CLINICAL PAPER
Single-Stage Reconstruction of Achilles Tendon and Overlying
Tissue With the Extended Temporoparietal Fasciagaleal
Flap—23-Year Follow-Up and the Review of the Literature
Marek Dobke, MD, PhD, Ahmed Suliman, MD, Gina A. Mackert, MD, Fernando A. Herrera, MD,
Robert Singer, MD, and Jeffrey Nelson, MD
Abstract: In the absence of an established “gold standard” for complex Achilles
tendon and regional soft tissue defect reconstruction, many techniques have been
advocated. Two cases describing a novel technique of successful repair with the
review of literature are presented. The underlying problem consisted of Achilles
tendon necrosis with local inflammation in the first case and tendon contracture
with foot malposition due to a burn injury in the other. Each patient, upon de-
bridement, had a 6-cm Achilles tendon defect with associated overlying soft tis-
sue deficits reconstructed with an extended temporoparietal fasciagaleal flap and
a split thickness skin graft. Both cases highlight the successful functional and aes-
thetic quality as well as the durability of concurrent vascularized tendon and soft
tissue replacement and coverage in 2 distinct clinical scenarios.
Key Words: Achilles tendon, Achilles tendon defect, functional reconstruction,
tendon contracture, lower extremity reconstruction, surgical flaps
(Ann Plast Surg 2016;76: S165–S170)
D efects of the Achilles tendon and the overlying soft tissues re-
main a difficult reconstructive and rehabilitative problem.1,2
Successful defect reconstruction must provide a strong, durable,
length-maintaining tendon, a soft tissue sleeve providing coverage
and allowing gliding, and a cushion thick and protective enough, al-
though thin enough, to permit wearing of normal footwear and ensure
good appearance. Skin coverage should withstand friction and the
entire repair should allow shearing forces of ambulation. Adequate
debridement reduces the risks of problems resulting from frequent de-
fect contamination and is essential for the reconstructive success especially
during single-stage repairs.1,3 The versatility of the temporoparietal fas-
cia flap in reconstructive surgery is well known. This flap has been
described for circumferential coverage of diseased and attenuated
Achilles tendon with skin grafting to the flap surface.4 The herein de-
scribed temporoparietal fascia flap modification includes a galeal ex-
tension of the flap interposed as a concurrent vascularized tendon
(with the galea rolled up as a “taco enrollado”—like component in the
center of the composite flap replacing the body of the tendon), and
the fascia was used for internal and external coverage of the rolled galea
(ensuring gliding capability between tissue planes) (Fig. 1).
Case Histories
Case 1
A 35-year old woman presented a 6  6 cm inflamed soft tissue
defect in the Achilles tendon area of her left leg. After blunt trauma to
Received June 30, 2015, and accepted for publication, after revision January 30, 2016.
From the Division of Plastic Surgery, Department of Surgery, University of California
San Diego, San Diego, CA.
Presented at the 65th Annual Meeting of the California Society of Plastic Surgeons,
Monterey, CA, May 22–25, 2015.
Conflicts of interest and sources of funding: none declared.
Reprints: Marek Dobke, MD, PhD, Division of Plastic Surgery UC San Diego, 200 West
Arbor Drive, MC 8890, San Diego, CA 92103-8890. E-mail: mdobke@ucsd.edu.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0148-7043/16/7605–S165
DOI: 10.1097/SAP.0000000000000789
Annals of Plastic Surgery • Volume 76, Supplement 3, May 2016
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
the posterior foot, subsequent treatment of the Achilles tendonitis with
injectable steroids and casting had led to tissue loss 5 months before the
presentation at the authors' clinic. A desiccated necrotic segment of the
Achilles tendon, 6-cm long in the vertical direction, was exposed
(Fig. 2A). Skin graft attempts as well as abductor hallucis muscle flap
reconstruction attempts performed elsewhere had failed. This was prob-
ably due to the abductor hallucis muscle flap devascularization through
excessive stretching. The patient also developed a chronic and in-
fected wound in the tissue overlaying the tendon (Fig. 2B). The pa-
tient continued to have progressive necrosis of the Achilles tendon
as the wound became colonized with Staphylococcus aureus and
strains of Pseudomonas aeruginosa which were resistant to multiple
antibiotics. A course of hyperbaric oxygen therapy led to improved
granulation tissue formation within the wound overlaying the exposed
Achilles tendon, but failed to improve the condition of the Achilles
tendon itself.
The patient underwent radical debridement of the wound
(Fig. 2C) and repair using the extended temporoparietal fasciagaleal
(TPFG) flap on April 17, 1992. The Doppler probe was used to map
out the vascular pedicle of the superficial temporal vessels. A narrow
band of skin on the scalp was shaved in preparation for a bicoronal in-
cision (Fig. 3A). The predicted location of the temporal branch of the
facial nerve was marked following a line 0.5 cm below the tragus to ap-
proximately 1.5 cm lateral to the eyebrow. The skin incision site was
injected with epinephrine solution (1:200,000). A preauricular facelift
incision was performed and carried across the scalp as a bicoronal inci-
sion. Skin flap elevation for the exposure of the TPFG flap structures
was performed just below the hair follicles and bipolar cautery con-
trolled bleeding. The fascial part of the flap was 8-cm wide whereas
the galeal extension measured 15 cm. As the flap elevation was per-
formed, anterior and posterior galeal edges were sewn to the pericra-
nium to reduce the risk of frontalis or occipitalis ptosis. Questions and
concerns regarding vascular continuity across the midline of the iso-
lated galea were dismissed during surgery (robust bleeding from the
very distal part of the galeal extension was observed, although galeal
extension past the midline was most likely a random flap).5 The galeal
portion of the flap was folded upon itself several times as a “taco
enrollado,” constructing the neotendon which was approximately
1.5 cm in diameter. Simultaneously, a second team performed debride-
ment and dissected the recipient posterior tibial vessels. The tendinous
defect (6 cm) was measured as a gauge to determine the width of the
dissection of the galeal flap segment. The galeal flap portion was dis-
sected to be 2.0 cm wider than the tendinous defect to allow for the sub-
sequent insert of the rolled galea into the ends of the Achilles tendon in
a “fishmouthing” fashion (Figs. 1, 3B). The opposite stumps of the
Achilles tendon were split and the extra width of galea (approximately
1 cm on each side) was sandwiched between the fish-mouthed ends
(Fig. 1). Two layers of mattress sutures of Polyglyconate (Maxon) se-
cured each end. The final wrap of TPFG with the vascular leash was
layered over the reconstructive site restoring the soft tissue layer over
the tendon with the subgaleal fascia providing the external surface
(Fig. 1). Before the final fascial flap component draping over the defect,
microvascular arterial anastomosis was performed with a standard end-
to-side technique. Venous anastomosis was performed in end-to-end
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Dobke et al Annals of Plastic Surgery • Volume 76, Supplement 3, May 2016

