Modified distally based sural neuro-veno-fasciocutaneous flap: anatomical study and clinical applications

The distally based sural neuro-veno-fasciocutaneous flap has been used widely for reconstruction of foot and ankle soft-tissue defects. The distal pivot point of the flap is designed at the lowest septocutaneous perforator from the peroneal artery of the posterolateral septum, which is, on average, 5 cm (4-7 cm) above the lateral malleolus. A longer neuro-veno-adipofascial pedicle would be needed to reversely reach the distal foot defect when the flap is dissected based on this perforating branch, which may result in more trauma in flap elevation and morbidity of the donor site. In this article, we explored new pivot points for this distally based flap in an anatomic study of 30 fresh cadavers. The results showed that the peroneal artery terminates into two branches: the posterior lateral malleolus artery and lateral calcaneal artery. These two branches also send off cutaneous perforators at about 3 and 1 cm above the tip of lateral malleolus, respectively, which can be used as arterial pivot points for the flap. A communicating branch between the lesser saphenous vein and the peroneal venae comitantes was found, accompanied by the perforator of the posterior lateral malleolus artery. This modified, distally based sural flap with lower pivot points was successfully transferred for repair of soft-tissue defects in 21 patients. The size of flaps ranged from 4 x 3 cm to 18 x 12 cm. All flaps survived without complications. Neither arterial ischemia nor venous congestion was noted. In conclusion, the vascular pivot point of a distally based sural flap can be safely designed at 1.5 cm proximal to the tip of the lateral malleolus. This modified flap provides a valuable tool for repair of foot and ankle soft-tissue defects.     

Experience with the distally based sural neurofasciocutaneous flap supplied by the terminal perforator of peroneal vessels for ankle and foot reconstruction

The distally based sural fasciocutaneous flap has been proved an excellent option for coverage of the soft tissue defects of the lower third of the leg, ankle, and foot. In this article, we reported on a series of foot and ankle reconstructions with a distally based sural neurofasciocutaneous flap supplied by the terminal perforating branch of the peroneal artery. The vascular pedicle of the flap includes the terminal perforator branch of the peroneal artery and concomitant veins. The pivot point is approximately 5 cm above the tip of lateral malleolus. Fifteen patients with soft tissue defects of the foot and/or ankle underwent the procedures of reconstruction. The flaps were designed with the size measuring 8 x 9 cm to 13 x 31 cm. Thirteen flaps survived completely and 2 with partial or margin necrosis. Our experience has demonstrated that this sural flap with a thin perforator pedicle can be easily rotated, used for coverage of a large tissue defect including the forefoot area, and provide a good texture match and contour for the recipient area.     

A reversed superficial peroneal neurocutaneous island flap based on the descending branch of the distal peroneal perforator: clinical experiences and modifications

The distally based neurocutaneous flaps have been popular for lower leg and foot reconstruction. On the basis of pre-existing anatomic studies and clinical experiences, we designed a reversed superficial peroneal neurocutaneous island flap with the descending branch of the distal peroneal perforator as the pedicle. The flap is supplied through both axial perforator and longitudinal chain-linked vascular plexuses. This modified neurocutaneous island flap, measuring around 5 cm x 4 cm to 12 cm x 13 cm in size, was transferred for coverage of foot soft-tissue defects in 21 cases with a low complication rate. Compared to the original neurocutaneous flap, the rotation point of this flap is more distal and the pedicle is thinner. It could provide good texture and contour matching to the recipient area. In conclusion, the modified neurocutaneous island flap provides a reliable tool for repairing soft-tissue defects of the ankle and foot.     

