A review of the Turned-down Onto Pericapsular-tissue Hemisectioned Amputated Toe (TOPHAT) flap for wound coverage during ray amputations of the toes

IntroductionExposure of the adjacent Metatarsal-Phalangeal Joint (MTPJ) commonly occurs after application of Topical Negative Pressure Wound Therapy (TNPWT) for a ray amputation wound. This is due to mechanical soft tissue erosion or trauma to the adjacent digital artery from direct pressure effect. This results in toe gangrene requiring a ray amputation and ultimately a larger wound bed. We describe the use of the Turned-down Onto Pericapsular-tissue Hemisectioned Amputated Toe (TOPHAT) flap – a filleted toe flap to protect the adjacent MTPJ capsule combined with a novel Negative Pressure Wound Therapy with instillation and dwell-time (NPWTi-d) dressing technique. The flap protects the adjacent joint capsule and reduces the wound burden whilst allowing the wound to benefit from TNPWT, thereby accelerating wound healing.Material and methodsA retrospective review was conducted of patients with toe gangrene requiring ray amputation that underwent the TOPHAT flap on in our institution from 2019 and 2020. Complications such as wound dehiscence, hematoma, flap necrosis and secondary infection were recorded. Other outcomes recorded were time taken to final skin grafting and time taken for complete wound epithelialization.Results9 patients underwent treatment with the TOPHAT flap. 2 patients had flap necrosis. 7 patients progressed to definitive skin coverage with skin grafting. One patient subsequently had progressive arterial disease despite successful skin grafting and required above knee amputation. The mean time to final skin grafting and complete wound epithelialization was 49.5 days and 107.5 days respectively. All patients were satisfied with the outcomes and were able to return to their pre-morbid function.ConclusionsThe TOPHAT flap has a consistent vascular supply that provides durable soft tissue coverage. It is a robust and easily reproducible technique to accelerate wound healing after ray amputations even in patients with peripheral vascular disease.     

Reconstruction of sternal defects with pectoralis major muscle flap

The earliest treatment of the median sternotomy defects was serial debridements and secondary healing. The muscle flaps that can be used in reconstruction of the presternal defects are pectoralis major muscle flap, rectus abdominis muscle flap, vertical rectus abdominis muscle flap, latissimus dorsi muscle flap with or without skin island, bipedicled pectoralis-rectus muscle flap, and external oblique muscle flap. Pectoralis major muscle flap can be used either as bilateral or unilateral rotation advancement flap, island flap, turnover flap, split turnover flap, and segmental muscle flap. Forty-eight patients with median sternotomy defects, who were treated with pectoralis major muscle flap, were included in this study. The complications were mortality, flap loss, flap dehiscence, persistent infection, and hematoma. The patients were evaluated in terms of functional loss after the operation by shoulder movement measurements. Various techniques of flap transfer can be used for the closure of a presternal defect; almost all presternal defects can be covered with the pectoralis major muscle in a single stage operation. In our opinion, the pectoralis major muscle flap should be the first choice of treatment for sternal defects.     

Simple and reliable way in sternum wound coverage--tripedicle pectoralis major musculocutaneous flap

Objective: Sternotomy wound infection requires radically debridements and need secondary reconstruction of the resulting defect. Pectoralis major muscular or musculocutaneous flap is quite common in sternal wound closure. We modified the pectoralis major musculocutaneous flap design: bipedicle advancement cutaneous flap combined with thoracoacromial myocutaneous perforators, as a “tripedicle” fashion. We tried to utilize the cutaneous pedicle to provide a reliable skin coverage and decrease the wound dehiscence rate in lower one third sternal wound. Methods: Four patients undergoing median sternotomy surgery between 2004 and 2007 suffered from sternal wound infection and received tri‐pedicle pectoralis major musculocutaneous flaps transfer. Results: No skin paddle necrosis or wound dehiscence occurred in the postoperative course. Cosmetically and chest stability were satisfactory without complains about the daily activity. Conclusions: Tripedicle pectoralis major musculocutaneous flap is a simple and reliable technique to cover sternal wound defect necessitating resurfacing surgery. The blood supply to the skin paddle can be enriched by the superior and inferior cutaneous pedicle and the wound dehiscence rate is decreased with this technique. © 2008 Wiley‐Liss, Inc. Microsurgery, 2008.     

