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\begin{document}

\title{Reconstruction of Achilles region defects: a single-center experience}



\author[1]{Cengiz Eser}%
\author[1]{Ozgün İlke Karagöz Ceylan}%
\author[1]{Eyuphan Gencel}%
\author[1]{Ibrahim Tabakan}%
\author[1]{Ömer Kokaçya}%
\author[1]{Metin Yavuz}%
\affil[1]{Cukurova University Faculty of Medicine}%


\vspace{-1em}



  
  \date{May 27, 2024}


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\selectlanguage{english}
\begin{abstract}
Background: Reconstruction of Achilles tendon and the overlying tissue
defects is a challenging undertaking. The spectrum of available repair
methods range from secondary healing to use of free flaps. Method: In
this study, we retrospectively evaluated 14 patients who underwent
reconstruction of Achilles region defect between 2016 and 2019 at a
single center. Results: Reconstructions were performed with secondary
healing (n=2), negative pressure wound therapy and skin grafting (n=2),
free flaps (n=6), and local and distant flaps (n=4). Satisfactory
aesthetic and functional outcomes were achieved in all patients. One
patient developed partial skin graft loss. Marginal necrosis occurred in
one of the local flaps. Wound dehiscence and flap retraction occurred in
one of the free (superficial circumflex iliac artery perforator) flaps.
One patient undergoing reconstruction with ulnar artery perforator flap
developed intraoperative atrial fibrillation; the operation was
terminated and reconstruction completed with skin grafting. Conclusion:
Orthoplastic reconstruction should be kept in mind for Achilles tendon
defects. Use of special digital imaging techniques facilitates flap
surgery and helps minimize the risk of flap complications. Conventional
approaches are suitable for shallow small skin lesions. Local flaps are
good options for deeper skin defects owing to superior aesthetic
outcomes. Superthin free flaps offer a distinct advantage in skillful
hands. Use of multi-content free chimeric flaps for reconstruction of
complex defects facilitates better anatomical repair. Cross leg or
flow-through flaps may be considered in patients with compromised distal
circulation. Selection of the most reliable approach for Achilles
reconstruction is a key imperative to achieve favorable outcomes.%
\end{abstract}%



\sloppy


\textbf{Introduction}

Reconstruction of defects of Achilles tendon and overlying tissues is a
challenging undertaking\textsuperscript{1,2}. These defects are
typically caused by trauma, infection, or excision of
tumors\textsuperscript{3}. The relatively poor blood perfusion and the
thin overlying skin renders this area vulnerable to trauma and
complications\textsuperscript{4}. Several different approaches are used
for reconstruction of the Achilles region depending upon the mechanism
of trauma and individual factors. The type of reconstruction is
determined based on several factors including the length of achilles
tendon defect, the extent of loss of overlying tissues, and the general
health of the patient. The spectrum of repair methods range from
secondary healing to use of free flaps\textsuperscript{5-9}. Owing to
the challenging nature of Achilles reconstruction, selection of the most
reliable option is a key imperative to achieve favorable outcomes.

In the contemporary literature, there is no clear consensus on the
optimal approach for reconstruction of defects of the Achilles tendon
and the overlying tissues. In this study, we describe our treatment
methods for repair of Achilles region defects and evaluated the outcomes
of Achilles region reconstruction in a cohort of patients treated at a
single center over a 4-year period.

\textbf{Patients and methods}

This study was conducted in accordance with the Helsinki Declaration
after the approval of the local ethics committee. Fourteen patients
(four female and ten male) who underwent surgical reconstruction of
Achilles region defect between 2016 and 2019 were retrospectively
evaluated. The mean age of patients was 39 years. If required, surgical
debridement was performed prior to final reconstruction. The size of
skin-soft tissue loss, length of the Achilles tendon defect, exposure of
vital structures (bone, tendon, vessel, nerve, joint, or foreign
material), sensation, motor function, and perfusion were evaluated and
abnormal findings noted. Patients were operated under local or general
anesthesia depending on operative needs. All interventions were
performed by the same team. Details pertaining to patient demographics,
etiology, size/content of the defect, reconstruction, and
complications/reoperations are summarized in Table 1.