腓肠神经营养血管蒂逆行岛状筋膜皮瓣修复足踝部软组织缺损

目的探讨应用腓肠神经营养血管蒂逆行岛状筋膜皮瓣修复足踝部软组织缺损的方法。方法1999年9月至2004年10月,应用腓肠神经营养血管蒂逆行岛状筋膜皮瓣修复踝部、小腿、足背及足跟部软组织缺损29例,其中创伤致皮肤软组织缺损15例,烧伤(包括电击伤)创面及瘢痕切除后创面11例,慢性溃疡3例。皮瓣切取范围5cm×7cm～12cm×20cm,蒂长5～12cm。结果本组27例术后皮瓣全部成活,创面一期愈合,2例皮瓣远端部分淤血坏死,经清创换药后创面游离植皮愈合。术后21例经3个月至5年随访,皮瓣外观、血运、质地、弹性佳,踝关节功能恢复良好,皮肤感觉均有一定程度的恢复,两点辨别觉为10～15mm,平均12mm。结论腓肠神经营养血管蒂逆行岛状筋膜皮瓣的适应证明确,操作简便,无需牺牲小腿主要动脉,不需吻合血管,且皮瓣成活率高,供区易于封闭,是足踝部软组织缺损的较好修复方法。     

Nerve sparing-distally based sural flap

The management of soft-tissue defects in the ankle and foot area is a challenging task. Distally based sural flap is widely used, however it leaves donor area paresthesia. For this purpose, the sural nerve was dissected and preserved in the distally based sural flap in five cases of ankle and foot soft tissue reconstruction. This modification did not cause any compromise in flap circulation. All flaps survived with one partial distal necrosis. We suggest that, the distally based nerve sparing sural flap can be securely elevated with only a 3-4 cm wide subcutaneous pedicle without any compromise in flap circulation.     

逆行腓动脉穿支蒂腓浅神经营养血管皮瓣修复足踝软组织缺损

目的评价逆行腓动脉穿支蒂腓浅神经营养血管皮瓣修复足踝软组织缺损的临床效果。方法对25例足踝部软组织缺损的患者采用逆行腓动脉穿支蒂腓浅神经营养血管皮瓣进行修复。其中,以腓动脉终末穿支的升支为蒂19例,以其降支为蒂6例。软组织缺损大小10cm×9cm～4cm×3cm,皮瓣面积11cm×9.5cm～6cm×5cm。结果 23例皮瓣完全存活,另2例皮瓣远端部分坏死,经换药后植皮修复。皮瓣术后轻度肿胀,无瘀血。术后随访6～18个月,皮瓣质地优良,蒂部无臃肿。结论以腓动脉穿支为蒂的腓浅神经营养血管皮瓣血供可靠、质地优良,是修复足、踝软组织缺损的良好选择。     

腓肠浅动脉逆行岛状筋膜皮瓣急诊修复下肢创伤性皮肤软组织缺损

目的探讨急诊一期修复小腿中下段及足部创伤性软组织缺损的方法. 方法 2000年2月～2003年12月,应用同侧腓肠浅动脉逆行岛状筋膜皮瓣急诊一期修复小腿及足部皮肤软组织缺损18例,并分析其可行性及手术注意点;切取皮瓣4 cm×5 cm～11 cm×12 cm. 结果除2例皮瓣远端1/3发绀并坏死经换药Ⅱ期愈合外,其余皮瓣均Ⅰ期愈合.随访1～2年,有2例皮瓣臃肿,其余外观满意,功能均恢复正常. 结论腓肠浅动脉逆行岛状筋膜皮瓣急诊修复创伤性皮肤软组织缺损,具有早期闭合创面、促进早期功能锻炼的优点,尤其适合于急诊修复小腿下1/3及其足踝部的皮肤软组织缺损.     