Utility of “open‐Y” anastomosis technique in the use of superior thyroid artery as recipient vessel for head and neck reconstruction with free flap

Background: The superior thyroid artery (STA) is the most commonly used recipient vessel in free tissue transfer for head and neck reconstruction. Size discrepancy between recipient and donor vessels might affect the patency rate. The objective of this study was to compare the outcomes of the “open‐Y” technique in end‐to‐end anastomoses between the STA and donor arteries to those of conventional anastomoses to the STA. Patients and methods: A total of 337 patients with free tissue transfer for head and neck reconstruction with the STA as the recipient artery were recruited between September 2011 and August 2013. The “open‐Y” technique of anastomosis was used in 72 cases, whereas the conventional technique was applied in 256 cases. The arterial anastomotic site‐related complications and size discrepancy rates of both groups were evaluated and compared. Results: The flap success rate was 98.6% (71/72) in the “open‐Y” group, which was similar to the conventional group [97.4% (245/252); P = 0.999]. Size discrepancy rate was higher in the “open‐Y” group [48/72(66.7%)] compared to that in the conventional group [31/265(11.7%), P < 0.001]. There was no significant difference regarding arterial anastomotic site‐related complications between the “open‐Y” and conventional groups (1.4% vs.4.2%; P = 0.473). Others complications, including re‐exploration, venous thrombosis, hematoma, fistula, infection, partial flap necrosis and total flap necrosis, had similar presentations. Conclusion: The utility of the “open‐Y” technique, applied to STA as a recipient vessel, appeared to be a reasonable option for head and neck reconstruction. This technique seems to be promising for cases with vessels size discrepancy. © 2015 Wiley Periodicals, Inc. Microsurgery 36:391–396, 2016.     

Endoscopic assisted harvest of the pedicled pectoralis major muscle flap.

The Pectoralis Major flap is a reliable and versatile flap for head and neck reconstruction. However, it is associated with donor site scarring on the anterior of the chest wall. Endoscopic assisted harvest of a pedicled pectoralis major muscle flap was performed on three patients for head and neck reconstruction. The average incision length was 4.5 cm, the average time taken to harvest the muscle was 37 min. All patients were discharged from hospital on the 5th to 8th postoperative day and one patient had a seroma. Endoscopic harvest of the pedicled Pectoralis major muscle flap minimises postoperative scarring.     

The operative treatment of pressure wounds: a 10‐year experience in flap selection

This study sought to both assist in the selection of flaps for ischial pressure wound re‐construction and to evaluate the overall complication rates associated with re‐construction. A retrospective medical record review was conducted for 78 patients following the surgical re‐construction of an ischial pressure sore. Records were reviewed for demographics, location of sores, methods of re‐construction and flap selection, as well as any complications and recurrences. Seventy‐two wounds were re‐constructed with an average of 1·4 flaps used per wound. An ischial flap complication rate of 16% was observed in flap follow up, with a recurrence rate of 7% recorded. The vast majority of complications went on to heal with 15% of patients requiring a second re‐construction. Our relatively large sample of ischial flaps allowed for a close comparison with previously published work. Both flap selection and site of reconstruction significantly affected the success rates for pressure sore coverage. The overall complication rates by flap and re‐constructive site in this review are lower than previously published reports. Our experience with ischial re‐construction was extensive enough to suggest a posterior medial thigh fasciocutaneous flap combined with a biceps femoris muscle flap as a first choice in ischial pressure wound re‐construction.     

The Boari bladder flap: an effective continent stoma for the high‐compliance neurogenic bladder

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

To determine if a continent urinary stoma can be created effectively using a Boari bladder flap (BBF) technique.

PATIENTS AND METHODS

Selected patients (15, eight women and seven men) with a neurogenic bladder and a bladder compliance of >20 mL/cmH₂O had a procedure to create a BBF continent urinary stoma. The technique consisted of tubularising a trapezoidal, full‐thickness detrusor flap 10 cm long, 5–6 cm wide at the base and 2 cm at the tip, over a 12 F catheter, and plication of detrusor muscle around the stomal base. Outcomes after surgery were assessed by reviewing stomal continence, stomal patency, and stability of the upper urinary tract.

RESULTS

Ten BBF procedures were performed using native detrusor muscle, four with enterocystoplasty tissue and one in a defunctionalized bladder. Over a mean follow‐up of 13 months, 11 patients had functioning stomas and 10 of these reported complete stomal continence. The mean change in serum creatinine level from the preoperative baseline for all patients was 0.1 mg/dL. The odds ratio for procedural failure, defined as a stoma unusable for self‐catheterization, was 7.5 (P = 0.04) when the BBF was created from augmented or defunctionalized bladder tissue, compared to native high‐compliance detrusor.