FIGURE 3. A, Topographic markings prior to flap elevation.

B, TPFG flap elevation: 8 cm in width and 15 cm in length
(with galeal dissection crossing the midline: yellow arrow).

postoperative follow-up, the patient had only 15 degrees of active range

FIGURE 1. Inset of TPFG into defect. Centrally, rolled galea
was inserted into “fishmouthing” native tendon ends. “A”
represents the backfold of the final overlying wrap of the
proximal superficial temporal fascia.
fashion. A split thickness meshed skin graft was placed over the TPFG
(Figs. 4A, B). Penrose drains were used to allow for local fluid drainage.
The patient was discharged on postoperative day 8. Cast support
of the ankle was maintained for 1 month (Fig. 5A). At the 1 month
of motion in the ankle. With daily physical therapy, the patient was am-
bulating with partial weight bearing at 6 weeks; full weight bearing at
8 weeks; and was fully ambulatory, including being able to stand on
tip-toes, at 10 weeks (Fig. 5B, 6).
At 12 weeks postoperatively, the patient could exercise ad lib.
At that time, the patient's ankle had a range of motion of 40 degrees
(Figs. 7A1, A2). The recipient site never required additional flap-skin
regrafting, debridement, debulking or contouring procedures. The
23-year follow-up revealed a continuous satisfactory functional out-
come with retained good range of motion, as well as a final aesthetic
appearance being considered very good (Figs. 7B1, B2). Note: The

FIGURE 2. A, Exposed necrotic segment of the left Achilles tendon and the surrounding soft tissue. Scar along the medial aspect of
the foot after attempted and failed reconstruction of tendon coverage with an abductor halluces muscle flap. B, Posterior view of the
same defect upon patient's presentation with an outline of the posterior tibial vessels. C, The wound after excisional debridement:
a 6-cm tendon defect.