\textbf{Reconstruction with secondary healing and split thickness skin
graft}

In secondary healed cases, medical dressings were applied once a day
(chlorhexidine acetate 0.5\% w/w tulle gras) taking into account the
rules of asepsis and antisepsis. Negative pressure wound therapy (NPWT)
was performed with 80 mm Hg continuous mode. In patients who underwent
skin grafting, split thickness skin grafts (STSGs) were obtained with an
electric dermatome under general anesthesia. After grafting, bolster
dressing was applied onto the graft and short leg splint was used for
seven days. Bolster dressing was removed three days after the
application and wound care continued with skin pomade including 2\%
Mupirocin.

\textbf{Reconstruction with local and free flaps}

Local rotation flaps were harvested based on preoperatively identified
perforator using handheld Doppler or angiography. We used superselective
angiography (SSA) for detection of specific peroneal perforator (Fig.
1). The pedicled hatchet shaped flaps were harvested based on posterior
tibial artery perforasomes zone, as described by Abraham et al (Fig.
2)\textsuperscript{10}. Cross-leg reverse sural flap was performed as
described in our previous study\textsuperscript{11}. Anastomosis of free
medial sural artery perforator (MSAP) (Fig. 3), superficial circumflex
iliac artery perforator (SCIP) (Fig. 4) and anterolateral thigh (ALT)
flaps were performed in the end-to-side fashion; the cross-leg free
latissimus dorsi (LD) and anterolateral thigh-tensor fascia lata
(ALT-TFL) flaps (Fig. 5) were anastomosed to the posterior tibial
vascular system in a flow-through fashion. All patients scheduled for
free flap reconstruction underwent preoperative computed tomography (CT)
or magnetic resonance angiography to identify the recipient vessels and
the vascular pedicle. Peroperative Indocyanine Green Angiography (ICGA)
was performed in cases with suspect free or local flap circulation. In
patients who underwent local or free flap repair, short leg splint was
applied for postoperative seven days. In patients who received cross-leg
flaps, postoperative stabilization was achieved by external fixator or
cast splints. Pedicles were cut on day ten after the first session. All
patients were followed up at 1st and 6th postoperative months.

\textbf{Results}

All patients showed satisfactory appearance, color, and texture of the
repaired area. Moreover, all patients exhibited satisfactory functional
recovery of the injured limb. None of the secondary healed cases
developed any wound-related problems. Partial loss of STSG was observed
in one patient owing to non-compliance with immobilization. In one of
the local flaps, marginal necrosis occurred at the location determined
with ICGA (Case 11). Wound dehiscence and flap retraction occurred in
one of the free flaps (SCIP) due to excessive mobilization of the
patient. The problem was solved by flap advancement and secondary suture
(Fig. 4). One of the patients in whom ulnar artery perforator flap was
used developed atrial fibrillation during the surgery (Case 8). The
operation was terminated due to the emergency and reconstruction
completed with NPWT and STSG.

\textbf{Discussion}

Achilles region reconstruction is one of the most challenging topics of
lower limb repair for plastic surgeons. The Achilles tendon is the
strongest tendon of the body and has a very thin and supple overlying
skin. The tibial neurovascular bundle is located just medial to the
Achilles tendon. Several factors should be carefully evaluated to ensure
successful outcomes of reconstruction; these include age of the patient,
exposed vital structures, size of the defect, comorbid diseases,
presence of scars, history of previous surgery, infection, medications,
smoking, and patient expectations.\textsuperscript{1,2} During
reconstruction in this region, neurovascular bundle repair and
tendon-skin-soft tissue reconstruction can be performed together or
sequentally, as per need. In the presence of a ruptured, necrotic or
weakened tendon, reconstruction should be performed concomitantly with
soft tissue-skin repair. Therefore, the orthoplastic approach is
neccessary for such repairs.