CONCLUSION

A BBF can be used to create a viable, functional stoma in the high‐compliance neurogenic bladder, although the rate of stomal complications is high when the BBF is created from enterocystoplasty tissue.     

胸大肌肌瓣转移术预防乳腺癌术后上肢淋巴水肿的临床研究

目的 探讨胸大肌肌瓣转移术对乳腺癌改良根治术后患侧上肢淋巴水肿的预防效果。方法 自2013年9月至2014年6月,将68例乳腺癌患者分成2组,35例行乳腺癌改良根治术+胸大肌肌瓣转移术(干预组),33例单纯行乳腺癌改良根治术(对照组),术后随访观察,分别在术后2周、1个月、3个月、6个月和9个月测量双侧臂围,判断有无上肢淋巴水肿的发生及程度。结果 随访结果表明,干预组和对照组相比,术后患侧上肢淋巴水肿发生率明显减少,差异具有统计学意义(P<0.05)。结论 乳腺癌改良根治术后行胸大肌肌瓣转移术,可显著减少乳腺癌术后患侧上肢淋巴水肿的发生率,提高患者的生活质量。     

Total management of the open abdomen

The management of complex abdominal problems with the 'open abdomen' (OA) technique has become a routine procedure in surgery. The number of cases treated with an OA has increased dramatically because of the popularisation of damage control for life-threatening conditions, recognition and treatment of intra-abdominal hypertension and abdominal compartment syndrome and new evidence regarding the management of severe intra-abdominal sepsis. Although OA has saved numerous lives and has addressed many problems related to the primary pathology, this technique is also associated with serious complications. New knowledge about the pathophysiology of the OA and the development of new technologies for temporary abdominal wall closure (e.g. ABThera? Open Abdomen Negative Pressure Therapy; KCI USA Inc., San Antonio, TX) has helped improve the management and outcomes of these patients. This review will merge expert physician opinion with scientific evidence regarding the total management of the OA.     

Ischial pressure sores: Reconstruction using the perforator‐based reverse flow musculocutaneous 180° propeller flap

The treatment of pressure sores requires soft tissue reconstruction with thick tissue to provide padding of bony prominences and obliterate dead space. Fasciocutaneous flaps may not provide adequate bulk. Propeller flaps (180°) based on perforators from the gluteal artery may be harvested as a reverse flow musculocutaneous flap including a muscle plug to reconstruct deep cavities. Three patients presenting with deep pressure sores required reconstruction of large cavities. In addition to a regular 180° propeller flap, a muscle plug based on a perforator found in the blade of the propeller was used to add bulk to the flap and obliterate the cavity with well‐vascularized tissue. One flap required secondary closure of the donor site due to dehiscence, one hematoma required drainage. All flaps survived completely. No recurrence of osteomyelitis or pressure sores was seen. The 180° propeller flap can be harvested as a reverse flow musculocutaneous flap including a muscle plug in the distal blade. This adds volume which is required to adequately obliterate large cavities in cases of osteomyelitis. This new technique may be useful in other areas as well. © 2009 Wiley‐Liss, Inc. Microsurgery 2009.     

Lower extremity free flap reconstruction outcomes using venous coupler

Background: Microvascular anastomotic coupling devices have been available to microsurgeons for over 20 years. Many studies have validated the efficacy of these devices for venous anastomosis. To date, there have been no large reports of their success in the anatomical region with the highest free flap failure rate, the lower extremity. Methods: A retrospective review of 67 consecutive patients who underwent lower extremity microvascular reconstruction performed from August 2003 to September 2010 was performed. Patient charts were reviewed for age, sex, medical comorbidities, etiology of defect, location of defect, flap type, anastomotic technique, complications, flap survival, and limb salvage outcome. Results: No patients returned to the operating room to have an arterial or venous anastomosis revised. Despite 100% vascular anastomosis patency rates in 67 consecutive lower extremity free flaps, flap survival rate was 95.5%. Total complication rate (13.4%) was due to two partial and one complete flap loss, three infections, two skin graft loses, and one hematoma. There were no intraoperative or perioperative complications involving the use of a microvascular anastomotic coupling device itself. Thirty‐day and long term limb salvage rate was 97% and 92.5%, respectively. Conclusion: Microvascular anastomotic coupling devices create effective venous anastomoses in lower extremity microvascular reconstruction. Thus, it presents an important tool in the armamentarium for lower extremity microsurgical reconstruction. © 2011 Wiley‐Liss, Inc. Microsurgery 2011.     