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Annals of Plastic Surgery • Volume 76, Supplement 3, May 2016
FIGURE 4. The flap immediately upon completion of the
microsurgical transfer (A) and after skin grafting (B).
patient became an operating room nurse and works long hours on her
feet. No alopecia occurred at the flap harvest site. Regarding the donor
site, there were never any problems reported. Several years later, at a
patient age of 55 years, the skin on the left temple was re-elevated dur-
ing a facelift procedure with the continued absence of any problems
regarding hair growth (Figs. 8A, B, C).
Case 2
A 20 year-old woman with a history of severe thermal burns ex-
emplifies successful complex Achilles tendon and overlying tissue re-
pair in the clinical scenario of an established pes equinus secondary to
severe, dense scarring and shortening of the triceps surae unit. In
1986, 6 years before her presentation at our clinic in 1992, she sustained
third degree facial as well as upper and lower extremity burns in a house
fire, involving approximately 40% of her body surface area in total. Her
wounds required extensive skin grafting. Her right posterior leg burn
wound was deep and included the gastrocnemius muscle. The soft
tissues on her posterior leg were densely scarred and contracted, and
her ankle dorsiflexion was limited to −30 degrees, practically fusing
FIGURE 5. A, Well healing skin graft 2 weeks after surgery. B,
“Tip-toe” stance 2 months after surgery.
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Reconstruction of Soft Tissue and Achilles Tendon
FIGURE 6. The patient was able to remain on a tip-toe stance
unaided 2 months after surgery. Some atrophy of the left leg
muscles is apparent.
her foot posture in a “tiptoe” position (Fig. 9A). The pes equinus defor-
mity was corrected by division of the Achilles tendon and overlying soft
tissue and the inset of the extended TPFG into the approximately 6-cm
defect and the repair using same technique as in case 1. No arthoplasty
or arthrodesis was needed.
DISCUSSION AND REVIEW OF THE LITERATURE
Multiple factors determine the choice of the reconstructive man-
agement of complex Achilles tendon and overlying tissue defects. They
include the size, the configuration, and the condition of the tendon and
tissue surrounding the tendinous defect. Lesions of the Achilles tendon
can be either open with a gap or closed, neglected, without a gap, but
with diseased and attenuated tissue, and they all may indicate tendon re-
placement and provision of durable gliding coverage.6 Tendon wrap-
ping with vascularized fascia brings a vital source of extrinsic blood
supply to the Achilles tendon, facilitating healing, and improving glid-
ing by the reduction of scarring and adhesions when replacement is
not performed.4,7,8
Single-stage procedures with the provision of a vascularized
neotendon for segmental reconstruction seems to be superior compared
with techniques relying on “avascular” tendon replacements.1,3,6,9,10
However, even microsurgical repairs are associated with up to a 20%
range of complications requiring additional operative interventions
and up to a 25% range of need for secondary flap contouring proce-
dures, all prolonging or delaying the rehabilitative process.3,9,10 One
of the longest outcome reports is based on an individual case with a sin-
gle stage repair using a free rectus abdominis muscle flap for the soft
tissue fill and its overlying abdominal wall fascia for the restoration
of the tendon. Documented results show sustained replaced tendon
strength, with a good overall functional and aesthetic outcome, includ-
ing an acceptable donor-site morbidity, at the 4-year follow-up.11
Latissimus dorsi and gracilis muscle free flaps allow reconstruction of
relatively large soft tissue defects as well as missing tendon replace-
ments. However, donor site scars for these flaps can be problematic.
Overall, reconstructions of complex defects that rely on muscle tissue
interposition into tendinous defects are relatively simple and successful
in chronically inflamed or infected environments.3,12–15 However, it
should be noted that these reconstructive techniques are associated with
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Dobke et al Annals of Plastic Surgery • Volume 76, Supplement 3, May 2016