According to the meta-analysis and algorithm developed by Hackenberg et
al.\textsuperscript{9}, primary tendon suturation is suitable for repair
of defects sized \textless{} 2 cm; V-Y tendinoplasty, tendon transfer,
tendon rotation, plantaris, flexor hallucis longus, peroneus brevis and
flexor digitorum longus tendon plasties and combinations can be applied
for defects ranging from 2--5 cm in size. For Achilles defects sized
6--10 cm, free tendon/muscle transplantations, fascia replacement
plasties, allografts, or synthetic materials can be used. Several
surgical interventions have been described for reconstruction of soft
tissue defects, ranging from secondary skin healing to use of free flaps
and amputation; the choice depends upon exposure of vital structures and
tissue vascularity.\textsuperscript{12,13} According to Monnere et
al.\textsuperscript{14}, adequate neo-Achilles tendon can be formed with
skin-soft tissue reconstruction without Achilles tendon repair. However,
according to a meta-analysis by Ochen et al.\textsuperscript{15},
operative treatment is associated with reduced rate of re-rupture of the
Achilles tendon. In our opinion, it seems reasonable to perform
operative treatment for Achilles tendon rupture.

In the present study, three patients had injuries in the form of skin
abrasions. Secondary healing was achieved by medical dressings performed
in the outpatient setting. Ankle foot orthoses were used for one week in
these patients with the ankle in the neutral zero position to improve
wound healing. At the end of one week, full motion was allowed with open
dressing. Secondary healing is beneficial for clean Achilles wounds with
small overlying skin defects. Repta et al.\textsuperscript{16} employed
STSG following NPWT therapy for repair of tendon exposure and skin
defect in patients with peripheral vascular disease. We also achieved
satisfactory results with NPWT plus STSG treatment in two patients with
diabetes mellitus and in one patient in whom the free flap operation had
to be stopped due to peroperative atrial fibrillation (Case 8). However,
prolonged hospitalization and graft adaptation problems are some of the
drawbacks of this approach. Application of NPWT plus STSG treatment is
particularly appropriate for patients with small skin defects, those
with compromised vascular supply, or for whom free flaps cannot be
applied. Although conventional methods such as secondary healing, NPWT,
and skin grafts are preferred in some patients, development of infection
in this region is liable to impair epithelialization and graft
adaptation. In addition, it is difficult to achieve long-term stable
coverage with conventional treatment due to chronic shoe friction.

Use of local flap is another option; however, use of local flap around
the Achilles region entails a certain degree of risk. Distal lower
extremity is a relatively dangerous part of the body for use of local
flaps. Owing to this issue, perforator or perforator based flaps have
been inreasingly used in recent years\textsuperscript{17,18}. We
performed perforator based flap reconstructions for shallow small skin
defects. Use of local flap not only helps maintain the color but also
allows for shallow skin replacement. The main problem in this area is to
find a reliable perforator for flap nourishment. For this purpose, we
relied on Mohan's hot spot theory\textsuperscript{19} and performed
superselective angiography to identify the reliable perforator located
nearest to the defect.

On the other hand, in terms of anatomic replication, the thickness of
flap used in the Achillles area should be very thin. Currently,
supermicrosurgical techniques allow for repair of shallow skin-soft
tissue defect repairs with use of super-thin free flaps by skilled
operators. Suprafascial flap dissection, perforator dissection, and
perforator to perforator anastomosis are main challenges in
supermicrosurgery. Using this principle, Hong et
al.\textsuperscript{20}have described foot and Achilles repairs with use
of super-thin gluteal perforator flaps and posterior interosseous
perforator flaps. Since super-thin free flaps contain only superficial
subcutaneous tissue and skin, these might be suitable alternatives for
reconstruction of skin overlying the Achilles tendon. These flaps can be
harvested and anastomosed based on perforator vessels without causing
any damage to the main vessels in the donor and recipient
areas\textsuperscript{21}. While the aforementioned repair techniques
require a very high level of surgical skill and instrumentation, donor
area scars (gluteal and dorsal forearm) may not be preferred in some
patients. In our study, free SCIP and MSAP flaps were used for this area
in two patients. The main purpose of SCIP flap application was to create
a thin layer where the shoe is in contact with the Achilles region. The
MSAP flap was applied to adhere to the principle of not changing the
position of the patient during surgery and using a thin flap again. The
main drawback with the use of MSAP flap is that pedicle dissection is
relatively difficult. However, appropriate postoperative results were
obtained with both flaps.