Improving wound healing and preventing surgical site complications of closed surgical incisions: a possible role of Incisional Negative Pressure Wound Therapy. A systematic review of the literature

Advances in preoperative care, surgical techniques and technologies have enabled surgeons to achieve primary closure in a high percentage of surgical procedures. However, often, underlying patient comorbidities in addition to surgical‐related factors make the management of surgical wounds primary closure challenging because of the higher risk of developing complications. To date, extensive evidence exists, which demonstrate the benefits of negative pressure dressing in the treatment of open wounds; recently, Incisional Negative Pressure Wound Therapy (INPWT) technology as delivered by Prevena? (KCI USA, Inc., San Antonio, TX) and Pico (Smith & Nephew Inc, Andover, MA) systems has been the focus of a new investigation on possible prophylactic measures to prevent complications via application immediately after surgery in high‐risk, clean, closed surgical incisions. A systematic review was performed to evaluate INPWT's effect on surgical sites healing by primary intention. The primary outcomes of interest are an understanding of INPWT functioning and mechanisms of action, extrapolated from animal and biomedical engineering studies and incidence of complications (infection, dehiscence, seroma, hematoma, skin and fat necrosis, skin and fascial dehiscence or blistering) and other variables influenced by applying INPWT (re‐operation and re‐hospitalization rates, time to dry wound, cost saving) extrapolated from human studies. A search was conducted for published articles in various databases including PubMed, Google Scholar and Scopus Database from 2006 to March 2014. Supplemental searches were performed using reference lists and conference proceedings. Studies selection was based on predetermined inclusion and exclusion criteria and data extraction regarding study quality, model investigated, epidemiological and clinical characteristics and type of surgery, and the outcomes were applied to all the articles included. 1 biomedical engineering study, 2 animal studies, 15 human studies for a total of 6 randomized controlled trials, 5 prospective cohort studies, 7 retrospective analyses, were included. Human studies investigated the outcomes of 1042 incisions on 1003 patients. The literature shows a decrease in the incidence of infection, sero‐haematoma formation and on the re‐operation rates when using INPWT. Lower level of evidence was found on dehiscence, decreased in some studies, and was inconsistent to make a conclusion. Because of limited studies, it is difficult to make any assertions on the other variables, suggesting a requirement for further studies for proper recommendations on INPWT.     

The latissimus dorsi‐groin‐lymph node compound flap: A comprehensive technique with three features including skin coverage,restoration of motor function,and prevention of upper limb lymphedema

Reconstruction of complex upper extremity defects requires a need for multiple tissue components. The supercharged latissimus dorsi (LD)‐groin compound flap is an option that can provide a large skin paddle with simultaneous functional muscle transfer. It is necessary to supercharge the flap with the superficial circumflex iliac pedicle to ensure the viability of its groin extension. In this report, we present a case of a supercharged LD‐groin flap in combination with vascularized inguinal lymph nodes, which was used for upper limb reconstruction in a young male patient, following excision of high‐grade liposarcoma. Resection resulted in a 28 cm × 15 cm skin defect extending from the upper arm to the proximal forearm, also involving the triceps muscle, a segment of the ulnar nerve and the axillary lymph nodes. Restoration of triceps function was achieved with transfer of the innervated LD muscle. Part of the ulnar nerve was resected and repaired with sural nerve grafts. Post‐operatively, the flap survived fully with no partial necrosis, and no complications at both the recipient and donor sites. At 1‐year follow up, the patient had a well‐healed wound with good elbow extension (against resistance), no tumor recurrence, and no signs of lymphedema. We believe this comprehensive approach may represent a valuable technique, for not only the oncological reconstruction of upper extremity, but also for the prevention of lymphedema. © 2015 Wiley Periodicals, Inc. Microsurgery 36:689–694, 2016.     