FIGURE 7. A1, A2, The range of motion at the ankle joint approximates 40 degrees 2 months after surgery. Initially, the range of motion
was limited and improved within weeks. This appeared to be due to acquired joint tightness rather than from the Achilles tendon
replacement. B1, Twenty-three years later the patient does not have any limitations in the ankle joint movement. Compared with
A1, there is a more harmonious foot flexion without hyperflexion of toes and ankle joint lagging. B2, Comfortable dorsiflexion without
soft tissues tethering.

such late wound problems as the loss of maximum dorsiflexion and the
failure of the heel raising ability (tiptoe stance) and the need for subse-
quent surgery for flap contouring.1,3,12,16–19
Inclusion of a fascial element provides the advantage of tre-
mendous and sustainable tensile strength of the fascia and reduces
late wound problems originating from slacking or shortening of the
neotendon or reconstructed tendon. Accordingly, restoration of the
Achilles tendon requires optimal, one-to-one defect replacement in
terms of length as well as stability of the length and the gliding proper-
ties for the physiological functioning of the triceps surae muscle-tendon
unit. Measurements of the length of the tendon replacing component
(auto-, allogeneic tissue, alloplastic material) should be performed at
full knee extension and neutral ankle plantar-dorsiflexion.20,21 Com-
posite free muscle flaps with a fascial component as part of the unit
or as chimeric flaps (anterolateral thigh flap with vascularized fascia
lata, lateral arm flap with vascularized triceps aponeurosis) provide
an alternative option for tendon reconstruction.3,22,23 However, in
addition to the relatively visible flap donor site scar, a disadvantage
of both flaps may be the relatively short vascular pedicle or the
inconsistent presence of cutaneous perforators if the skin or vascularized
fascia of the lateral thigh flap is supposed to be included.3,10,24,25 In
the setting of inadequate anterolateral perforators, some advocate the

FIGURE 8. Inconspicuous left temporal scars with good hair growth. A, Two months after flap harvest. B, Twenty years later prior to
facelift surgery. C, After facelift surgery.

