PMC4959408_01
Preoperative picture before debridement
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F1
The first patient was attacked by armed robber; he sustained Gustilo 3B open fractures with two soft tissue defects: A lateral one measuring 12 cm x 7 cm and a medial defect 14 cm x 6 cm [Figure 1] with injury to the recurrent sural artery precluding the use of the reversed sural artery flap for wound coverage.
Immediate postoperative picture
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F2
He subsequently had wound coverage with two perforator-based propeller flaps raised from the medial and lateral aspect of the leg [Figure 2].
Follow-up picture 6 weeks postoperatively
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F3
Figure 3 shows the surgical outcome six weeks postoperatively.
Preoperative picture showing exposed Achilles tendon. The cavitation effect of the gunshot damaged the sural artery
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F4
The sural artery was found severed in the wound [Figure 4].
Immediate postoperative picture
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F5
A perforator-based propeller flap was raised to cover the wound and split thickness skin graft was applied to the secondary defect [Figure 5].
Fifth postoperative day
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F6
Flap survived without any area of loss [Figure 6].
Preoperative planning showing the flap outline. Identified perforators were marked as x on the outline
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F7
Perforators in the proposed donor tissue close to the defect were located preoperatively using handheld Doppler (probe) and marked on the skin using methylene blue [Figure 7].