Reverse Sural Artery Island Flap With Skin Extension Along the Pedicle

Reliability of reverse sural artery fasciocutaneous flap in older adult patients: Comparison study between older and younger patients

BACKGROUND

The reverse sural artery fasciocutaneous (RSAF) flap is a popular option for patients with soft tissue defects of the distal lower extremities. However, most studies have focused on young patients without comorbidities. This study aimed to report the clinical application of the RSAF flap and to evaluate its reliability in older adult patients.

METHODS

A retrospective study of fifty-one patients who underwent RSAF flap was included in this study between September 2016 and October 2021. Reconstruction outcomes and wound complications were compared between groups A (21 patients over 60 years of age) and B (30 patients under 60 years of age).

RESULTS

Overall, 74.5% of the flaps healed primarily. The demographics of the two groups were similar, except for comorbidities (P = 0.01). The risk factors that affected the survival of RSAF flaps were not significantly different between the two groups (P > 0.05). The rate of wound complications in group A (42.85%) was significantly higher than that in group B (13.3%) (P = 0.04). However, all wound complications were treated using a simple procedure (skin grafting or simple suturing).

CONCLUSIONS

The RSAF flap can be a reliable salvage option to repair soft tissue defects of the lower extremities in older adult patients. It is safe and easy to harvest and transfer the flap; however, surgeons should be aware of the possibility of wound complications in older patients with comorbidities.

How to measure success in lower extremity reconstruction, which outcome measurements do we use a systematic review and metanalysis

Different factors have to be considered and weighted in the treatment algorithm of lower extremity reconstruction. A combination of both clinicians' and patients' perspectives is necessary to provide a conclusive picture. Currently, there aren't any standardized and validated measurement data sets for lower extremity reconstructions. This makes it necessary to identify the relevant domains. We, therefore, performed a systematic review and metanalysis of outcome measurements and evaluated their ability to measure outcomes after lower extremity reconstruction. A systematic review and metanalysis according to the 'Preferred Reporting Items for Systematic Reviews and Meta-Analyses' protocol were performed for studies reporting at least one structured outcome measurement of lower extremity reconstruction. Both Patient (PROMs)- and Clinician reported outcome measurements (CROMs)were analyzed. Of the 2827 identified articles, 102 were included in the final analysis. In total 86 outcome measurements were identified, 34 CROMs, 44 PROMs and 8 (9.3%) outcome measurements that have elements of both. Twenty-four measure functional outcome, 3 pain, 10 sensations and proprioception, 9 quality of life, 8 satisfaction with the result, 5 measure the aesthetic outcome, 6 contours and flap stability and 21 contain multidomain elements. A multitude of different outcome measurements is currently used in lower extremity reconstruction So far, no consensus has been reached on what to measure and how. Validation and standardization of both PROMs and CROMs in plastic surgery is needed to improve the outcome of our patients, better meet their needs and expectations and eventually optimize extremity reconstruction by enabling a direct comparison of studies' results.

HARVESTING SURAL FLAP WITH COVERED PEDICLE

Objectives

The aim was to evaluate the viability and the outcomes of the sural flap performed with the pedicle covered by a strip of skin.

Methods

A prospective cohort of 20 consecutive cases were evaluated in terms of flap viability, complication rate, and the amount of skin graft required. The location of the defects was the middle third of the tibia in 3 cases, the ankle and hindfoot in 15 cases, the middle foot in 1 case, and the forefoot in 1 case. The flap design was the same as described by Masquelet. The only modification included a strip of skin over the entire length of the pedicle. The intermediary skin between the donor site and the defect was incised and the skin was undermined to accommodate the pedicle without compression.

Results

All cases had a satisfactory evolution, with adequate healing and without flap loss. Both the donor site and the pedicle were primarily closed in all cases. In one patient, the flap developed a limited area of superficial epidermolysis that healed spontaneously.

Conclusion

the modified sural flap with a covered pedicle is feasible and reliable with a lower rate of complications when compared with the conventional sural flap. Level of Evidence IV, Cohort Studies .

Reconstruction of Heel Soft Tissue Defects: An Algorithm Based on Our Experience

BACKGROUND

Sensory recovery and durability of the flap is the primary goal of heel soft tissue reconstruction. From the different options, the choice of the flap depends on the size of the defect, its location, and the availability of the donor area.

METHODS

In this retrospective study, 40 patients having heel defects were included from Jan 2016 to Dec 2018 in which different flaps were used for the reconstruction. The outcome was evaluated in terms of flap survival, recovery of sensation, the durability of coverage, and functional denouement. We also analysed the outcome between neuropathic and non-neuropathic ulcers of the heel.