逆行腓肠神经营养血管筋膜皮瓣修复足踝部软组织缺损

目的研究应用逆行腓肠神经营养血管筋膜皮瓣修复足踝部软组织缺损的方法.方法 1994年7月～2002年12月,对足踝部软组织缺损52例应用逆行腓肠神经营养血管筋膜皮瓣修复,其中创伤致皮肤软组织缺损47例,慢性溃疡3例,肿瘤切除术后2例.切取皮瓣范围4 cm×6 cm～10 cm×21 cm.结果术后48例皮瓣全部成活,创面Ⅰ期愈合;4例皮瓣远端部分坏死,经游离植皮后创面愈合.所有软组织缺损均修复,骨骼、肌腱外露均覆盖.术后46例皮瓣经5个月～4年随访,平均2.4年,均有一定程度的感觉恢复,两点辨别觉为11～17 mm,平均14 mm;有40例皮瓣质地、弹性好,踝关节功能良好,6例皮瓣弹性较差,踝关节功能欠佳.结论逆行腓肠神经营养血管筋膜皮瓣手术设计、操作简便,易于切取,不需牺牲小腿主要动脉,不吻合血管,且皮瓣成活率高.     

Distally based sural fasciomyocutaneous flap: Anatomic study and modified technique for complicated wounds of the lower third leg and weight bearing heel

The reconstruction of the distal third leg and weight‐bearing heel, especially when complicated with infection and/or dead space, remains a challenge in reconstructive surgery. The distally based sural neurofasciomyocutaneous flap has been proved a valuable tool in repair of the soft tissue defects of those areas. In this report, we present the results of the anatomical study on vascular communication between the suprafascial sural neurovascular axis and the deep gastrocnemius muscle and a modified technique in clinical applications for reconstruction of the soft tissue defects in the distal lower leg and heel. Six lower limbs of fresh cadavers were injected with red gelatin and dissected. A constant vascular connection with average four musculo‐fasciocutaneous perforators with diameter 0.2–0.5 mm was identified in the overlapping area between the suprafascial sural neurovascular axis and the deep gastrocnemius muscle. Based on these findings, a modified distally based sural neurofasciomyocutaneous flap including the distal gastrocnemius muscle component was designed and used for repairs of the soft tissue defects in the distal lower limb and plantar heel pad in six patients. The blood supplies of flaps comprised either the peroneal perforator and adipofascial pedicle or the peroneal perforator only. The average size of the fasciocutaneous flap was 51 cm², and the muscle component 17.7 cm². All flaps survived uneventfully. Our results suggest that this technical modification could provide wider range for applications of the distally based sural neurofasciomyocutaneous flap in repair of the soft tissue defects of the lower extremity and heel. © 2008 Wiley‐Liss, Inc. Microsurgery, 2009.     

Free medial sural artery perforator flap for ankle and foot reconstruction

Resurfacing shallow defects over the ankle and foot with an appropriately thin flap is a common but difficult task. This can be accomplished by harvesting the medial sural artery perforator flap from the medial aspect of the upper calf. Based on the musculocutaneous perforator of the medial sural artery, this flap preserves the medial gastrocnemius muscle and avoids unnecessary flap bulkiness. Between January 2002 and February 2004, we used 2 variants of the free medial sural artery perforator flap for ankle and foot reconstruction in 13 patients (10 fasciocutaneous flaps and 3 adipofascial flaps). In these patients, skin defects were combined with bone, joint, or tendon exposure. The main advantage of this flap is that it provides a thin and pliable coverage to achieve better accuracy in the reconstructive site. Other advantages include maintaining the function of the medial gastrocnemius muscle, providing a long vascular pedicle, and avoiding the need to sacrifice major arteries of the leg. The main disadvantages are the tedious process of intramuscular retrograde dissection of the perforator and the unsightly skin graft over the medial calf.     