As mentioned earlier, concomitant repair of soft tissue and tendon can
be performed in the Achilles region. Lin et
al.\textsuperscript{22}performed skin-soft tissue reconstruction with
posterior tibial perforator flap while repairing the Achilles tendon
with free fascia lata graft. They mentioned that this approach can be
used safely, especially in children. Although, this approach offers the
advantage of single-stage surgery and avoidance of free flap
complications in children, a more anatomical repair may be preferred
with single-session composite flaps in such cases. Li et
al.\textsuperscript{23} performed NPWT therapy and free flap surgery
following prompt debridement, and achieved satisfactory results in
children with mangled extremities. Dobke et al.\textsuperscript{24} used
the free temporopatietal fascia flap for soft tissue repair and the
galeal extension of the fascia for Achilles tendon reconstruction.
Although they achieved long-term stable tendon repair, a long scar in
the scalp, especially in males, can be considered as a major drawback of
this method. In addition to previous options, the number of multiple
donor areas can be reduced to a single area by using chimeric free
flaps. Wei et al.\textsuperscript{25} used composite free groin flaps
for complex Achilles region reconstructions. In addition to tendon
reconstruction, they also performed calcaneal bone and skin-soft tissue
reconstruction. While the main advantage of the mentioned flap is their
thinness and composite nature, the long-term risk of abdominal hernia
can be considered as a disadvantage. Deiler et al.\textsuperscript{5}
performed reconstruction of complex Achilles region defects with free
composite TFL flap. The fascial component of the flap was used for
Achilles tendon reconstruction, while the skin portion was used for
reconstruction of the overlying tissue. The disadvantage of this
approach is that it may require debulking for good aesthetic results,
especially in patients who have thick skin-subcutaneous tissue on the
lateral aspect of thigh.

The technique of flow-through repair was first described by Soutar et
al.\textsuperscript{26} in 1983. Ever since, this technique has been
used to protect the circulation in the distal extremity, especially in
traumatic complicated lower extremity defects. Several reports have
described the use of this approach for the reestablishment of
circulation in the extremity and repair of complicated lower limb
defects. Koshima et al.\textsuperscript{27} used the thin LD perforator
flap, \selectlanguage{ngerman}Özkan et al.\textsuperscript{23} used the radial forearm flap, and
Yang Z et al.\textsuperscript{24} used the ALT flap in flow-through
fashion. However, significant scarring and seroma problems in the donor
area may restrict the use of these flaps.

Especially in single artery extremities, without harming the remainder
artery, cross-leg free flow-through, cross-leg pedicled or cross-leg
flow-through flaps can be used as alternatives to flow-through free
flaps\textsuperscript{28-30}. In the present study, we used cross-leg
reverse sural artery flap (CLRSAF) and cross flow-through LD (CFTLD)
flap in order to protect the exposed Achilles tendon. We obtained
satisfactory resuls with both flaps; however, postoperative awkward
position is the main drawback of this approach. Instead of a free flap
surgery, the main reasons for using CLRSAF were previous operations in
dorsal leg and single artery extremity. Circulation of the CLFTLD flap
was preferred from the opposite extremity because the patient was in the
subacute traumatic period according to Godina's timing of microvascular
reconstruction, and was exposed to electrical burns. Both reasons may
cause thrombotic events after free flap
surgeries.\textsuperscript{31,32}

In addition to use of flow-through flaps, repairing the affected nerve
in the distal limb complex defects is of special importance. Agarwal et
al.\textsuperscript{33} transferred saphenous nerve to the posterior
tibial nerve, which helped restored protective sensations in the heel.
One of the patients in the present study had a complex defect involving
the Achilles tendon, posterior tibial artery, vein, and nerve. The
tendon and vessels were reconstructed with composite flow-through
ALT-TFL flap while the posterior tibial nerve was grafted with the
contralateral proximal sural nerve graft. This was because the patient's
distal sural nerve had burned and the proximal healthy sural nerve was
nonfunctional. The patient was able to walk two months after the
operation; EMG performed one year after the operation showed restoration
of protective sensation in the heel. Using this method, the three main
vital structures and the skin were reconstructed in a single operation.

