Reverse sural island flap elevated from the proximal third of the leg: its reliability and versatility in distal leg and foot reconstruction

Soft tissue loss around the distal third of the leg and foot has remained a considerable challenge. A reconstructive option providing supple tissue, while avoiding the complexity and the high technical demand of free flaps is a welcome alternative. The sural island flap largely satisfies these criteria. A number of authors have suggested raising the skin island from the junction of the middle and upper third of the leg to improve its reliability. However, raising the flap over the upper third of the leg may provide a larger amount of tissue and often makes dissection of its most distal perforator unnecessary. This study aims to assess the reliability and versatility of the reverse sural island flap elevated from the proximal third of the leg for soft tissue reconstruction of the distal leg and foot. Consecutive patients with soft tissue loss around the distal third of the leg and the ankle region requiring flap cover who met the inclusion criteria were managed using the distally based sural island flap elevated from the upper third of the leg. The outcome has been analysed. There were 15 patients, 11 males and four females with an age range of 22 to 54 years. Thirteen patients had distal third open tibial fractures while two had open calcaneal injuries. Nine resulted from motorcycle accidents, four from motor vehicular accidents while two were gunshot wounds. Flap sizes ranged from 10 × 7 cm to 22 × 12 cm. Thirteen flaps had full survival while two flaps had partial necrosis. All donor sites were skin grafted with 95% to 100% graft take. The use of the reverse sural island flap elevated from the proximal third of the leg for coverage of soft tissue defects of the distal leg and foot is safe and reliable in our experience. It provides a sizeable amount of soft tissue while maintaining a robust blood supply.     

Free medial sural artery perforator flap for resurfacing distal limb defects

BACKGROUND: The need for thin flap coverage has increased, especially for contouring or covering shallow defects of distal limbs. The free medial sural artery perforator flap harvested from the medial aspect of the upper calf can be useful for this purpose. METHODS: Between January 2002 and February 2003, we used the free medial sural artery perforator flap for distal limb reconstruction in 11 clinical cases, including four hands and seven feet. This perforator flap is based on the proximal major perforator of the medial sural artery, which can be identified along the axis of the medial sural artery and usually emerges in an area between 6 and 10 cm from the popliteal crease and approximately 5 cm from the posterior midline of the leg. RESULTS: Most of the flaps were safely raised with a single perforator. One flap developed venous congestion during the postoperative course and finally underwent total necrosis. CONCLUSION: The main advantage of the medial sural artery perforator flap is that it only requires cutaneous tissue to achieve better accuracy in reconstructive site, and it preserves the medial gastrocnemius muscle and motor nerve to minimize donor-site morbidity. However, the tedious process of intramuscular retrograde dissection of the perforator and the unsightly scar of the donor region are the major concerns.     

Der distal gestielte adipofasziale Suralislappen zur Rekonstruktion von Defekten der distalen unteren Extremität

Objective

Problematic tissue defects in the distal one-third of the lower leg represent a special challenge for the operative therapy. The distally based adipofascial sural artery flap is a safe and effective modification of the classical fasciocutaneous sural artery flap technique and makes the reconstruction in this problematic area more feasible. The surgical aim is soft tissue reconstruction with local tissue avoiding free tissue transfer.

Indications

Complex or chronic wounds (maximum width of 8 cm) of the distal lower leg with exposed bone, joints, tendons, and/or neurovascular structures, especially in cases of missing skin perforators.

Contraindications

Arterial vascular disease (stage III–IV), especially peroneal artery occlusion. Postthrombotic syndrome with occlusion of the small saphenous vein. Chronic lymphedema.

Surgical technique

Preparation of the vascular pedicle of the distally based flap (including small saphenous vein, sural artery and nerve), the adjacent crural fascia and the subcutaneous fat without a skin island. The pivot point is about 6 cm cranial to the malleolus lateralis. The flap can be raised proximally up to the heads of the gastrocnemius muscle. After harvesting the flap there will be a change in blood flow direction in the small saphenous vein. The donor site can be closed primarily. The flap is covered with meshed split skin graft at the end of surgery.

