The venoneuroadipofascial pedicled distally based sural island myofasciocutaneous and muscle flaps: anatomical basis of a new concept

Versatility of Proximal Sural Island Sensate Fasciocutaneous Flap in Reconstruction of Soft Tissue Defects of Knee and Proximal Leg

Background: The proximal sural island sensate (PSIS) fasciocutaneous flap presents an ideal alternative in reconstruction of defects of the knee and proximal leg. It provides a thin sensate flap with good aesthetic outcomes and reduced donor site morbidity. However, only limited reports exist in the literature about this flap.Methods: This is a retrospective study done between December 2018 and December 2021 including 30 patients, among which seven cases had defects located on the knee and 23 cases in the proximal part of the leg. Mean age of the study population was 41 years. The maximum flap size was 8×12 cm, while the maximum pedicle length was 15 cm.Results: All 30 flaps survived well with only minimal complications occurring in a few patients such as epidermal loss and distal tip necrosis. No arterial or venous crisis occurred postoperatively in any case. Donor sites were managed with one-stage primary closure or split-thickness skin grafts. Functional deficits were not detected in any of the cases.Conclusion: We found the PSIS fasciocutaneous flap to be a simple and reliable technique to perform. The flap offers extensive coverage, reaching from the knee to the proximal leg, and provides thin, pliable, and sensate skin, resulting in excellent aesthetic and functional outcomes.

Análise comparativa do tratamento de lesões cutâneas dos membros inferiores com retalho sural versus retalho propeller

Objective  The objective of the present study was to prospectively compare the sural and propeller flaps for soft-tissues coverage of the lower extremity. The following variables were evaluated: incidence of complete or partial flap loss and donor area morbidity (primary closure versus skin graft).

Methods  Prospective and randomized analysis of data collected from all patients presenting with soft tissue defects of the lower third of the leg and heel treated with reverse sural or propeller flaps.

Results  Twenty-four patients aged between 4 and 60 years old were evaluated between 2011 and 2017. Complete coverage was obtained in 22 of the 24 patients (91.6%). Two flaps failed (8.4%). The sural flap, being the most popular option, continues to represent a safe and versatile alternative for skin defects of the lower third of the leg and heel region. Likewise, the propeller flap was a comparable option to treat these challenging defects.

Conclusion  Sural and propeller flaps are good options for soft tissues coverage of the lower extremity, with low complication rates (partial or total flap loss).

Functional reconstruction of complex tendo Achilles defect by free latissimus dorsi muscle flap

Managing the complex tendo Achilles defect involves reconstructing the Achilles tendon as well as providing soft tissue cover to the heel area. The advent of microsurgery has revolutionised the reconstruction of this difficult defect providing a number of options to the reconstructive surgeon. We present a case of complex tendo Achilles defect reconstructed by the latissimus dorsi free flap.

Increasing versatility of the distally based sural flap

Repairing distal lower limb soft tissue defects remains challenging for reconstructive surgeons. Relatively few procedures have real efficiency and low morbidity. Since its initial description, the distally based sural flap has been used increasingly for this indication. However, controversy exists about the upper limit of the skin paddle of the sural flap. In the present series, 11 patients underwent surgery with distally based sural flaps. In 6 patients, the flap skin paddle was partially or totally placed beyond this controversial limit on the proximal calf region. To increase the skin irrigation of this region, whole mesenteric tissue under the deep fascia of the leg was included in the flap. Venous congestion and distal tip necrosis can impair the success of flap surgery. To overcome these problems, the flap pedicle was not passed through the subcutaneous tunnel. All flaps survived completely, and no cases of venous congestion developed. Thus, extending the donor area to the upper part of the leg is a reliable maneuver to repair more distal defects of the leg and foot, and abstaining from passing the pedicle through a subcutaneous tunnel could contribute to a decreased risk of venous congestion.