Pre- and postoperative imaging is very important in the context of
complex repairs. In the present study, vascular structures were
evaluated preoperatively with color Doppler, CT, or MRI angiography.
While planning the local flaps, we were inspired by the perforator zones
and hot spots described by Taylor, Abraham, Saint Cyr, and Mohan. Most
hot spots can be found adjacent to joints and at the midpoint between
two joints in the extremities; however, in the trunk, the perforators
are clustered parallel to the posterior and anterior midline, and in the
midaxillary regions\textsuperscript{10,19,34,35}. We performed
superselective digital substraction
angiography\textsuperscript{36}(SDSA) in one patient who had a small
skin defect over the Achilles tendon. SDSA helped identify the
stereotaxic location and direction of the perforator located nearest to
the defect (Fig. 1b). Finally, similar to an axial flap, we harvested a
perforator based flap according to the course of the perforating vessel,
and avoided the risk of necrosis. Moreover, this approach complied with
the `like to like reconstruction' principle. We believe that this method
allows for harvesting of reliable pedicled flaps and application of
`like to like repair' even in the coldspot regions specified by Mohan et
al\textsuperscript{19}. Of course, high radiation dose is the most
important drawback of this method. IGA, which is frequently used to
evaluate the viability of mastectomy skin flaps, has recently been
applied for assessment of skin flaps prior to their
transfer\textsuperscript{37,38}. IGA helps identify the viable portion
of the flap and the location of the nutrient vessels. In our study, we
also performed IGA for the perforator flap harvesting and free flap
follow-up. Use of IGA helped decrease the flap dissection time, avoided
dissection errors, and decreased the risk of flap necrosis.

The main limitations of this study was the small number of patients.
Although lower leg injuries are frequently encountered in clinical
practice, the focus of this study was specifically on the Achilles
region, and not the whole lower limb.

\textbf{Conclusion}

Reconstruction of the Achilles tendon and the overlying skin
necessitates in-depth knowledge of the lower leg reconstructive
armamantorium. Orthoplastic reconstruction should keep in mind for
tendon defects. Special digital imaging facilitates flap surgery and may
reduce the risk of flap complications. Conventional approaches are
suitable for shallow small skin lesions of the Achilles region. For
deeper skin defects, local flaps are good options for good aesthetic
outcomes. In addition, super-thin free flaps provided excellent results
in skillful hands. For complex defects, use of multi-content free
chimeric flaps for reconstruction allows for better anatomical repair.
Cross-leg or flow-through flaps may be considered for Achilles repairs
in patients with compromised distal circulation. Selection of the most
reliable approach for Achilles reconstruction is a key imperative to
achieve favorable outcomes.

Conficts of interest: None

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\textbf{Figure Legends:}

Figure 1: The patient whose defect was repaired with PAP based rotation
flap

\begin{enumerate}
\tightlist
\item
  Posterior view of skin-soft tissue defect.
\item
  Digitally substracted view of superselective angiography of PAP. The
  flap was designed according to the suitable perforator located nearest
  to the defect.
\item
  The designed PAP based rotation flap
\item
  Two years follow-up
\end{enumerate}

PAP: Peroneal artery perforator

Figure 2: Shallow Achilles overlying skin reconstruction with PTA based
hatchet flap

\begin{enumerate}
\tightlist
\item
  Acute defect of the skin overlying the Achilles tendon
\item
  Harvested medially based hatched fasciocutaneous flap (yellow spots
  show probable location of PTA perforators)
\item
  Two years follow-up
\end{enumerate}

PTA: posterior tibial artery

Figure 3: Traumatic Achilles region defect reconstructed with free MSAP
flap

\begin{enumerate}
\tightlist
\item
  Unhealed Achilles overlying skin defect
\item
  The harvested MSAP flap
\item
  Two months follow-up
\end{enumerate}

