It is usually a major task providing soft tissue cover to significant defects of the lower leg. A wide variety of flaps and techniques are available, each with its advantages and limitations. Previously described anatomic study of the septocutaneous vessels of the leg have indicated a consistent lower most perforator at 9-12 cm from the tip of the medial malleolus. An island fasciocutaneous flap based on this perforator vessels can be raised subfascially. After the vessels have been dissected clean down to the posterior tibial artery, it can be rotated up to 180 degrees degrees. Successful soft tissue reconstruction was achieved in 18 patients. Most of the tissue loss was due to trauma and were around the ankle and the heel. There were 7 minor complications which resolved completely after 2 months. Its simplicity of design and elevation plus its extensive arc of rotation makes it a reliable and versatile flap in the reconstruction of lower leg defects.
Postoperative prostate radiotherapy requires large planning target volume (PTV) margins to account for motion and deformation of the prostate bed. Adaptive radiation therapy (ART) can incorporate image-guidance data to personalize PTVs that maintain coverage while reducing toxicity. We present feasibility and dosimetry results of a prospective study of postprostatectomy ART. Twenty-one patients were treated with single-adaptation ART. Conventional treatments were delivered for fractions 1 to 6 and adapted plans for the remaining 27 fractions. Clinical target volumes (CTVs) and small bowel delineated on fraction 1 to 4 CBCT were used to generate adapted PTVs and planning organ-at-risk (OAR) volumes for adapted plans. PTV volume and OAR dose were compared between ART and conventional using Wilcoxon signed-rank tests. Weekly CBCT were used to assess the fraction of CTV covered by PTV, CTV D99, and small bowel D1cc. Clinical metrics were compared using a Student's t-test (p < 0.05 significant). Offline adaptive planning required 1.9 ± 0.4 days (mean ± SD). ART decreased mean adapted PTV volume 61 ± 37 cc and bladder wall D50 compared with conventional treatment (p < 0.01). The CTV was fully covered for 96% (97%) of fractions with ART (conventional). Reconstructing dose on weekly CBCT, a nonsignificant reduction in CTV D99 was observed with ART (94%) compared to conventional (96%). Reduced CTV D99 with ART was significantly correlated with large anterior-posterior rectal diameter on simulation CT. ART reduced the number of fractions exceeding our institution's small bowel D1c limit from 14% to 7%. This study has demonstrated the feasibility of offline ART for post-prostatectomy cancer. ART facilitates PTV volume reduction while maintaining reasonable CTV coverage and can reduce the dose to adjacent normal tissues.