The distally based lateral sural neuro-lesser saphenous veno-fasciocutaneous flap: anatomical basis and clinical applications

BACKGROUND

Soft tissue management around the lower third of the leg and foot presents a considerable challenge to the plastic surgeon. The aim of this research was to investigate the anatomical relationships of artery, nerve, vein and other adjacent structures in the posterolateral region of the calf, and our experience with using a distally based island flap pedicled with the lateral sural nerve and the lesser saphenous vein for soft tissue reconstruction of lower third of leg, foot, and ankle defects in 15 patients.

MATERIALS AND METHODS

Five fresh cadavers (ten lower limbs) were infused with colored red latex. The origin of the nutrient vessel of the lesser saphenous vein and the lateral sural nerve was identified. Based on the anatomical studies, an island flap supplied by the vascular axis of the lesser saphenous vein and the lateral sural nerve was designed for clinical reparative applications in 15 cases.

RESULTS

The nutrient vessel of the lesser saphenous vein and the lateral sural nerve originates from the superficial sural artery, musculocutaneous perforators of the posterior tibial artery, and septocutaneous perforators of the peroneal artery in different segment of the calf. Meanwhile, these vessels have many sub-branches nourishing subcutaneous tissue and skin, form a favorable vascular chain around the nerve and the vein, and also communicate with vascular plexus of superficial and deep fascia. Among 15 flaps, 13 showed complete survival (86.66 %), while marginal flap necrosis occurred in one patient (6.67 %) and distal wound dehiscence in another (6.67 %). Their appearance and function were satisfactory, with feeling maintained in the heel and lateral side of the foot.

CONCLUSIONS

The distally based flap pedicled with the lateral sural nerve and lesser saphenous vein was a reliable source for repairing soft tissue defects in the lower leg and foot due to its advantages of infection control, high survival rate, and sufficient blood supply without the need to sacrifice a major blood vessel.

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 cm(2), and the muscle component 17.7 cm(2). 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.

Lateral Retromalleolar Perforator???Based Flap: Anatomical Study and Preliminary Clinical Report for Heel Coverage

BACKGROUND

Repair of heel soft-tissue defects remains a challenging problem in reconstructive surgery. The distally based sural neurofasciocutaneous flap is among the flaps of choice for coverage of this difficult region. The authors describe a modified lateral retromalleolar perforator-based neurocutaneous flap with a lower pivot point.

METHODS

This study was divided into two parts: anatomical study and clinical application. In the anatomical study, 12 cadavers were injected with red gelatin, and all fasciocutaneous perforators between the lateral malleolus and Achilles tendon (called the lateral retromalleolar space) were identified. Clinically, based on the anatomical study, five cases of heel soft-tissue defects were reconstructed with the modified lateral retromalleolar perforator-based sural neurofasciocutaneous flap.

RESULTS

The anatomical study showed that there are usually two to three retromalleolar cutaneous perforators arising from the terminal part of the peroneal artery in the lateral retromalleolar space. Their outer diameters range from 0.1 to 0.8 mm. A direct venous communicator, usually accompanied by the larger perforator, connected the superficial lesser saphenous vein and the deep peroneal venae comitantes. Five patients with heel soft-tissue defects were treated with flaps ranging from 3 x 6 cm to 5 x 12 cm. The distal pivot point was designed at 1 to 3 cm above the tip of the lateral malleolus. All flaps survived without complications.

CONCLUSIONS

The lateral retromalleolar perforator is predictable and reliable for the design of a lower pivot point, distally based sural neurocutaneous flap. The procedures are simple and rapid, and the flap can be rotated easily without dog-ear deformity. This flap should be considered among the preferred flaps for heel reconstruction.

The Distally Based Sural Musculoneurocutaneous Flap for Treatment of Distal Tibial Osteomyelitis

BACKGROUND

The treatment of distal tibial osteomyelitis represents a challenge for orthopedic and plastic surgeons. The affected tissues should be debrided and good vascularized tissue should cover the defect, but the option of a muscle flap covering the area is limited. Free flaps are used but require longer operating time and experience with microsurgery, may result in donor-site morbidity, and sometimes add bulky tissue to the area. The authors present their experience with a sural musculoneurocutaneous flap for the treatment of chronic osteomyelitis of the distal tibia.