Free tissue transfers in head and neck reconstruction: Complications,outcomes and strategies for management of flap failure: Analysis of 2019 flaps in single institute

Background: Free tissue transfer has become the preferred option for complex reconstructions in head and neck cancer ablation. This study reviewed the surgical outcome and analyzed the evolution of microsurgical head and neck reconstruction over 20 years in single institute. Patients and Methods: A total of 1,918 patients underwent microsurgical head and neck reconstructions in 20‐year period. The surgical outcome and complications among these 2,019 flaps (1,223 anterolateral thigh flaps, 372 fibula flaps, 353 radial forearm flaps, 12 jejunal flaps, and 59 others) were retrospectively reviewed and analyzed. Results: A total of 201 cases required emergent surgical re‐exploration and the overall flap success rate was 96.2%. Venous insufficiency was the most common cause for re‐exploration. Other major complications included fistula formation (5.4%), partial flap necrosis (7.5%), and infection (17.8%). The fibula flap had frequent complications compared with soft tissue flaps. The familiarity to the ALT flap had minimized complications and allowed for widely versatile uses. Conclusion: Free tissue transfer is shown to be highly reliable option for head and neck reconstruction. For soft tissue defect, ALT flap is the first choice. Fibula flap is ideal for bone defect reconstruction. In case of complex composite defects, double flaps, which include ALT and fibula flaps could reconstruct bone and soft tissue defects simultaneously with high success rate. © 2013 Wiley Periodicals, Inc. Microsurgery 34:339–344, 2014.     

Immediate nipple reconstruction utilizing the DIEP flap in areola‐sparing mastectomy

The surgical treatment of breast cancer has dramatically evolved over the past decade toward an approach combining oncologic safety with aesthetic outcomes. The skin‐sparing mastectomy initiated this paradigm shift amongst breast surgeons and can be oncologically safe, in some cases sparing both the areola and the nipple. In accordance with the emphasis on aesthetics, some general surgeons have adopted new methods of resecting only the nipple, sparing the areola in select patients. The superior aesthetic results, durability, and decreased donor site morbidity of perforator flaps have brought autologous reconstruction back to the forefront of breast reconstruction with the deep inferior epigastric artery perforator (DIEP) flap as the gold standard. We describe a technique utilizing the DIEP flap skin paddle for immediate nipple reconstruction at the time of mastectomy and reconstruction, eliminating the need for delayed reconstruction and limiting donor site morbidity by concealing the donor site below the mastectomy skin flaps. In the six cases described performed between 2010 and 2012 (mean with 53 years; range 46–59 years), there have been no complications to the flap or the nipple postoperatively, nor has there been a need for further nipple revisions for 6 months. The nipple position relative to the flap breast mound has remained unchanged for up to 6 months. The immediate nipple reconstruction does not significantly lengthen operative time, requiring approximately 30 additional operative minutes per nipple. Immediate nipple reconstruction utilizing the DIEP flap can be a cost‐effective and feasible technique for recreating a natural‐appearing and aesthetic nipple in select patients. © 2012 Wiley Periodicals, Inc. Microsurgery, 2013.     

Skin grafted latissimus dorsi flap for reconstruction of lateral aesthetic units of the face

Reconstruction of large defects of the lateral region of the face is rather challenging due to the unique color, texture, and thickness of soft tissues in this area. Microsurgical free flaps represent the gold standard, providing superior functional and aesthetic restoration. Purpose of this study was to assess reliability of skin‐grafted latissimus dorsi (LD) flap, for a pleasant and symmetric reconstruction of the lateral aesthetic units of the face compared to a control group of patients addressed to perforator flaps. From November 2008 to June 2012, 5 patients underwent skin‐grafted LD flap reconstruction of defects involving the lateral aesthetic units of the face, with 8.1 ± 0.5 × 9.7 ± 1.3 cm mean size. A 1‐to‐4 Likert scale was used to assess skin color, texture, shape, and bulkiness. Using the Pressure‐Specified Sensory Device epicritic, proprioceptive, and protopathic sensitivities were tested. Outcomes were compared with those of a control group of 5 patients addressed to reconstruction with perforator flaps (3 anterolateral thigh flap, 2 vertical deep inferior perforator flap). At mean 21‐month follow‐up all flaps healed uneventfully without need for revisions, all developing more satisfactory results in terms of skin color (P = 0.028) and texture (P = 0.021) match, shape (P = 0.047) and bulkiness (P = 0.012) compared with perforator flaps. No differences in epicritic, proprioceptive, and protopathic sensitivities were observed (P > 0.05) between the two groups. Skin‐grafted LD flap may be a suitable option for reconstruction of wide defects of the lateral aesthetic units of the face. © 2014 Wiley Periodicals, Inc. Microsurgery 35:177–182, 2015.     

