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Bipedicle Flap for Wounds following Achilles Tendon Repair

Makhlouf, M Vincent M.D.; Obermeyer, Ziad M.Phil.

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Plastic and Reconstructive Surgery: April 2008 - Volume 121 - Issue 4 - p 235e-236e
doi: 10.1097/01.prs.0000305395.82008.96
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Surgical repair of Achilles tendon rupture carries a significant risk of postoperative complications.1 These can culminate in skin loss with the risk of exposure and subsequent necrosis of the tendon. Such skin defects in the distal leg represent a challenge to reconstruction, as complications of tendon repair can further compromise an already poorly vascularized bed. The search for alternatives to simple local flaps has led to more elaborate reconstruction techniques, which carry significant cost in terms of donor-site morbidity, operative complexity, and cosmesis.2–4

We have used a bipedicle fasciocutaneous flap to cover skin defects in three patients, ranging in age from 37 to 52 years old, who experienced wound breakdown following Achilles tendon repair. In all cases, the wound was widely debrided. A longitudinal bipedicle flap was raised lateral to the defect in the subfascial plane, with care taken not to injure the sural nerve. The horizontal width of the flap was designed to be 25 percent greater than the defect itself, and the total vertical length was at least twice the width. The donor site was covered with a partial-thickness skin graft. The ankle was immobilized for 4 weeks in a cast, with a posterior window for wound care. Patients were placed on prophylactic antibiotics for 3 weeks (Fig. 1.)

Fig. 1.
Fig. 1.:
Before and after pictures of a patient with skin defect following tendon repair that was covered with a bipedicle flap. (Above) A frayed Achilles tendon exposed with visible suture material, and the bipedicle flap design. (Below) Satisfactory result after superficial tendon debridement, removal of suture material, and closure (4-year follow-up).

The bipedicle fasciocutaneous flap has the two major advantages of good vascularity and minimal tension. The longitudinal incision preserves axial cutaneous perforators and parallels the orientation of the most widely used incisions for tendon repair, avoiding additional trauma. Perhaps most importantly, the procedure itself is technically straightforward; with an average operative time of less than 1 hour, it can easily be performed in the outpatient setting. Finally, there is minimal donor-site morbidity, and results are satisfying both functionally and cosmetically.

One potential caveat is that we have as yet made use of this technique in only three patients. It is possible that, in the setting of a severely infected or otherwise compromised bed, the bipedicle flap may not provide sufficient coverage. However, the patients described here are representative of the spectrum of patients presenting to the plastic surgeon. The viability of the flap in all cases is encouraging.

M. Vincent Makhlouf, M.D.

Rush North Shore Hospital

Chicago, Ill.

Ziad Obermeyer, M.Phil.

Harvard Medical School

Boston, Mass.


Neither of the authors has any competing financial interests or commercial associations to declare.


1. Khan, R. J. K., Fick, D., Keogh, A., et al. Treatment of acute Achilles tendon ruptures: A meta-analysis of randomized, controlled trials. J. Bone Joint Surg. (Am.) 87: 2202, 2005.
2. Braye, F., Versier, G., Comtet, J. J., et al. Cover of the Achilles tendon by peroneus brevis and flexor hallucis longus flaps: Apropos of 5 clinical cases. Ann. Chir. Plast. Esthet. 41: 137, 1996.
3. Chana, J. S., Chen, H. C., and Jain, V. A new incision for surgery on tendo Achillis using a distally-based fasciocutaneous flap. J. Bone Joint Surg. (Br.) 84: 1142, 2002.
4. Papp, C., Todoroff, B. P., Windhofer, C., et al. Partial and complete reconstruction of Achilles tendon defects with the fasciocutaneous infragluteal free flap. Plast. Reconstr. Surg. 112: 777–83, 2003.

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