METHODS

Over a 2-year period, nine distally based sural musculoneurocutaneous flaps were used in the treatment of chronic osteomyelitis of the distal tibia. Four patients had comorbid conditions (smoking, diabetes mellitus, venous insufficiency, or obesity). The clinical aspect was represented by drainage sinuses located in the distal part of the tibia. Five patients had postsurgical scars on the lateral malleolar region and one had medial and lateral malleolar scarring. Three patients had an Ilizarov device at the time of wound coverage.

RESULTS

All wounds were closed successfully. Dehiscence surrounding the flap was encountered in a single case that was attributable to inadequate bone debridement; this flap was raised to allow extending the debridement, and a local medial fasciocutaneous flap completed wound coverage. Distal tip necrosis of the flap was encountered in two cases.

CONCLUSIONS

The sural musculoneurocutaneous sural flap was successfully used for treatment of distal tibia osteomyelitis. Although it is believed that lateral malleolar scars might compromise the flap, the flaps in the authors' series survived. This flap can also be applied to patients with external fixators without removing the apparatus.

Anatomic study and clinical application of distally-based neuro-myocutaneous compound flaps in the leg

OBJECTIVE

Anatomical study on the anastomosis between the neurovascular axis and the musculocutaneous perforators in leg. The distally-based neuron-myocutaneous flap was used for repairing special patients with soft tissue defect in foot and ankle.

METHODS

Systematical observation was carried out on 30 injected lower legs about the anastomosis between the neurovascular axis and the musculocutaneous perforators, and we summarized the clinical experiences from February 2004 on 12 cases using distally-based neuron-myocutaneous flap for repairing special patients with soft tissue defect in foot and ankle.

RESULTS

The neuron-vessels of sural nerve anastomosed permanently with the musculocutaneous perforators of medial and lateral head of gastrocnemius. There were two to three anastomoses found, respectively. The medial anastomotic branches were found larger in caliber than the lateral ones. The spatium intermuscular branches of the posterior tibial artery gave off their junior branches and anastomosed with the vessels in or out of the soleus muscle. There were two to three muscular branches perforated out of the soleus muscle, with mean caliber 0.5 +/- 0.2 mm and accompanying with one to two veins. The neuron-vessels of the superficial fibular nerve gave off alone its course two to three muscular branches to the long extensor muscle digits and the long fibular muscle, and one to two fasciocutaneous to the skin. The diameter of the muscular branches was 0.4 +/- 0.2 mm in average. Accounting for the operating models in the 12 cases, we had distally-based sural neuron-myocutaneous flap in 7 cases, saphenous neuron-myocutaneous flap in 4 cases, and superficial fibular neuron-myocutaneous flap in 1 case. All these cases were followed up at least for 2-6 months and had the significant results of nice limb's shape and cured osteomyelitis.

CONCLUSION

Distally-based neuro-myocutaneous flap in leg can live with reliable blood circulation. These flaps offer excellent donor sites for repairing special the soft tissue defect in foot and ankle.

The distally based sural artery flap for ankle and foot coverage

The sural artery flap is a distally based fasciocutaneous flap that has many advantages to offer for coverage in the foot and ankle area. It has the largest arc of rotation of all the regional flaps and does not require sacrifice of any major artery, and moderate-to-large-sized defects can be covered adequately. The dissection technique is simple, and donor site morbidity is minimal. We report our experience with 17 cases. Age range was from 13 to 56 years. Ten (59%) defects were posttraumatic, 3 (17%) were related to reconstructive surgery of the foot or tendon Achilles', 2 (11%) resulted from tumor resection, and 1 each were from infection and gunshot wound. The smallest flap was 6 x 4 cm and the largest was 15 x 12 cm, with the average size being 11 x 7.5 cm. In 5 cases, the donor site was closed primarily, and in other cases, split-thickness skin graft was needed. The short saphenous vein was included in the pedicle in all cases. There was no incidence of complete flap necrosis. Follow-up ranged from 3 to 30 months. Two cases (12%) developed partial superficial necrosis. In 1 case, there was partial wound dehiscence that needed debridement and repair. Another case had postoperative discharge, which subsided after removal of the calcaneal plate. None of the patients complained of any functional problem related to loss of sensation along the lateral border of the foot. The sural island flap is a reliable, safe, and easy method of providing soft tissue coverage in the area of the foot and ankle.