RESULTS

Out of 40 patients’ medial plantar artery islanded flap was performed in eight cases, extended reverse sural flap in 16 cases, islanded reverse sural flap in six cases, local flaps in six cases, cross-leg flap in two cases, and free Latissimus Dorsi muscle flaps with Skin Graft cover in two cases. The patients were observed for a mean follow-up time of 15 months (12-20 months). Only two flaps showed marginal necrosis as an immediate complication. The majority of the flaps were tenacious in the follow-up period except for the six flaps that developed delayed ulceration. Return of protective sensation (P=0.006) and mean American Orthopaedic Foot and Ankle Society subjective score (P=0.025) was significantly higher in the non-neuropathic ulcer group.

CONCLUSION

Locoregional flaps can cover most of the heel defects with a satisfactory outcome. The functional outcome was lower in the reconstructed neuropathic heel ulcer group.

Revisit of flap factors relating to partial necrosis of distally based sural flaps: an analysis of 435 cases in a single center

BACKGROUND

Partial necrosis is an ongoing topic in regard to flap complications of the distally based sural (DBS) flap However, the factors influencing partial necrosis of the flap remain in debate. The aim of the present study is to further illuminate the flap-related risk factors and the effects of several technical improvements.

METHODS

We retrospectively reviewed the data of 429 patients who underwent 435 DBS flaps between April 2001 and December 2019. The reconstruction outcomes, flap viability-related complications, and potential risk factors were compared between the survival group and partial necrosis group, as well as between group A (the procedures performed from April 2001 to March 2010) and group B (those from April 2010 to December 2019).

RESULTS

Among the 435 flaps, 39 flaps (8.97%) exhibited partial necrosis. With the increase of the top edge of the flap, the partial necrosis rate increased significantly (P < 0.05). When the length-to-width ratio [LWR] of the flap was more than 5:1 or the total length of the flap (the length of the skin island plus the length of the adipofascial pedicle) was more than 20 cm, the partial necrosis rate increased significantly (P < 0.05). The partial necrosis rate in group B (5.86%, 15/256) was significantly lower than that in group A (13.41%, 24/179) (P = 0.007).

CONCLUSIONS

The top edge of the flap is an essential indicator for predicting the prognosis of the DBS flap. When the total length of the flap is more than 20 cm or the LWR of the flap more than 5:1, the partial necrosis rate will increase significantly. Various technical modifications can lower the top edge of the flap and reduce the LWR of the flap and width of the skin island, and thus improve the flap survival effectively.

Composite sural neurocutaneous flap with gastrocnemius tendon for repairing defects of Achilles tendon and overlying soft tissue

PURPOSE

Defect of Achilles tendon and overlying soft tissue remains a surgical challenge due to its insufficient blood supply and high requirement of function. This study aims to report the clinical efficacy of the composite sural neurocutaneous composite flap with gastrocnemius tendon on the complicated defect of Achilles region.

METHODS

Seven cases of defects of Achilles tendon and overlying soft tissue were reconstructed by the composite sural neurocutaneous composite flaps with gastrocnemius tendons. It is important to keep the connection between gastrocnemius tendon and deep fascia of the composite flap during operation. The smallest and the largest areas of transferred skin flaps were 7.5 cm × 4.5 cm and 11 cm × 10 cm respectively. The size of gastrocnemius tendon ranged from 5 cm × 3 cm to 9 cm × 4 cm. Patients was evaluated by using the Arner-Lindholm scale at the last follow-up.

RESULTS

Six flaps survived completely with no complication. One flap developed wound dehiscence and went on to heal by daily dressing. With 12-60 months follow-up, all patients gained satisfactory appearance and function of ankle, without tendon re-rupture or recurrent infection. Based on Arner-Lindholm scale, six cases were noted to be excellent and one was good.

CONCLUSION

The composite sural neurocutaneous flap with gastrocnemius tendon is a viable and practical method to salvage Achilles tendon defect and overlying soft tissue coverage, with minimal adhesion and satisfactory function.