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Annals of Plastic Surgery • Volume 76, Supplement 3, May 2016
FIGURE 9. A, 20-year-old woman after a severe burn of the
lower extremities developed progressive loss of right ankle
dorsiflexion pes equinus gastroc-soleal type. B, Her ankle
dorsiflexion was limited to −30 degrees, practically fusing her
foot posture in a “tip-toe” position. C, Three-year follow up
after Achilles tendon division with inset of the extended TPFG
into an approximately 6 cm large defect and repair utilizing
the same technique as in case 1.
intraoperative change of plans and utilization of the same dissection
field to raise a composite rectus femoris myofascial free flap.24 Un-
fortunately, there is also a functional consequence related to a free
anterolateral thigh with vascularized fascia or rectus femoris muscle
flaps harvest: a 10% to 25% reduction of hip flexion and knee extension
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Reconstruction of Soft Tissue and Achilles Tendon
strength (even with the centralization of the medial and lateral
vastus muscles).22,23,26
Achilles tendon derangements or tendon itself and surrounding
tissue defects with concurrent foot deformities secondary to and with
established contracture of the gastrocnemious-soleus muscle complex
may pose a special reconstructive challenge.7,9,27,28 Preexisting foot de-
formities, which have a tendency toward recurrences (eg, pes equinus),
or contracture of nonused calf muscles could affect the length and
functionality of the gastrocnemius-soleus muscle-Achilles tendon unit
making intraoperative judgment regarding the restoration design of
the tendon itself challenging and require significant clinical experi-
ence.27,29 Even the intraoperative reduction of the foot deformation
from equinous to neutral, enforcing relaxation or requiring lengthening
of the triceps surae muscle unit, may be impacted by secondary muscle
contracture.28 If a large portion of Achilles tendon is reconstructed from
the interposed muscle, which may also contract—as opposed to the
length-maintaining fascia—some set back in terms of foot positioning
is likely.27,29 In the long-term, fibrosed contracted muscle tissue used
as a tendon replacement, just as a lengthened tendon, may not maintain
the length designed during the original reconstructive surgery.17,18
Significant physical stresses involving the Achilles tendon may
change the length of the replacement tissue or rearranged but dis-
eased otherwise original tendon: they may contract or become slack.
Therefore, although reconstructions of complex defects that rely
solely on muscle interposition into the tendinous defect are rela-
tively simple and successful in chronically inflamed or infected
environments with satisfactory short-term results, they do seem less
favorable than those based on folded, not distensible fascial material.
When the maintenance of the triceps surae muscle-tendon unit mat-
ters, for example, in cases with preexisting, potentially unstable foot
deformities, or with a tendency for deformity reoccurrence, and/or in
young athletic individuals, corrections using distensible material or
different techniques for tendon lengthening, such as a described
scar-tendinous en block Z-plasty, increase the risk of the develop-
ment of one of the aforementioned problems resulting from contrac-
ture or stretching of the repair unit.1,10,12–14,16,18,19,27,28,30 When
confronted with established postburn pes equinus one must be pre-
pared to address the skin and subcutaneous tissue scar-contracture,
plus the components of the complex scarring and shortening of the
triceps surae, as well as the bone and joint pathology at the same
time.7,18,30–32 Surprisingly, in the presented case (case 2), the ankle
joints appeared to be supple. The repair using extended TPGF flap on
a patient with postburn contracture resulted in a very good and func-
tionally stable long-term outcome (Figs. 9A, B, C).
On the contrary, situations with triceps surae unit shortening or
excessive tendon or neotendon elongation (and fascial material is not
at significant risk for slacking) after reconstruction leads to foot weak-
ness, gait disturbance, and limitation of activity.19
Other special considerations requiring customized solutions in-
clude situations where there is a concurrent tendinous defect, a bone de-
fect or a distal stump, inadequate for tendon defect bridging repair.33 If
the defect includes not only the Achilles tendon and overlying soft tis-
sue but also the calcaneal bone, then composite flaps including a bone
segment are a strongly considered option. A choice for example could
be a free groin flap with an external oblique aponeurosis sheet with
a segment of iliac bone to reconstruct the calcaneal defect and fix
neotendon. The disadvantage of this relatively bulky flap is the need
for secondary flap contouring (thinning) procedures and the complex
repair of the abdominal wall. Its pedicle vessels are also relatively short
and thin-walled (superficial circumflex iliac).10,33 For a distal stump in-
adequate for Achilles tendon repair, a creative single-stage reconstruc-
tive technique using a flexor halluces longus tendon transfer, and a
simultaneous free radial fasciocutaneous forearm flap was proposed.
The tendon was passed through the tunnel in the calcaneal tuberosity
for a firm and stable distal attachment.34 Similar applications could
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Dobke et al
be found in a free radial forearm flap using the folded and looped
palmaris longus tendon within the flap.2
CONCLUSIONS
Despite the fact that there is a consensus that complex Achilles
tendon and overlying soft tissue defects are a problem difficult to solve,
and attempts to systematize algorithms of surgical options have not
been based on large series, there is a scarcity of long term follow-up out-
come assessments or comparative studies.1,3,10,11 Therefore, reports
based on single or small case series are valuable.9,11,35 Minimal donor
site morbidity, the cosmetically advantageous location of the scar after
flap harvest, the ability to reconstruct combined tendon and overlying
soft tissue defects in a single stage, with filling dead space with flap tis-
sue, the gliding and skin graftability from both sides of the flap planes
are very advantageous. The overall good functional results of the repair
and the low probability for the need of secondary adjustments, such as
debulking, contouring, or tendon length adjustment procedures, merits
the temporoparietal fascia free flap with galeal extension as an alterna-
tive which is worthy of consideration.
It is proposed that the herein presented TPFG-based reconstruc-
tion should be categorized as an example of a vascularized tendon re-
placement. However, it is probable that the galeal flap segment, which
was isolated beyond the midline, could rely on a random type of circu-
lation.5 Its unquestionable time tested durability, functionality, and aes-
thetics all support the notion that the approach presented above can be
successful and should be a valued technical option for complex Achilles
tendon and overlying soft tissue repair.
ACKNOWLEDGMENT
Informed consent was received for publication of the figures in
this article.
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