MSAP: medial sural artery perforator

Figure 4: Achilles overlying skin defect reconstruction with free SCIP
flap

Exposed Achilles tendon

Advanced and re-sutured SCIP flap

SCIP: superficial circumflex iliac artery perforator

Figure 5: The patient whose composite Achilles region defect were
repaired with flow-through ALT-TFL chimeric flap and sural nerve graft.

\begin{enumerate}
\tightlist
\item
  Medial view of perforated and burnt lower extremity due to hot metal
  injury
\item
  Peroperative view of the posterior tibial neurovascular defect
\item
  Inset of flow-through ALT-TFL chimeric flap. Note that the TFL mimics
  Achilles tendon, the vascular pedicle mimics the posterior tibial
  artery and vein, and the sural nerve graft mimics the posterior tibial
  nerve
\item
  Two years follow-up
\end{enumerate}

PSPTN: Proximal stump of posterior tibial nerve; PVS: proximal vascular
stump; DSPTN: distal stump of posteriot tibial nerve; DVS: distal
vascular stump; ALT: anterolateral thigh; TFL: tensor fascia lata; LCFA:
lateral Circumflex Femoral Artery; FTP: flow-through pedicle, NG: nerve
graft

Table 1:\selectlanguage{english}
\begin{longtable}[]{@{}lllllllll@{}}
\toprule
\textbf{Case} & \textbf{Age/Sex} & \textbf{Etiology} &
\textbf{Size/Content of the Defect} & \textbf{Reconstruction} &
\textbf{Reconstruction} & \textbf{Reconstruction} &
\textbf{Complication/Secondary Procedure} &
\textbf{Complication/Secondary Procedure}\tabularnewline
\midrule
\endhead
1 & 80/f & Necrotizing fasciitis & 20\selectlanguage{ngerman}×20 cm/skin and exposed Achilles &
Debridement +NPWT+STSG & Debridement +NPWT+STSG & Debridement +NPWT+STSG
& 20\% graft loss/Regrafting & 20\% graft loss/Regrafting\tabularnewline
2 & 3/m & Traffic accident & 3\selectlanguage{ngerman}×3 cm/skin-soft tissue & NPWT+STSG &
NPWT+STSG & NPWT+STSG & None & None\tabularnewline
3 & 12/f & Trapped by bicycle chain & 3\selectlanguage{ngerman}×3 cm/skin-soft tissue and
exposed foreign matterial & Cross-leg Reverse Sural Flap & Cross-leg
Reverse Sural Flap & Cross-leg Reverse Sural Flap & None &
None\tabularnewline
4 & 35/m & Trapped by motocycle chain & 4\selectlanguage{ngerman}×3 cm/skin-soft
tissue+superficial tendon & Free MSAP flap & Free MSAP flap & Free MSAP
flap & None & None\tabularnewline
5 & 41/m & Trapped by bicycle chain & 4\selectlanguage{ngerman}×4 cm/skin-soft tissue & Free
SCIP flap & Free SCIP flap & Free SCIP flap & Flap dehiscence/Secondary
suture & Flap dehiscence/Secondary suture\tabularnewline
6 & 82/f & Shoe trauma & 2\selectlanguage{ngerman}×1 cm skin/soft tissue & Secondary healing &
Secondary healing & Secondary healing & None & None\tabularnewline
7 & 2/m & 3rd degree scald burn & 2\selectlanguage{ngerman}×2 cm/skin-soft tissue & Secondary
healing & Secondary healing & Secondary healing & None &
None\tabularnewline
8 & 55/m & PAOD & 3\selectlanguage{ngerman}×2 cm/skin-soft tissue+superficial tendon & Free
ulnar artery perforator flap & Free ulnar artery perforator flap & Free
ulnar artery perforator flap & Total flap loss/NPWT+STSG & Total flap
loss/NPWT+STSG\tabularnewline
9 & 59/m & Hot metal burn & 17\selectlanguage{ngerman}×14 cm/skin-soft tissue+tendon+PTNVS &
Free flow-through ALT\_TFL composite flap+Sural nerve graft & Free
flow-through ALT\_TFL composite flap+Sural nerve graft & Free
flow-through ALT\_TFL composite flap+Sural nerve graft & None &
None\tabularnewline
10 & 23/m & Trapped by motocycle chain & 4\selectlanguage{ngerman}×5 cm/skin-soft