Distally Based Sural Fasciocutaneous Flaps for Reconstructing Soft Tissue Defects Proximal and Distal to the Tarsometatarsal Joints: A Comparative Analysis

Distally based sural fasciocutaneous (DBSF) flaps are widely used for reconstructing soft tissue defects of the foot. The purpose of this paper was to compare the clinical efficacy of the use of flaps to repair defects in areas proximal and distal to the level of the tarsometatarsal joints in a relatively large number of patients and to analyze the effects of factors on the risk of developing partial necrosis of the flaps. Between April 2001 and December 2019, a total of 355 DBSF flaps were utilized to cover soft tissue defects in the foot. According to the furthest location of the defects reconstructed with the flaps, the flaps were divided into the proximal foot group (n = 260) and the distal foot group (n = 95). The partial necrosis rates, their influencing factors, and the clinical outcomes of the procedure were compared between the two groups. In the proximal foot group, the partial necrosis rate (6.2%, 16 of 260) was significantly lower than that in the distal foot group (14.7%, 14 of 95) (P < .05). The proportion of successful coverage of the defects using the flaps alone or in combination with a simple salvage treatment was comparable between the groups (P > .05). The ratio of unfavorable conditions in the distal foot group was higher than that in the proximal foot group (P < .05). DBSF flaps can be effectively utilized to repair defects in the proximal and distal areas of the foot. The use of a DBSF flap to repair defects in the proximal areas of the foot is superior to the use of DBSF flaps for repairing defects in the distal areas of the foot in terms of reliable survival of the flap.

Distally Based Perforator-Plus Sural Neurocutaneous Flap with High or Low Pivot Point: Anatomical Considerations and a Retrospective Study of a Clinical Series of 378 Flaps

BACKGROUND

 This study is to describe the distribution of natural true anastomoses associated with the distally based perforator-plus sural neurocutaneous flap (sural flap), summarize our experience in the flap with high pivot point, and compare the outcomes between the flaps with high and low pivot points.

METHODS

 Five amputated lower limbs were perfused, and the integuments were radiographed. We retrospectively analyzed 378 flaps, which were divided into two groups: pivot points located ≤8.0 cm (low pivot point group) and >8.0 cm (high pivot point group) proximal to the tip of the lateral malleolus. Partial necrosis rates were compared between two groups.

RESULTS

 The arterial chain surrounding the sural nerve was linked by true anastomoses from the intermalleolar line to popliteal crease. True anastomoses existed among peroneal perforators and between these perforators and the arterial chain. There were 93 flaps with high pivot point and 285 flaps with low pivot point. Partial necrosis rates were 16 and 9.1% in the high and low pivot point group (p = 0.059), respectively.

CONCLUSION

 True anastomosis connections among peroneal perforators and the whole arterial chain around sural nerve enable the sural flap to survive with a greater length. The sural flap with high pivot point is a good option for reconstructing soft-tissue defects in the middle and distal leg, ankle, and foot, particularly when the lowest peroneal perforator presents damage, greater distance to the defects, discontinuity with the donor site, or anatomical variation.

Utilisation of distally based sural fasciocutaneous flaps in lower extremity reconstruction: a single-centre experience with 88 paediatric patients

BACKGROUND

No large series have analysed distally based sural fasciocutaneous (DBSF) flaps in paediatric patients. The aims of this study were to assess the reliability and analyse the potential risk factors for these flaps and to describe complications in the donor site and the functional follow-up results.

METHODS

Between June 2002 and November 2017, 88 DBSF flaps were used to reconstruct soft tissue defects in paediatric patients. Potential risk factors, reconstruction outcomes, and complications in the donor site of the flaps were analysed.

RESULTS

Among the 88 flaps, partial necrosis developed in 8 flaps (9.1%). The partial necrosis rate was significantly higher in flaps with the top edge located in the 9th zone (26.1%), with a length-width ratio (LWR) ≥ 5:1 (28.6%), and with a dimension of the skin island ≥ 100 cm² (22.7%). Partial necrosis did not occur in flaps with a dimension of the skin island < 80.0 cm² or with a skin-island width < 7.0 cm. The reconstruction outcomes in most paediatric patients were evaluated as "excellent" or "good". The incidence of obvious scarring was higher in the donor site.

CONCLUSIONS

Partial necrosis of DBSF flaps will significantly increase when the top edge of the flap is located in the 9th zone, when the LWR of the flap is ≥ 5:1, or when the dimension of the skin island is ≥ 100.0 cm². Flaps with a skin-island width < 7.0 cm or with a dimension of the skin island < 80 cm² are relatively safe and reliable.

Non-microsurgical bipedicled reverse sural fasciocutaneous flap with preservation of medial and lateral sural cutaneous nerve: Current surgical management of skin defect after traumatic Achilles tendon rupture - A case report

INTRODUCTION

The challenging issue that still remains for reverse sural flap is the withstand of the flap against time, the width of coverage area, and the donor site morbidity such as pain after the medial or lateral sural cutaneous nerve harvested.