带皮穿支血管的皮神经营养血管皮瓣的临床应用

目的探讨带皮穿支血管与皮神经营养血管相结合的皮瓣手术方法及临床应用效果。方法以深部知名血管发出的皮肤穿支为皮瓣转轴点,切取皮神经营养血管带蒂皮瓣或岛状皮瓣,转位修复肢体远端皮肤软组织缺损创面。结果临床已应用43例,其中腓动脉穿支腓肠神经营养血管皮瓣13例,面积30 cm×12 cm~16 cm×8 cm;胫后血管穿支隐神经营养血管皮瓣9例,面积17 cm×9 cm~5 cm×4 cm;以骨间前血管腕背穿支前臂背侧皮神经营养血管皮瓣8例,面积16 cm×6 cm~10 cm×4 cm;以掌指动脉指蹼穿支手背皮神经营养血管逆行皮瓣13例,皮瓣面积6.0 cm×3.5 cm~2.5 cm×1.5 cm;皮瓣完全成活42例,1例因静脉回流障碍远端1/4坏死。随访6~24个月,皮瓣质地优良,外形与功能恢复满意。结论该术式结合了穿支蒂皮瓣与皮神经营养血管皮瓣的优点,扩大了皮瓣切取面积与修复范围,皮瓣设计灵活,切取方便,血供可靠,是修复肢体皮肤软组织缺损的一种可取的方法。     

穿支皮瓣游离移植修复足部创面缺损

目的 探讨应用穿支皮瓣游离移植修复足部创面缺损的临床疗效.方法 2006年3月至2009年12月,应用下肢4种穿支皮瓣游离移植修复20例足部创面缺损患者,男15例,女5例;年龄18～61岁,平均28.5岁;左侧7例,右侧13例.缺损创面部位:足背12例,足跟足底部5例,足踝部3例;创面大小为2.0 cm×3.5 cm～12.0 cm×18.0 cm.皮瓣选择:股前外侧穿支皮瓣5例,股前内侧穿支皮瓣7例,腓浅动脉穿支皮瓣5例,腓动脉穿支皮瓣3例. 结果 本组20例患者皮瓣全部成活,术中2例患者出现血管危象,经及时处理后血运恢复.20例患者术后获3～6个月(平均5.2个月)随访,皮瓣质地、外观均良好,其中13例吻合皮神经恢复了保护性感觉,供区愈合可,功能无影响.结论 应用穿支皮瓣游离移植修复足部创面缺损,临床效果满意,是修复此类创面的较理想选择.     

以腓动脉远端穿支血管供血为蒂的小腿后外侧（复合）组织瓣的临床应用

目的探讨腓动脉穿支供血的小腿后外侧（复合）组织瓣在足踝部软组织缺损、骨感染修复中的临床效果。方法2007年3月至2010年9月,对23例足踝部软组织（跟腱）缺损及骨感染的患者,设计以腓动脉终末穿支为血管蒂,沿腓肠神经营养血管轴线切取皮瓣转位修复小腿下段及足踝部皮肤软组织缺损。采用腓动脉下段穿支供血携带腓肠神经逆行岛状（复合）皮瓣或肌皮瓣进行修复。皮瓣切取范围3cm×5cm～10cm×18cm。结果术后21例皮瓣完全成活,创面一期愈合,2例皮瓣边缘部分坏死,后经过二期扩创游离植皮后痊愈,平均住院时间21d。随访2～9个月,皮瓣质地优良,外观满意,无色素沉着、溃疡,皮瓣感觉恢复约S2,跟腱重建患者踝关节达功能位,恢复了劳动能力。结论以腓动脉远端穿支血管供血为蒂的小腿后外侧（复合）组织瓣血供可靠,变异率低,切取方便,供区隐蔽,可恢复部分感觉,且不牺牲肢体主要血管,是修复小腿中下部、踝关节周围及足部软组织缺损的一种良好方法。尤其对修复足踝部骨外露,骨髓炎,跟腱缺损,复合组织瓣（携带跟腱及肌肉）是一种较好的选择。     

The distally based sural fasciomusculocutaneous flap for foot reconstruction.