Postoperative management

Strict elevation of the extremity for 5 days, then flap conditioning.

Results

Between 1997 and 2012, this technique was used in 104 consecutive patients with soft tissue defects in the distal one-third of the lower leg. Flap survival was achieved 91 patients. In 2 patients amputation of the lower leg was necessary at the mid tibia level. In 3 cases flap necrosis occurred, requiring free tissue transfer.     

Reverse fasciosubcutaneous flap versus distally pedicled sural island flap: two elective methods for distal-third leg reconstruction

In case of soft-tissue injury to the distal third of the leg, a safe and effective repair technique should be adopted. The use of complex procedures such as free flaps and cross-leg flaps is not always advisable. The authors present two methods that have proved to be both reliable and effective in obtaining long-lasting satisfactory results: the reverse fasciosubcutaneous sural flap and the reverse fasciocutaneous island sural flap. Since 1992 the authors have operated on 25 patients affected by traumatic tissue loss of the distal third of the leg and the calcaneal region. They used the fasciosubcutaneous flap in 14 patients and the sural flap in 11. Both of these flaps are technically simple, safe, and effective, and cause minimal injury to the donor site. The sural flaps are more useful for moderate-size wounds, especially in the calcaneal region, whereas the fasciosubcutaneous flap is better for repairing larger lesions of the leg and the ankle.     

Reverse peroneal artery flap for large defects of ankle and foot: A reliable reconstructive technique

Background:

Large soft tissue defects around the lower third of the leg, ankle and foot always have been challenging to reconstruct. Reverse sural flaps have been used for this problem with variable success. Free tissue transfer has revolutionised management of these problem wounds in selected cases.

Materials and Methods:

Twenty-two patients with large defects around the lower third of the leg, ankle and foot underwent reconstruction with reverse peroneal artery flap (RPAF) over a period of 7 years. The mean age of these patients was 41.2 years.

Results:

Of the 22 flaps, 21 showed complete survival without even marginal necrosis. One flap failed, where atherosclerotic occlusion of peroneal artery was evident on the table. Few patients had minor donor site problems that settled with conservative management.

Conclusions:

RPAF is a very reliable flap for the coverage of large soft tissue defects of the heel, sole and dorsum of foot. This flap adds versatility in planning and execution of this extended reverse sural flap.KEY WORDS: Distally based peroneal flaps, extended reverse sural flaps, foot reconstruction, peroneal artery, reverse peroneal flaps     

Transverse splitting of the gracilis muscle free flap: Maximal use of a single muscle

The gracilis muscle, based on the dominant pedicle, has been used extensively for free tissue transfer. Recent studies have described the constant anatomy, ease of dissection, and low donor-site morbidity of the distal segmental gracilis free muscle flap. We present three cases of free distal segmental gracilis muscle transfer. In one case, the gracilis muscle was divided transversely into one proximally based and one distally based free flap and used for coverage of two separate wounds in a patient with bilateral open calcaneal fractures. In two cases, the preserved proximal gracilis was used as a reoperative free flap after failure of the initial distal segmental gracilis free muscle. With recent advances in microsurgery and ever-growing demands for low donor-site morbidity, it is important to ensure each free muscle flap harvested is used efficiently. Use of the free distal segmental gracilis muscle flap maximally uses one muscle while minimizing donor site morbidity and retaining the proximal muscle for future uses.     

Distally based gastrocnemius myocutaneous flap augmented with an arterial anastomosis--a combination of myocutaneous flap and microsurgery

Microsurgical techniques can augment the arterial blood supply of a distally based myocutaneous flap, by reanastomosis of the sural artery to a main artery of the leg, allowing the flap a greater length and arc of rotation to cover defects of the distal half of the leg. No venous anastomosis is required. This procedure was used in 17 patients with open tibial fractures. They all healed primarily without any early or late complications. The use of this augmented flap provides a simple and reliable method for reconstruction of difficult wounds of the distal lower leg. It is easier and safer than a free flap.     

