limb ulcerations as peripheral
7,8
arterial diseases may increase the risk of flap avascular necrosis
However, in recent years, mounting evidence had shown the advantages
of free flaps for reconstruction in the diabetic foot. Free flaps cover the
wound defects and simultaneously improve the blood circulation in the
affected feet. Meta-analysis of a systematic review conducted by Oh et al.
demonstrated that the 5-year survival rate of diabetic patients who had had
skin flap transplantation for limb salvage was as high as 84.9%, thereby
improving the quality of life for pa-tients suffering from diabetic foot
9
ulcers.
Several classic free flaps were often selected for covering the defects
that span a large area of the lower limbs. However, the use of small free
flaps for reconstructing small-size toe defects significantly increased the
difficulty of the procedure along with increasing the incidence of
postoperative compli-cations. This is because harvesting the small-size
flaps and anastomosing small vessels both require sophisticated sur-gical
procedures. Also, small vessel anastomosis increased the risk for skin flap
ischemia and anastomotic embolization in diabetic patients. In addition,
according to our previous study, many flap revisions, after
reestablishment, were performed because when we tried to repair the toe
defects with multiple small-size free flaps (anterolateral thigh flaps,
medial upper arm flaps, groin flaps, and so forth), they had a bloated
appearance and functional shortage.
Fascia flaps, especially the ATFL flap and STF flap, are widely used in
the reconstruction of tissue defects because of their advantages, including
flexibility, toughness, thin flaps, and abundant blood. The ATFL flap is
mainly clinically applied in the repair of abdominal wall and Achilles
10
tendon, whereas the STF flaps showed their merits in reestablishing the
11
head, face, and other parts of the body’s soft tissue defects. In this
article, the free vascularized fascia flaps combined with skin grafting were
effectively applied in treating diabetic patients with deep toe ulcers. Their
advantages are as follows: (1) a relatively simple operation: It is not
difficult to harvest the ATFL flaps compared with the small anterolateral
thigh flaps. The STF flap
171
is characterized by an invariable anatomical relationship with relatively
simple harvesting procedures. (2) Esthetic outcome: toe wounds repaired
by conventional free flaps always engender adverse consequences like
bloated appearance, which needs further revision. Although the ATFL
flaps and STF flaps are thin enough, the vascularized fascia flaps,
combined with skin grafting, are thinner than them. (3) Better deform-
ability: both of these two fascia flaps show soft textures and abundant
blood supply. They can be easily clipped for covering multiple toe defect
wounds (in case 2). Moreover, they are flexible enough to be folded to fill
the lacuna of a wound. (4) Rich blood supply: abundant blood supply of
fascia flaps could in-crease the regional blood flow at the donor site,
which could also provide a better infection control against wounds such as
osteomyelitis (as in case 2). Besides, the vessels of both the ATFL flap and
STF flap have a wide diameter. It is equivalent of reconstructing another
major blood vessel in the dorsum of the foot after the end-to-side
anastomosis to the dorsalis pedis artery. This method will greatly improve
the foot blood supply and reduce the incidence of foot ulcers. (5) For
reconstruction of joint capsule: owing to their reliable toughness, fascia
flaps are helpful in reconstructing the joint capsule and improving toe
function for patients with joint capsule defect and articular cavity
exposure.
12,13
It is important to establish the presence of a peripheral vascular
disease to assess the recipient site vessel conditions before the patient is
recommended to undergo the surgery. Routine physical examinations
(checking arterial pulsation, evaluating toe capillaries filling reaction, and
so forth) and ultrasonic Doppler should be performed for all patients to
assess the vascular status of their lower extremities. If the vascular status
is uncertain, CT-angiography, MRA, or even invasive angiography should
be recommended. All of those preoperative examinations are very
beneficial to improve the success rate of operation. For those patients with
lower limb vascular occlusion or stenosis, interventional surgery (balloon
dilatation, and so forth) for vascular recanalization should be performed
timely. Microsurgery is not recommended for pa-tients for whom balloon
dilatation failed to not effectively recanalize the vasculature. In the cases
that we dealt with, flaps in nine patients who suffered from normal lower
limb vascular status survived completely. Six patients who un-derwent
balloon dilatation had improved lower limb blood supply. However, two
patients suffered from partial skin grafting ischemic necrosis of fascia
flaps and eventually un-derwent amputation. Based on the analysis of 15
cases, we consider it quite safe and efficient for patients with normal
lower limb vascularity to receive fascia flap transplantation. However, for
those with abnormal lower limb vascular status, especially with anterior
tibial artery abnormality, high risks of ischemic necrosis still existed even
when the vascular recanalization was performed. In addition, we reviewed
our experience with perioperative comprehensive therapy in diabetes
patients, and it is very important to work closely with internal medicine,
such as glycemic control and other basic diseases treatment.
Although our method provides several advantages, it still has the
following limitations: (1) postoperative observation of the blood
circulation of the fascia flaps is difficult. After free transplantation of the
STF flaps followed by thin split-
172 journalofsurgicalresearch
skin grafting, gauze was wrapped around the operational area which made
it difficult to observe the blood circulation of the fascia flaps with the
naked eye. We propose that this can be circumvented by using an
ultrasonic doppler exami-nation. (2) A traditional pressure dressing after
skin grafting was also not suitable for the operation area in the cases that
we studied as it would have affected the survival rate of the skin grafts.
Conclusion
This study provides a useful method for repairing deep toe ulcer in
diabetic patients using free vascularized fascia flap combined with skin
grafting. This method offers the advan-tages of an accepted esthetic
outcome, abundant vascularity, simple operation, and good deformability
that deserve further research and extension. However, it is important to
assess the peripheral vascular status comprehensively before perform-ing
the surgery as poor peripheral vascular status would lead to a failure of the
transplantation.
Acknowledgment
The authors confirm that none of the authors have any con-flict of interest.
Author’s contributions: X.Y. and Z.F. contributed equally to this work
and should be considered as co-first authors. X.Y., Z.F., and D.H.
contributed to the study conception and design. Z.F., M.L., and Y.Z.
contributed to the acquisition of data and drafting of the article. Q.C.,
K.T., and J.H. contributed to the analysis and interpretation of data,
literature review, and critical revision. The Department of Burns and
Cutaneous Surgery, Xijing Hospital, Fourth Military Medical University
was acknowledged for proving unrestricted grants.
Disclosure
The authors reported no proprietary or commercial interest in any product
mentioned or concept discussed in this article.
n o v e m b e r 2 0 1 8 ( 2 3 1 ) 1 6 7 e1 7 2
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