Finding appropriate soft-tissue to cover a wound located over the middle or distal portion of the foot can be challenging. A distally based sural fasciomusculocutaneous flap including the sural nerve and a midline cuff of the gastrocnemius muscle can be used for this purpose. This flap is designed on the proximal third of the posterior calf and is nourished in a retrograde manner by the lower peroneal septocutaneous perforators, through the vascular axis of the sural nerve to the musculocutaneous perforators of the gastrocnemius muscle. Between October of 2002 and January of 2004, this flap was applied in nine individuals, including four diabetic patients. The skin defects all resulted from trauma, osteomyelitis or chronic ulcer, and combined with bone or tendon exposure. One flap developed distal necrosis. The other flaps survived fully and provided good contour. In our series, diabetes mellitus seemed not to compromise the vascularity of the flap. The distally based sural fasciomusculocutaneous flap is very useful for lower limb reconstruction, particularly for the foot, because of its long vascular pedicle and the availability of the skin portion of the proximal calf based on direct branches between the musculocutaneous perforators and the neurovascular axis of the sural nerve. This is an important variant of the sural neurocutaneous flap and it appears to be a good alternative to free flaps for resurfacing the foot.     

腓动脉穿支供血的腓肠神经营养血管逆行岛状皮瓣肌皮瓣临床应用

目的探讨腓动脉穿支供血的腓肠神经营养血管逆行岛状皮瓣、肌皮瓣在足踝部软组织缺损、骨感染修复中的效果.方法 1997年6月～2004年10月,对21例足踝部软组织缺损及骨感染的患者,采用腓动脉穿支供血的腓肠神经营养血管逆行岛状皮瓣或肌皮瓣进行修复.其中男20例,女1例,年龄6～78岁.创伤致软组织缺损18例,电烧伤3例,其中足部贴骨瘢痕、骨髓炎4例.术中切取岛状皮瓣17例,肌皮瓣4例.皮瓣、肌皮瓣切取范围5 cm×4 cm～22 cm×16 cm.供瓣区拉拢缝合4例,游离植皮17例.结果术后21例皮瓣、肌皮瓣完全成活,创面Ⅰ期愈合.随访3～6个月,无任何并发症,皮瓣质地优良,外观满意,行走正常,术后皮瓣感觉恢复欠佳.结论腓动脉穿支供血的腓肠神经营养血管逆行岛状皮瓣、肌皮瓣为一可靠的皮瓣,切取方便,供瓣面积大,血供丰富且不牺牲主要动脉,是修复小腿中下部、踝关节周围及足部软组织缺损的一种良好方法.尤其对修复足踝部深洞状缺损、骨髓炎,肌皮瓣是一种较好的选择.     

Distally based perforator sural flaps for foot and ankle reconstruction

Distally based perforator sural flaps from the posterolateral or posteromedial lower leg aspect are initially a neurofasciocutaneous flap that can be transferred reversely to the foot and ankle region with no need to harvest and sacrifice the deep major artery. These flaps are supplied by a perforating artery issued from the deep peroneal artery or the posterior tibial artery, and the chain-linked adipofascial neurovascular axis around the sural/saphenous nerve. It is a versatile and reliable technique for soft-tissue reconstruction of the heel and ankle region with 180-degrees rotation. In this paper, we present its developing history, vascular basis, surgical techniques including flap design and elevation, flap variations in pedicle and component, surgical indications, and illustrative case reports with different perforating vessels as pivot points for foot and ankle coverage.     

逆行腓肠神经营养血管皮瓣治疗小腿及足踝部软组织缺损

目的：观察应用腓肠神经营养血管皮瓣修复小腿下段及足踝部创伤性软组织缺损的临床效果。方法：以逆行腓肠神经营养血管皮瓣修复小腿下段及足踝部因创伤致软组织缺损187例。皮瓣最大面积14cm×13cm,最小4cm×3cm。结果：修复小腿下段113例皆获成功,伤口1期愈合,11例皮肤边缘坏死,换药治愈,4例坏死面积较大,经换药,邮票植皮且治愈,足及踝部修复54例,伤口1期愈合,5例局部坏死,经换药后获治愈。结论：应用逆行腓肠肌神经营养血管皮瓣可以有效修复小腿及足踝部皮肤缺损,此皮瓣血运丰富,手术操作简便。     