Thirteen-Year Follow-Up Reverse Sural Artery Flap for Plantar Calcaneal Wound: A Case Report

Reconstruction of soft tissue defects in the lower leg and foot after traumatic injury is a challenging problem owing to lack of locally reliable flaps. The traditional options for wound coverage often do not provide feasible or adequate treatment for many of these wounds. The lack of skin laxity in the lower leg and foot often make local flaps unavailable. Split-thickness skin grafts will not be robust enough. Free tissue flaps have a litany of potential complications and guaranteed comorbidities. The present case reinforces that appropriately selected patients with significant open bony and soft tissue trauma to the foot and ankle can be treated with a reverse sural artery fasciocutaneous flap. The reverse sural artery flap allows for full-thickness skin coverage with its own blood supply, maximizing the healing potential and should be considered a viable first option for soft tissue coverage.     

The reverse sural artery adipofasciomuscular flap for the reconstruction of a heel sinus with underlying calcaneal osteomyelitis

The reverse sural artery fasciomusculocutaneous flap has become an acceptable technique of lower-limb reconstruction despite the grafted appearance of the donor site in the upper leg. In an attempt to reduce the donor-site morbidity, we describe the use of the adipofasciomuscular reverse sural artery flap in a patient with a heel sinus and underlying calcaneal osteomyelitis.     

Comparison of the outcomes of adipofascial and two–staged fasciocutaneous reverse sural flap in patients with lower leg trauma

BackgroundDistal one – third trauma of the lower limb is a complex condition to treat. The reverse sural flap is a time tested procedure for reconstruction of such defects especially in patients where free flaps are ruled out due to comorbidities. The purpose of this study is to compare the two modifications of the classical technique of reverse sural flap (adipofascial and fasciocutaneous) which is lacking in the literature.Material & methodsIn this study, the authors conducted a retrospective analysis of 67 patients with lower one-third leg defects reconstructed with either adipofascial reverse sural flap (Group A, n = 37) or two-staged fasciocutaneous reverse sural flap (Group B, n = 30) in a tertiary care hospital in North India between 2015 and 2019. An evaluation of the different flap characteristics of the two variants of the reverse sural flap was done and compared. Mean follow up period was 12 months.ResultsThe adipofascial group showed shorter operative time, was a single-stage and with better reach and aesthetic outcome. The complications did not differ except that for the adipofascial group was associated with unstable skin graft over the flap initially which did not require any treatment.DiscussionLower one-third defect of the lower limb has been a challenge for reconstructive surgeons all over the world. The goal of reconstruction is a functional lower limb. Although free tissue transfer is the preferred modality of treatment of such cases but it may not be possible in all cases due to various reasons. Reverse sural flap is a very lucrative local option for such reconstructions as it is easy to perform, reliable, low profile and bulk, require minimal facilities with less operative time. Adipofascial flaps represent an extremely useful modification of the reverse sural flap which is quick to perform with minimal donor site morbidity.ConclusionAdipofascial reverse sural artery flap is a good option for patients with lower limb trauma with the added advantage of being single-stage and with better donor site cosmesis as compared to the fasciocutaneous reverse sural artery flap.     

Experience with the Distally Based Sural Flap: A Review of 25 Cases

The reconstruction of soft tissue defects in the distal areas of the lower extremity remains a challenge. The distally based sural neurocutaneous flap based on the sural nerve and the superficial sural artery has been used for skin defect reconstruction of the distal third of the leg, the hindfoot, ankle, and heel. We describe our experience and evaluate the reliability of this surgical technique. From 2004-2010, 25 patients with an average age of 32.5 (6 to 70) years were treated using the distally based sural flap for reconstruction of skin defects of the lower third of the leg, the heel, the ankle, and the hindfoot. The skin defect was secondary to trauma in 20 patients (80%) and compromised tendon or bone in all cases. One venous congestion and 2 partial flap necroses were observed. The mean follow-up was 25 (9 to 46) months. The plastic result was assessed as satisfactory in all patients. The donor site morbidity was minimal. The sural flap is a good way to reconstruct soft tissue defects of the lower extremity; this surgical technique provides an alternative to microsurgical reconstruction.     

