Left, the bigger cranial perforator is found to limit the caudal reach of the flap. Right, Increased caudal 2 perforators, both arising from the medial mobility of the flap after Y-V pedicle lengthening technique application; the flap easily reaches branch of the medial sural artery MSA , with the defect and can be sutured without tension. The distal perforator was found to be too little to use, and the proximal one was too much cranial to allow distal movement of the flap.
So, the MSA medial branch was cut proximally to the ori- the popliteal artery and divides into medial the medial branch we sectioned Fig. As a gin of the biggest perforator allowing the flap and lateral branches in the proximal part of consequence, the flap was nourished by reverse to be raised in a reverse-flow fashion and su- the medial gastrocnemius muscle.
More fre- flow from the distal intramuscular anastomoses tured without tension. The MSA arises from quently, musculocutaneous perforators arise with the lateral branch of the MSA, the lateral from the lateral branch. Clinical findings in According to this technique, a flap is have shown that a distally based gastrocne- raised on a branch of a Y-shaped vascular mius muscle flap can be safely harvested on structure.
When the vascular trunk is sectioned the same distal vascular network, interrupt- Conflicts of interest and sources of funding: none declared. In our case, by interrupt- flap Y-V pedicle extension, confirms that E-mail: b. Unauthorized reproduction of this article is prohibited.
Plast Reconstr Surg. Find articles by David L. Author information Article notes Copyright and License information Disclaimer. Corresponding author. Received Nov 22; Accepted Jul Published by Wolters Kluwer Health, Inc. All rights reserved. The work cannot be changed in any way or used commercially. This article has been cited by other articles in PMC. Abstract Background: Soft-tissue defects of the distal lower extremity and foot present significant challenges to the reconstructive surgeon. Open in a separate window.
Operative Technique The patient was placed in the prone or lateral decubitus position. Table 1. Patient Demographics. Table 2. Wound Characteristics. Table 3. Postoperative Complications.
Footnotes Disclosure : The authors have no financial interest to declare in relation to the content of this article. Lower limb salvage in trauma. Plast Reconstr Surg. Heller L, Levin LS. Lower extremity microsurgical reconstruction. Free tissue transfers and replantation. Donski PK, Fogdestam I. Distally based fasciocutaneous flap from the sural region. A preliminary report. Scand J Plast Reconstr Surg. Skin island flaps supplied by the vascular axis of the sensitive superficial nerves: anatomic study and clinical experience in the leg.
Vascular supply of the distally based superficial sural artery flap: surgical safe zones based on component analysis using three-dimensional computed tomographic angiography. The distally based sural flap. Venous drainage of the distally based lesser saphenous-sural veno-neuroadipofascial pedicled fasciocutaneous flap: a radiographic perfusion study. A realistic complication analysis of 70 sural artery flaps in a multimorbid patient group. Modified reverse sural artery flap with improved venous outflow in lower-leg reconstruction.
Ann Plast Surg. Intermittent short saphenous vein phlebotomy: an effective technique of relieving venous congestion in the distally based sural artery flap. Enhanced survival using the distally based sural artery interpolation flap. Supercharged reverse-flow sural flap: a new modification increasing the reliability of the flap.
Sural flap delay procedure: a preliminary report. Al-Qattan MM. Lower-limb reconstruction utilizing the reverse sural artery flap-gastrocnemius muscle cuff technique. Reverse sural artery flap: caveats for success. Versatility of the sural fasciocutaneous flap in the coverage of lower extremity wounds. The distally based island superficial sural artery flap: clinical experience with 36 flaps. Comparative study of two series of distally based fasciocutaneous flaps for coverage of the lower one-fourth of the leg, the ankle, and the foot.
The distally based superficial sural artery island flap: clinical experiences and modifications. The distally based superficial sural flap for reconstruction of the lower leg and foot. Br J Plast Surg. The distally based superficial sural artery flap. Mahakkanukrauh P, Chomsung R. Anatomical variations of the sural nerve. Clin Anat. Yang D, Morris SF. Reversed sural island flap supplied by the lower septocutaneous perforator of the peroneal artery. Angiosomes of the leg: anatomic study and clinical implications.
Per operatively dimensions of the flap, level of proximal flap margin where designed on the leg, island or paddled, tunnelling or exteriorising of the pedicle, capillary refill or any congestion at the end of the procedure were recorded.
In the immediate postoperative period the flap was monitored for any venous congestion or pallor. Functional and aesthetic outcome was noted in terms of complete or partial flap survival, successful coverage of the recipient defect, healing of any underlying fracture, ease or difficulty in walking or wearing shoes, ambulatory status of the injured limb after six months and any concerns of the patient regarding the aesthetic appearance of the flap and developement of useful sensations in the flap.
Donor site healing or any complication was also recorded; loss of sensibility in the sural distribution area, i. Patients were discharged on the 3rd postoperative day in case of uneventful recovery and called back on the 5th postoperative day to remove the graft dressing.
They were followed for at least 6 months. Results:- Over the period of 10 years, a total of distally based sural fasciocutaneous flaps were performed. Eighty patients were male while 20 were female. Their age ranged from 18 to 60 years, with a mean age of 35 years.
Trauma was the cause of soft tissue defect in 52 patients; cancer resection in 17 patients, severe contracture release in 16 patients, and unstable scar and burn in 4 patient each,diabeties in 4 patients and chronic non healing ulcer in 3 patients Table 1.
The mean length was 8. The flaps for defects on the distal leg, Achilles tendon, malleolus and posterior non weight bearing heel, were designed lower in the leg in its middle third and the flaps proximal limit did not encroach the upper third of the leg. The remaining flaps were designed higher in the proximal third of the leg and a gastrocnemius cuff was included in the upper part of the flap.
The pivot point was kept 5 cm proximal to the tip of lateral malleolus in all cases. Table Flap Size No of patients Percentage 12x4. Healing of tibial fractures was noted in all but one patient where later chronic osteomyelitis required raising of the flap and debriding the infected bone.
Out of the heel flaps one needed debulking later, for easy fit in the shoes. Rest did not have any problem with wearing shoes. The patients did not experience any difficulty in walking after coverage of the anterior weight bearing heel defects. Most of the patients especially where chronic exposure was a problem, found a relief in the coverage of the defect.
They were later serially debulked. In all cases the donor site showed uneventful recovery and good graft take. None complained of any painful neuromas or showed any concern about the sensory loss over the lateral aspect of the foot.
Esthetically 32 patients found the donor site appearance of concern while the rest 68 were not bothered. Discussion:- Reconstruction of the lower leg and foot continues to be one of the most challenging tasks for the reconstructive plastic surgeon. Following the developments in flap surgery, pedicled fasciocutanous flaps and free flaps have been used.
The introduction of distally based sural fasciocutaneous flap provides reliable and effective method to cover skin defects of distal leg, foot and ankle. The flap can be used to cover exposed vessels, bones, tendons, and internal fixation hardware. It has been shown to be more reliable and a better choice than the lateral supramalleolar flap another distally based fasciocutaneous flap used in the distal lower extremity.
The flap has been shown to be successful in diabetic and medically compromised patient. Complete flap necrosis was reported in 3. The flaps that showed marginal or partial necrosis showed postoperative congestion. The flaps usually have some partial necrosis that may require debridement, dressing changes, and surgeon patience. The main morbidity of the operation is lateral foot numbness and the need to harvest a split thickness skin graft.
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