Reverse sural artery flap for the reconstruction of chronic lower extremity wounds in high-risk patients

Soft tissue defects in patients with chronic comorbidities place these patients at high risk for amputation, even when their underlying problems are controlled. The reverse sural artery flap is an effective technique for closing these defects and saving the limb. We retrospectively reviewed 15 consecutive high-risk patients who underwent a sural artery flap procedure between 2003 and 2005 as a final attempt to prevent having a below-the-knee amputation. All of our patients presented with at least 1 comorbidity, with a majority having multiple. Comorbidities in our patient population consisted primarily of diabetes mellitus with neuropathy, critical limb ischemia, end-stage renal disease, and various cardiomyopathies. All patients presented before surgical intervention with a longstanding history of chronic ulcerations that had failed multiple healing strategies. Ulcerations were located at various regions of the foot and ankle such as the heel, lateral malleolus, medial malleolus, and the lateral midfoot. Of those 15 procedures, three failed completely and two had complete dermal necrosis with viable adipose tissue that healed secondarily. The remaining ten flaps healed primarily. We used negative pressure therapy preoperatively in seven patients and postoperatively in five patients. We obtained a success rate of 80%. The reverse sural artery flap has many advantages over free flaps, which has made it a viable treatment option in chronic ulcerations that have failed conservative attempts.

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.

Reconstruction of Soft-Tissue Defects of the Heel With Local Fasciocutaneous Flaps

Soft tissue heel defects reconstruction represents a challenge for plastic surgeons because of the poor availability of regional tissue to perform the reconstruction. We divide the heel on the anterior or weight-bearing heel and the posterior or non-weight-bearing heel. Our preferences are the fasciocutaneous instep flap for anterior heel defects and the reverse sural flap for posterior heel defects. We have performed 11 reconstructions of the heel. The complications were total necrosis of 1 instep flap in a previously irradiated patient and 1 case of partial tip necrosis in a reverse sural flap. Functional recovery has been very satisfactory for both procedures. Regional island flaps are for us the first therapeutic option because the skin is similar to the lost one and less time consuming than a free-flap reconstruction.

Recent advances in the reconstruction of complex Achilles tendon defects

Large, complex lower-extremity defects in the region of the Achilles tendon occur when tendon loss or disruption is complicated by damage to surrounding structures, including soft tissue, vessels, or bone. The surgical approach to these complex defects has evolved from simple amputation to the recognition that satisfactory reconstruction has three components: functional reconstruction of the tendon, importation of vascularized soft tissue, and skin coverage. Many techniques have been developed to address these difficult reconstructive goals, which often require multiple procedures or complicated single-stage operations. Microsurgical advances have begun to reduce the complexity of Achilles tendon region reconstruction, and excellent results can be obtained which restore function, form, and cosmesis with minimal morbidity.

The venoneuroadipofascial pedicled distally based sural island myofasciocutaneous flap: case reports

Complex soft-tissue defects of the lower third of the leg, the heel and the ankle still present a challenge for the reconstructive surgeon. In addition to skin replacement, many of these defects require muscle bulk, which promotes the healing of open bone fractures, effectively fills osteomyelitic cavities and deep three-dimensional defects, and helps to reconstruct the Achilles tendon. In an anatomical study, we developed a new flap based on the 'neuromuscular concept'. This flap consists of a paddle of gastrocnemius muscle and a skin paddle based distally on the sural venoneuroadipofascial pedicle supplied by the lower peroneal perforators. Three cases are presented to illustrate the versatile use of this flap.