Use of distally based superficial sural island artery flaps in acute open fractures of the lower leg.

The reverse sural artery flap is a fasciocutaneous flap based on the median superficial sural artery and its communication with the perforating branch of the peroneal artery situated in the region of the lateral malleolar gutter. Reverse flow is established after elevation of the flap and with division of the sural artery and the nerve proximally. The authors present resurfacing of acute open fractures of the lower third of the leg in 7 patients immediately after the acute phase of injury. Reconstruction was carried out within an average of 3 days after injury. All 7 patients sustained low-velocity injuries. Although 2 patients had partial necrosis of the distal tip of the flap, all patients had excellent recovery with minimal donor site morbidity.     

Versatility of the distally based superficial sural flap for reconstruction of lower leg and foot in children

Twenty children are presented after undergoing a distally based superficial sural flap for coverage of defects at the lower leg and foot. The age of the patients was between 1 and 12 years. Fifteen patients had trauma to the lower leg, with eight of them having associated injuries. Three had postburn contracture and two had pressure sore. In 14 cases, the flap was used as a fasciocutaneous flap, whereas in six cases it was used as a fascial flap covered with a skin graft. The flaps were used to cover the defects from the dorsum of the foot distally up to the mid third of tibia proximally. The mean follow-up was for a period of 2 years. Even though free tissue transfer is reliable and safe for the reconstruction of major leg injuries in children, the distally based superficial sural flap has the advantage of being easy to perform, with short operating time, minimal donor side morbidity, and preservation of major arteries of the leg.     

An algorithm for reconstruction of soft tissue defects of the distal lower leg, ankle and heel

AIM: The purpose of the study was to establish an algorithm for the reconstruction of soft tissue defects of the distal lower leg, ankle and heel. METHOD: 81 patients presenting with soft tissue defects in these regions underwent flap coverage. The average age was 44.1 years. Small defects (up to 4 x 4 cm) were covered by local flaps. The neurovascular sural flap was the predominant flap procedure for medium size defects (up to 10 x 15 cm). Free flaps were used for larger defects or in cases of stenosis or occlusion of the peroneal artery. Femoro-crural bypasses were performed in three cases to improve peripheral arterial perfusion. RESULTS: The reconstructive goals were achieved in 95% of the cases by performing reconstruction according to the established algorithm. Minor complications occurred in 29.6% of the cases. CONCLUSION: The results appear to be very good considering a patient population with complex and predominantly contaminated wounds. A preoperative angiography represents an important part of the algorithm for flap reconstruction to detect abnormal arterial vascular conditions and thus to plan vascular reconstruction prior to or simultaneously with free flap coverage. Additionally, a non-patency of the peroneal artery represents a contraindication for sural flaps.     

The reversal sural artery neurocutaneous island flap in composite lower extremity wound reconstruction.

Reconstruction of the lower third of the leg and the forefoot remains a challenge due to a lack of regional muscle units and minimal subcutaneous tissues. Reverse island flaps have been applied to similar reconstructive problems in the upper extremity. Recently, the reverse sural artery neurocutaneous island flap has been utilized to reconstruct complex wounds of the lower extremity and forefoot in young and middle-aged individuals. We present our use of the flap in a patient cohort 65 years of age or older. Unique among this group was the high prevalence of diabetes and peripheral vascular disease. Nonetheless, the reverse sural artery neurocutaneous island flap proved a safe and reliable means of achieving wound closure.     