Tensor fasciae latae combined with tangentially split vastus lateralis musculocutaneous flap for the reconstruction of pressure sores

Pressure sores in the ischial and the trochanteric regions are usually encountered in long-term bedridden and wheelchair-dependent patients. A number of techniques have been developed for the reconstruction of pressure sores. Tensor fasciae latae musculocutaneous flap has been extensively employed to close the trochanteric defect. Despite its utility of having a constant pedicle and proximal bulky muscle, the relative shortness of the flap and insufficient padding in the distal portion limit the applications for distant locations of pressure sores. From January 2001 to December 2003, 8 patients with ischial and trochanteric pressure sores underwent tensor fasciae latae reconstruction in combination with tangentially split vastus lateralis muscle. The descending branches of the lateral circumflex femoral arteries were also included in these flaps. All of the procedures have been successful, and no flap necrosis has been observed. Sufficient bulk of the flap and reliable distal skin paddle constitute the advantages of this flap.     

Reconstruction of large head and neck deformities: Experience with free gracilis muscle and myocutaneous flaps

Microvascular free flaps continue to revolutionize coverage options in head and neck reconstruction. The authors describe their experience with the gracilis free flap and the myocutaneous gracilis free flap with reconstruction of head and neck defects. Eleven patients underwent 12 free tissue transfer to the head and neck region. The reconstruction was performed with the transverse myocutaneous gracilis (TMG) flap (n = 7) and the gracilis muscle flap with skin graft (n = 5). The average patient age was 63.4 years (range, 17–82 years). The indications for this procedure were tumor and haemangioma resections. The average patient follow‐up was 20.7 months (range, 1 month–5.7 years). Total flap survival was 100%. There were no partial flap losses. Primary wound healing occurred in all cases. Recipient site morbidities included one hematoma. In our experience for reconstruction of moderate volume and surface area defects, muscle flaps with skin graft provide a better color match and skin texture relative to myocutaneous or fasciocutaneous flaps. The gracilis muscle free flap is not widely used for head and neck reconstruction but has the potential to give good results. As a filling substance for large cavities, the transverse myocutaneus gracilis flap has many advantages including reliable vascular anatomy, relatively great plasticity and a concealed donor area. © 2009 Wiley‐Liss, Inc. Microsurgery, 2010.     

Laparoscopic harvest of the gastro‐omental free flap for reconstruction after total pharyngolaryngectomy: Operative technique

Circumferential defects following salvage pharyngolaryngectomy present significant challenges in reconstructive surgery. The gastro‐omental free flap has been shown to reduce the incidence of major fistula and catastrophic complications. The current technique for harvest of the flap requires laparotomy, which is potentially associated with significant post‐operative complications. Laparoscopic harvest of the gastro‐omental free flap can negate some of the risks associated with open surgery. We describe here the operative technique for laparoscopic gastro‐omental free flap harvest for use in reconstruction following total pharyngolaryngectomy. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1696–1698, 2017     

Lower-limb reconstruction utilizing the reverse sural artery flap-gastrocnemius muscle cuff technique

The reverse sural artery flap was described in 1992 and has become an acceptable technique of lower-limb reconstruction. In 2001, Al-Qattan introduced the concept of raising the reverse sural artery flap with a gastrocnemius muscle cuff for lower limb reconstruction and used it in 9 cases and noted a dramatic reduction in the ischemic events with this distally based flap technique. In the current paper, 30 consecutive patients with lower-limb defects were operated upon between 2001 and 2004. All patients underwent reconstruction utilizing Al-Qattan's reverse sural artery flap-gastrocnemius muscle cuff technique. The defects were classified into 4 types: open lower and midtibial fractures (n = 9), Achilles tendon defects (n = 6), heel defects exposing the calcaneus (n = 7), and complex ankle and foot defects exposing bone (n = 8). No cases of major vascular compromise were noted. Two diabetic patients had minor complications in the flap: one patient developed mild venous congestion and epidermolysis limited to the distal edge of the flap, and the second patient had a minor delayed wound healing at the most distal part of the flap. Both patients did not require further surgery. No cases of infection, hematoma, or painful neuroma were noted. After a mean follow-up period of 2 years (range 1-4 years), all flaps remained stable and all Achilles tendon repairs remained intact. The results of this series compares favorably with the results of other series in the literature, indicating the versatility and the better blood supply of the reverse sural artery flap when raised with a gastrocnemius muscle cuff. Other technical tips to ensure a successful outcome are also discussed.