tissue+superficial tendon & Posterior tibial perforator based hatchet
flap & Posterior tibial perforator based hatchet flap & Posterior tibial
perforator based hatchet flap & None & None\tabularnewline
11 & 19/f & Trapped by bicycle chain & 3\selectlanguage{ngerman}×3 cm/skin-soft tissue &
Posterior tibial perforator based hatchet flap & Posterior tibial
perforator based hatchet flap & Posterior tibial perforator based
hatchet flap & Marginal necrosis & Marginal necrosis\tabularnewline
12 & 27/m & Trapped by motocycle chain & 3\selectlanguage{ngerman}×1 cm/skin-soft tissue &
Detected peroneal perforator based rotation flap & Detected peroneal
perforator based rotation flap & Detected peroneal perforator based
rotation flap & None & None\tabularnewline
13 & 45/m & Necrotizing fasciitis & 25\selectlanguage{ngerman}×14 cm /skin-soft
tissue+superficial tendon & Flow-through free LD flap+STSG &
Flow-through free LD flap+STSG & Flow-through free LD flap+STSG & None &
None\tabularnewline
14 & 61/m & Excision of malignant mesenchymal tumor & 4\selectlanguage{ngerman}×4 cm/skin-soft
tissue & Free ALT flap & Free ALT flap & Free ALT flap & None &
None\tabularnewline
STSG: split thickness skin graft; NPWT: negative pressure wound therapy;
MSAP: medial sural artery perforator; SCIP: superficial circumflex iliac
artery perforator; PAOD: peripheral arterial occlusive disease; PTNVS:
posterior tibial neurovascular system; ALT: anterolateral thigh; TFL:
tensor fascia lata; KIPF: Keystone island perforator flap; LD:
latissimus dorsi. & STSG: split thickness skin graft; NPWT: negative
pressure wound therapy; MSAP: medial sural artery perforator; SCIP:
superficial circumflex iliac artery perforator; PAOD: peripheral
arterial occlusive disease; PTNVS: posterior tibial neurovascular
system; ALT: anterolateral thigh; TFL: tensor fascia lata; KIPF:
Keystone island perforator flap; LD: latissimus dorsi. & STSG: split
thickness skin graft; NPWT: negative pressure wound therapy; MSAP:
medial sural artery perforator; SCIP: superficial circumflex iliac
artery perforator; PAOD: peripheral arterial occlusive disease; PTNVS:
posterior tibial neurovascular system; ALT: anterolateral thigh; TFL:
tensor fascia lata; KIPF: Keystone island perforator flap; LD:
latissimus dorsi. & STSG: split thickness skin graft; NPWT: negative
pressure wound therapy; MSAP: medial sural artery perforator; SCIP:
superficial circumflex iliac artery perforator; PAOD: peripheral
arterial occlusive disease; PTNVS: posterior tibial neurovascular
system; ALT: anterolateral thigh; TFL: tensor fascia lata; KIPF:
Keystone island perforator flap; LD: latissimus dorsi. & STSG: split
thickness skin graft; NPWT: negative pressure wound therapy; MSAP:
medial sural artery perforator; SCIP: superficial circumflex iliac
artery perforator; PAOD: peripheral arterial occlusive disease; PTNVS:
posterior tibial neurovascular system; ALT: anterolateral thigh; TFL:
tensor fascia lata; KIPF: Keystone island perforator flap; LD:
latissimus dorsi. & & & &\tabularnewline
\bottomrule
\end{longtable}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/fig-1/fig-1}

\end{center}
\end{figure}\selectlanguage{english}
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\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/fig-2/fig-2}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/fig-3/fig-3}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/fig-4/fig-4}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/fig-5/fig-5}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