腓肠神经营养血管复合皮瓣一期修复跟腱区软组织缺损并感染

目的探讨应用腓肠神经营养血管远端蒂肌腱筋膜复合皮瓣修复跟腱区复杂软组织缺损并感染的手术方法和临床疗效。方法回顾性分析我科白2005年7月至2011年11月收治的13例跟腱区复杂软组织缺损患者的临床资料,其中男10例,女3例;年龄11～41岁,平均19岁;皮瓣面积14cm×8cm～18cm×10cm,均采用腓肠神经营养血管远端蒂肌腱筋膜复合皮瓣一期覆盖创面并修复跟腱缺损。结果随访2个月～2年,13例皮瓣术后均全部成活,2例皮瓣蒂部浅层坏死,4例皮瓣远端边缘散在浅层坏死,均经短期换药后愈合,患踝及小腿外形满意,提踵有力,踝关节功能基本正常,负重及行走不痛,无跛行,AOFAS评分88分,根据ArnerLindholm评定标准进行疗效评价,优9例,良4例,优良率100％。结论腓肠神经营养血管远端蒂肌腱筋膜复合皮瓣血供可靠,操作简单,能够在修复创面的同时修复重建跟腱的连续性和功能,是修复跟腱区复杂软组织缺损的理想方法。     

腓动脉及穿支血管蒂皮瓣逆行转移修复足踝部软组织缺损

目的 探讨应用腓动脉及穿支血管蒂皮瓣逆行转移修复足踝部软组织缺损的手术方法 和临床效果.方法 2007年4月至2008年2月,收治10例足踝部软组织缺损患者.男7例,女3例;年龄8～52岁,平均34.2岁.致伤原因:车祸伤6例,坠落伤2例,慢性溃疡1例,烫伤1例.在患肢小腿外侧区沿腓动脉轴线设计皮瓣,术中游离包含于皮瓣内的1～3支腓动脉穿支,于腓动脉穿支近端结扎切断腓动脉及静脉,向远端游离至外踝尖上约5 cm并以此为旋转点,连同皮瓣向远端逆行转移覆盖足踝软组织缺损区.切取皮瓣范围为10 cm×5 cm～25 cm×15 cm,血管蒂长6～17 cm.结果术后10例皮瓣全部成活.仅1例皮瓣远端局部回流不畅、浅表坏死,经换药及抗感染治疗后愈合.供区均Ⅰ期愈合.全部病例获5～14个月(平均9.5个月)随访,所有患者皮瓣外形及功能满意,行走正常.结论 腓动脉及穿支血管蒂营养皮瓣血管蒂长,蒂部细小易转移而不易受压,血供可靠,切取范围大,皮肤质地良好,用于足踝部皮肤软组织缺损的修复效果满意.     

Fasziokutane Insellappen zur Defektdeckung am Sprunggelenk und am Rückfuß

Covering tertiary soft-tissue injuries on the ankle joint and on the calcaneal part of the foot has so far been the domain for free flap use. With the distally based neurocutaneous sural artery flap (sural flap) and the distally based lateral supramalleolar flap, there are now fasciocutaneous island flaps available which allow quick covering of injuries in this region, requiring only simple planning and no microsurgical techniques. When partially de-epithelialized, they are also suitable for filling cavities, as is necessary particularly after infected calcaneal osteosynthesis on the lateral calcaneal part of the foot. In our group of seven patients, sural flaps were used in five cases while two patients received lateral supramalleolar flaps. The injuries were covered with no difficulties. The flap sizes ranged from 3 × 3 to 15 × 7 cm. Donor sites were unproblematic. However, lifting a sural flap involves neurotomy of the sural nerve, and lifting the lateral supramalleolar flap involves neurotomy of the superficial peroneal nerve. Wound healing was delayed in three patients.