Reconstruction of soft tissue defects in the Achilles tendon
region with perforator-based fasciocutaneous flaps
Received: 3 April 2013 / Accepted: 28 June 2013 / Published online: 20 August 2013
Springer-Verlag Berlin Heidelberg 2013
Background Reconstruction of soft tissue defects in the
Achilles tendon region can be technically demanding.
Perforator-based flaps can be an effective local solution,
replacing like-for-like skin. We report our experience with
perforator-based flap reconstruction of the Achilles tendon
region with or without rupture of the Achilles tendon.
Methods Between January 1999 and 2011, 11 patients had
perforator-based flaps based on peroneal and posterior tibial
perforators. There were six V-Y advancement flaps, four
propeller flaps and one peninsular flap. The mean defect size
was 19.3 (range 9–36)cm
. One patient had reconstruction of
a composite Achilles tendon defect.
Results There were no flap failures. Mean follow-up was
26.4 (range 3–120)months. Post-operative complications
included haematoma in one patient and dehiscence of wound
because of further sloughing of the tendon—at the distal
edge of a V-Y advancement flap. This patient needed a
second local flap. There were no wound breakdowns, painful
sensitivity or difficulty with walking. All patients who had
skin and soft tissue reconstruction only were partially weight
bearing by 2 weeks and gradually increased weight bearing
and fully weight bearing by 4 weeks.
Conclusions Perforator-based flaps are a robust method of
covering small- to medium-sized defects in the Achilles
tendon region. Presence of multiple perforators on either side
of the Achilles tendon invites a number of flap designs,
tailored to the defect.
Level of Evidence: Level IV, Therapeutic study.
Keywords Achilles tendon
The reconstruction of soft tissue defects overlying the Achilles
tendon is a well-recognised reconstructive challenge. The advent
of microsurgery, however, has greatly increased the armamentar-
ium of reconstructive methods. Moreover, combined defects of
the Achilles tendon and soft tissue can now be simultaneously
addressed with composite local or free flaps [1–3]. Free flap
reconstruction, however, is not without disadvantage.
Long operative time, flap bulkiness, lack of protective
sensation and decreased range of movement at the ankle joint
and donor site morbidity are all disadvantages [4–6]. A pa-
tient’s inability to undergo long surgery due to co-morbidity or
lack of microsurgical facilities may preclude free tissue trans-
With greater understanding of vascular anatomy, distribu-
tion of perforating vessels and flap perfusion, the concept of
perforator flaps emerged [7–9]. These flaps represent an
evolutionary milestone in reconstructive surgery and have
been successfully used to reconstruct soft tissue defects in
the lower leg and foot.
Perforator-based flaps are a further refinement, characterised
by preservation of the source artery. If a perforator-based island
flap can be sufficiently advanced or rotated into the defect,
dissection and division of the source artery becomes unnecessary.
Perforator-based propeller and V-Y advancement flaps
have been used for upper and lower limb reconstruction
and are gaining popularity [10–12]. Local perforator-based
flaps not only achieve the goal of reconstruction but also
minimise the degree of donor site morbidity.
Perforator-based flaps for reconstruction of skin and soft
tissue overlying the Achilles tendon can be based on the
multiple perforators that emerge from either side of the
tendon. These medial or laterally based flaps can be safely
raised and inset into adjacent defects either by advancement
or rotation. The abundance of perforators around the Achil-
les tendon region offers a number of flap designs (Fig. 1).
N. Mopuri (*)
St Andrews Centre for Plastic Surgery and Burns,
Broomfield Hospital, Chelmsford, UK
Eur J Plast Surg (2013) 36:701–706