Reliability of Reverse Sural Flap in the Reconstruction of Midfoot and Forefoot Defects

Reconstruction of mid- and forefoot defects involves few options as versatile as free flaps; however, free flaps are not universally available and require long operative time and can be difficult to successfully heal. Although the reverse sural flap is commonly used for lower limb reconstructions, it has been used mainly for reconstruction of defects around the distal leg, ankle, and hindfoot. Few studies have demonstrated the use of this flap in the reconstruction of mid- and forefoot defects. Herein we describe our experience with patients that underwent reconstruction using reverse sural flaps for mid- and hindfoot defects. A total of 16 patient, ranging in age 6 to 54 years, were treated with reverse sural flaps between January 2010 and December 2018. The defects were mainly incurred as a result of trauma. All reconstructions were performed in 2 stages, and success was achieved in 15 (93%) of the 16 cases. No cases of donor site morbidity were observed. Our findings suggest that the reverse sural flap can be used for reconstruction of mid- and forefoot defects as a 2 staged procedure. The flap is easy to raise and can be considered in selected patients with such defects.     

腓肠内侧动脉穿支蒂皮瓣修复膝和小腿上1/3软组织缺损

目的 报道应用腓肠内侧动脉穿支带蒂皮瓣修复膝和小腿上1/3软组织缺损的临床应用效果. 方法 应用腓肠内侧动脉穿支带蒂皮瓣修复膝和小腿上1/3软组织缺损16例.其中,髌前4例,前外侧2例,前内侧l例;小腿上1/3 9例.供区均选用同侧小腿.结果 手术后经过顺利,1例术后发生表浅感染,经更换敷料逐渐愈合,皮瓣全部成活.随访3.0个月至3.5年,平均1.7年.供区愈合良好,未见明显的供区功能障碍.受区皮瓣质地、厚薄及颜色均较好,功能恢复较好,取得了较满意的效果. 结论 腓肠内侧动脉穿支带蒂皮瓣以腓肠内侧动脉的肌皮穿支为血供,具有血供丰富、血管解剖恒定、血管蒂长以及皮瓣较薄的优点.带蒂移植适宜修复膝和小腿上1/3软组织缺损.     

腓肠内侧动脉穿支皮瓣修复上下肢创面

目的介绍吻合血管的腓肠内侧动脉穿支皮瓣修复上下肢创面的临床方法和经验。方法采用吻合血管的腓肠内侧动脉穿支皮瓣修复上下肢创面11例，女6例，男5例。皮瓣设计区域为同侧小腿，腓肠内侧肌肌腹以远1／2的表面部分，前内界为胫骨的内后缘，后外侧界为小腿后正中纵轴线，皮瓣的轴行线为前内界和后外侧界的中线。皮瓣长8～15cm，宽6～14cm。结果10例皮瓣成活，皮瓣质地柔软，富有弹性，不臃肿，恢复了一定的触觉；1例皮瓣全部坏死，经扩创、断层皮片修复创面；不影响供区的运动功能。结论腓肠内侧动脉穿支皮瓣可以用来修复上下肢创面，尤其对手足部创面的修复有较为满意的临床疗效。     

Caveats of Local Fasciocutaneous Flaps for Distal Leg Defects—Anatomical Study and Clinical Application

The present trend for the management of distal leg defects is to opt for a free flap with local flaps being relegated to the backseat. We studied the perforator anatomy of the distal leg in the Indian population to see if there were any ethnic differences and then correlated it with a clinical study of local flaps used for the coverage of distal leg defects. A prospective observational study was carried out in 2 phases—anatomical study and clinical study from December 2018 to March 2020. In the anatomical study, 8 fresh cadavers, i.e., 16 lower limbs were dissected and the perforator anatomy in the distal leg was identified. In the clinical study, all patients undergoing local, pedicled fasciocutaneous flap cover for defects involving distal third leg were included with ages between 15 and 60 years. In the anatomical study, posterior tibial artery perforators in the distal-most part were found as a group of up to 3 perforators. In the clinical study, a total of 47 patients were included with a mean age of 38.0 ± 10.9 (range 17-55) years and female:male ratio being 1:2.6. The largest defect size was 120 cm² (mean 28.2 ± 23.8 [range 6-120] cm²) and the most commonly used flap was the reverse sural artery flap in 20 (42.6%) cases. Overall, complications were seen in 7 (14.9%) cases and there was no case of flap failure. Thus, local flaps are an excellent option for coverage of distal leg defects and offer results comparable to free flaps.