PRESENTATION OF CASE

A 55 years old male was suffered from traumatic Achilles tendon rupture for 3 months and was repaired with Krakow's technique in a medical center in Pemalang, Indonesia. After the surgery, the defect was revealed as another surgery was planned to cover the skin defect. The author had chosen the bipedicled reverse sural fasciocutaneous flap in regular basis which addressed the superiority and viability of the flap, thus the donor site morbidity was also concerned as the preservation of medial and lateral sural cutaneous nerve, which leading to good quality of life as the patient still could feel and sensate his medial and lateral leg.

DISCUSSION

The bipedicled reverse sural fasciocutaneous flap was successfully covered the skin defect on post traumatic Achilles tendon reconstruction, with retained medial sural nerve on its place, and the remaining harvested skin area was leave opened without skin graft which healed spontaneously.

CONCLUSION

Bipedicled reverse sural fasciocutaneous flap with retained medial sural nerve offer a good clinical outcome either the viability of the flap and the maintained sensation along the medial and lateral sural cutaneous nerve distribution.

Distally based peroneal artery perforator-plus fasciocutaneous flap in the reconstruction of soft tissue defects over the distal forefoot: a retrospectively analyzed clinical trial

BACKGROUND

Distally based peroneal artery perforator-plus fasciocutaneous (DPAPF) flaps are widely used for reconstructing soft-tissue defects of the lower extremity. However, reports on the reconstruction of the defects over the distal forefoot using the DPAPF flaps are scarce. Herein, we describe our experience on the reconstruction of these defects using DPAPF flaps in a considerable sample size.

METHODS

Between February 2005 and August 2019, a total of 56 DPAPF flaps in 56 patients were used to reconstruct soft-tissue defects in the forefoot. In order to reduce the length of fascial pedicle and the total length of the DPAPF flaps, the ankles were fixed in dorsiflexion using a Kirschner wire before designing the flaps. The flaps were elevated by the anterograde-retrograde approach. Patient factors and flap factors were compared between the "survival" and "partial necrosis" groups.

RESULTS

Overall, 47 flaps had survived completely in one stage. Partial necrosis developed in nine flaps, with only one remnant defect covered using a local flap. By fixing the ankles in dorsiflexion, the length of the fascial pedicle was reduced approximately 2.35 ± 0.58 cm, the total length of the flap was simultaneously shortened by the same amount as the length of the fascial pedicle. The width of the fascia pedicle varied from 3.0 cm to 6.0 cm. The fascial pedicle width > 4 cm was found in 21 flaps. The partial necrosis rate of the DPAPF flaps with the top edge located in the 8th zone was significantly lower than that in the 9th zone (p < 0.05).

CONCLUSIONS

The DPAPF flaps can be effectively used to reconstruct the defects over the distal forefoot because of convenient harvest and reliability. By fixing the ankle in dorsiflexion with Kirschner wire and widening the fascial pedicle appropriately, the top edge and LWR of the flaps will be decreased, and thus the procedures are helpful for the flaps survival.

The Reverse Sural Artery Flap: A Reliable and Versatile Flap for Wound Coverage of the Distal Lower Extremity and Hindfoot

The reverse sural artery flap is a distally based fasciocutaneous or adipofascial flap used for wound coverage of the distal one-third of the lower extremity, ankle, and posterior heel. The flap harvest can be performed without sacrificing major arteries of the lower extremity. It can be elevated and mobilized with relative ease and a short operative time. It provides a good alternative to free tissue transfer in complex lower-extremity wounds with exposed bone, tendon, or hardware. The surgeon must be familiar with the management of venous congestion to improve the success of the flap.

Lower Limb Salvage Using the Medial Hemisoleus Flap Associated with the Reverse Sural Flap

The paper aims to present the reconstructive surgical approach in the case of a patient with complex soft tissue lesions of the calf. The patient was the victim of a road accident resulting in the fracture of the right tibia for which screw-plate osteosynthesis was performed. The chosen therapeutic solution was represented by covering the soft tissue defects using a complex algorithm that involved the use of a reverse sural flap associated with a medial hemisoleus muscle flap and a split-thickness skin graft.

Considering functional recovery and the degree of patient satisfaction, the result of the therapeutic conduct was appreciated as very good. The association of the reverse sural flap with the medial hemisoleus flap can be a solution for solving complex cases with multiple soft tissue defects located in the middle and lower third of the calf.

Free perforator flaps vs propeller flaps in lower limb reconstruction: A cost/effectiveness analysis on a series of 179 cases

PURPOSE

The aim of this report is to compare free perforator flaps and propeller flaps in the coverage of lower limb soft tissue defects.

PATIENTS AND METHODS

179 patients (age between 5 and 92 years old), underwent soft tissue reconstruction of the lower limb between January 2009 and January 2015, either by free flap or propeller flap. The two groups were retrospectively evaluated in order to assess the outcome, complications and potential risk factors. Correlations between risk factors and presence/absence of failure or complications have been evaluated with descriptive statistical analysis and a set of logistic regression models. Finally, an economic analysis was conducted to evaluate the different tecniques.

RESULTS

In a simple descriptive statistical analysis, the overall failure rate is 6% for free flaps and 3.7% for propeller flaps; the complication rates are 14% vs 21.5% and it increases as dimension increases. The logistic models relating failure and complications with potential risk factors do not show significant differences, whereas the economic analysis show that the average expense of free flaps is 5077.5€ per patient, 1595.6€ per patient for propeller flaps.

CONCLUSIONS

Our results do not demonstrate significant differences between the two groups about correlation of risk factors or flap size with complication or failure. The surgical option choice should be taken only after accurate evaluation of the soft tissue surrounding the defect. Propeller flaps should be preferred in case of small/medium size defects in otherwise healthy extremities. Free perforator flaps should be the choice in large defects due to trauma or vascular diseases. The economic analysis suggests that propeller flap should be considered when possible.

Reduction of Morbidity With a Reverse-Flow Sural Flap: A Two-Stage Technique

The reverse sural flap has often been used for cutaneous coverage of the distal region of the leg and ankle. When the flap is performed in 2 stages, the vascular pedicle is exteriorized and later resected. Our goal was to assess the reverse sural flap performed in 2 stages regarding its viability and low morbidity along the flap-donor area. Eleven patients with cutaneous coverage loss found in the area between the distal third of the leg and ankle underwent cutaneous coverage surgery with a reverse-flow sural flap with an exteriorized pedicle, without violation of the skin between the base of the flap pedicle to the margin of the wound. After a minimum period of 15 days with flap autonomy, the pedicle was resected. The flap dimensions, its viability before and after the pedicle ligature, and the distance from the intact skin between the flap base and the margin of the wound were evaluated. Any losses were measured as a percentage of the total flap size. The respective length and width of the flap were a mean average of 7.45 cm × 4.18 cm. All the flaps survived. Partial loss of the flap occurred in 3 patients, ranging from 20% to 30%. The mean average distance of the intact skin between the pedicle base and the margin of the wound was 5.59 (range 4 to 8) cm. Our results showed that the 2-stage reverse sural flap ensures good flap survival and low morbidity.

Retrospective study of freestyle perforator-based peninsular flaps: A simple, fast, and safe technique for pressure sore reconstruction

This study aimed to present a simple, fast, and safe technique, called freestyle perforator-based peninsular flap (FPBPF), for pressure sore reconstruction.Among the 21 patients who underwent pressure sore reconstruction between May 2013 and October 2016, 12 patients (Group A) and 9 patients (Group B) were subjected to perforator-based island flap (PBIF) and FPBPF, respectively. We retrospectively reviewed and statistically analyzed the data of both groups.All flaps completely survived in both groups. No significant differences were found in patient demographics, complications, hospital stay, and follow-up period. The mean arc of rotation (102.50 ± 17.645° vs 83.33 ± 14.142°; P = .01), mean flap harvest time (35.83 ± 2.552 minutes vs 20.88 ± 1.763 minutes; P < .001), and mean operative time (145.41 ± 6.788 minutes vs 131.66 ± 10.770 minutes; P = .002) were significantly decreased in Group B compared with Group A.The FPBPF is a simpler and faster technique than the PBIF. FPBPF is a good modality with a few complications for sore reconstruction.

Medial sural artery perforator free flap for the reconstruction of leg, foot and ankle defect: an excellent option

BACKGROUND

The defects over the leg, foot and ankle are best covered with a thin pliable flap. The use of muscle flap for the reconstruction of these defects leaves a grafted, aesthetically inferior result. The medial sural artery perforator (MSAP) free flap gives a thin pliable tissue for the reconstruction with better aesthesis.

METHODS

The study design was retrospective case analysis over a period of 2 years. All the patients who underwent flap for leg, foot and ankle defect reconstruction in the form of MSAP free flap were included in the study. The flap characteristics and aesthesis were assessed along with the patient satisfaction. The flap complication and donor site morbidity were also analysed.

RESULTS

A total of seven MSAP free flaps were done for leg, foot and ankle reconstruction. The mean flap size was 14.29 × 6.6 cm and mean pedicle length was 9.71 cm. One flap had venous congestion post-operatively resulting in marginal flap loss. All the flaps had acceptable aesthesis with good patient satisfaction. There was donor site morbidity in two patients, in the form of wound dehiscence.

CONCLUSION

MSAP free flap is a reliable choice for leg, foot and ankle defect reconstruction.