Distally based fasciocutaneous flap of the calf for cutaneous coverage of the lower leg and dorsum of the foot

Comparison of distally based sural artery and supramalleolar flap for coverage of dorsum of foot and ankle defects; a cross-sectional study of 53 patients

Background

Soft tissue defects over the foot and ankle region are most challenging in reconstructive surgery. Sural artery and supramalleolar flaps have been commonly used for the reconstruction of non-weight-bearing surfaces of the foot. This article aimed to evaluate the long-term outcome comparisons between a sural artery and Supramalleolar flap in the reconstruction of extensive defects of foot and ankle only.

Methods

Between 1996 and 2020, a retrospective analysis of 53 fasciocutaneous flaps (27 sural and 26 Supramalleolar) used for reconstruction of soft tissue defects of foot and ankle were reviewed in this study. The parameters included were demographics data, causes, site and size of the defect, flap size, hospital stay, complications, and outcomes in a pre-structured proforma. The clinical outcome was assessed by a Self-Designed Tool based on flap survival, coverage of defect, weight-bearing status, functional activities of daily living, and cosmetic appearance. Data were analyzed through SPSS version 25.

Results

Among 53 flaps, the major cause of the defect was Trauma (60.4%). The maximum flap size harvested was 25*10 for sural and 20*8 cm for supramalleolar. Complications were seen in 8 (15%) cases in both flaps. Flap tip necrosis and venous congestion were seen in 4 cases. 2 each in Supramalleolar whereas 1 partial necrosis, 1 venous congestion, and 2 infections were seen in the sural artery flap. The flap survival rate in both flaps was 96.2%. Based on the self-designed Tool, flaps were graded Excellent in 43, Good in 8, and Fair in 2 cases. There was no case of Poor in both flaps.

Conclusion

Compared with the sural artery flap, the lateral supramalleolar flap demonstrated higher rates of functional outcomes although flap tip necrosis was higher in Supramalleolar.

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The comparative long-term clinical and functional outcomes of Sural and Supramalleolar flap is based on defect coverage, cosmetic appearance of surgical limb and activity of daily living.

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Compared with the sural artery flap, the lateral Supramalleolar flap is more reliable and exhibit higher rates of functional outcomes.

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Outcomes of Supramalleolar Flap was better than Sural artery flap as it was much more vascular and robust.

Reconstruction in pediatric orthopedic trauma: the role of primary cross leg flap cover

Composite defects of the leg often involve microsurgical reconstruction. Microsurgery is technically demanding in post-trauma situations in very young children. There is renewed interest in cross leg flaps in this scenario. Children aged up to 5 years, who had open fractures or exposed bones in the leg, were followed up prospectively. Eight children, with a mean age of 4 years, underwent nine flaps for extensive tissue defects over the leg and foot. Six of these flaps were cross leg flaps. No flap failed and all wounds acquired early stable cover. The cross leg flap is a useful alternative in the pediatric population in lieu of microsurgical tissue transfer.

Modified reversed superficial peroneal artery flap in the reconstruction of ankle and foot defects following severe burns or trauma

OBJECTIVE

Challenges persist in the reconstruction of the ankle and the foot with exposed tendons, joints, and bones as a result of severe burns and trauma. In flap elevation involving the sensitive superficial nerve, the local nerve was always sacrificed to obtain an anesthetic donor site; however, such a procedure introduced the possibility of painful neuromas. In this study, we present a desired clinical application of a modified reversed superficial peroneal artery flap, in which the superficial peroneal nerve is preserved.

METHODS

From 2008 to 2015, 12 patients with ankle or foot defects were treated with the modified reversed superficial peroneal artery flap. The defects of the patients were caused by hot liquid scald (one patient), electrical injury (five patients), and trauma (six patients). The flap was utilized for covering defects on the ankle (seven patients) and the foot (five patients). The size of the flaps ranged from 4.0cm×6.0cm to 18.0cm×10.0cm. The superficial peroneal artery was involved in the flap, whereas the superficial peroneal nerve was spared by dedicate dissection. The reverse-flow flap was nourished by the superficial peroneal artery through the terminal peroneal artery perforator.

RESULTS

The obtained outcomes were satisfactory functionally and aesthetically. The flaps in 11 patients survived completely without complications, whereas partial necrosis occurred in a 78-year-old patient when the flap survived a week later during follow up. CT angiography revealed the stenosis of the popliteal artery. The wound healed after interventional treatment involving placing a stent and changing the dressings. Basic functions and configurations were salvaged in all cases. All patients were completely satisfied with the proposed flap and suffered no paresthesia in their lower leg.

CONCLUSION

Exhibiting beneficial characteristics such as reliable blood supply, favorable thickness, wide rotating arc, and retention of major vessels and the superficial peroneal nerve, the modified reversed superficial peroneal artery flap is useful in the reconstruction of ankle and foot defects that would not cause any hypoesthesia of the foot.

Reverse Sural Artery Island Flap With Skin Extension Along the Pedicle

The distally based sural flap is an efficient flap for reconstruction of soft tissues defects of lower limb. The unstable vascular pedicle, however, is prone to compression by the subcutaneous tunnel, especially when a long pedicle covers the distal area of the foot. The aim of the present study was to introduce a modified surgical technique that leaves the skin extension over the pedicle and to report the clinical results of this modification. A total of 25 consecutive patients with a mean age of 51.7 ± 14.7 years underwent surgery. We modified the conventional sural flap technique by leaving a skin extension over the entire length of the pedicle, creating a fasciocutaneous vascular pedicle. The postoperative flap survival rates, complications, and the characteristics of the flaps such as flap size, pedicle length, and the most distal area that could be covered with this modification, were reviewed. At the last clinical follow-up examination, all the flaps survived, although partial necrosis was observed in 2 (8%) cases. Four cases of venous congestion developed but healed without additional complications. The mean flap size was 5.9 ± 1.8 × 9.2 ± 2.7 cm. With this modification, the sural flap could cover the defect located in extreme distal areas, such as the medial forefoot and dorsum of the first metatarsophalangeal joint, with a longer pedicle (≤27 cm) in 7 patients (28%). A skin extension along the pedicle achieved the favorable survival rate of the sural flap and successfully extended the surgical indications to more distal areas.

Management of post road traffic accident compound leg defects using fasciocutaneous flaps

OBJECTIVE

To highlight the role of fasciocutaneous flaps in the management of leg and foot defects sustained after trauma, in rural India.

METHOD

This was a prospective study conducted on patients with traumatic defects of the leg and foot, admitted between May 2001 and April 2007. Selection of flaps was done on the basis of defect size, site and condition of surrounding tissue. Ipsilateral flaps (proximally- and distally-based), contralateral-leg flaps and free flaps (anterolateral thigh and radial forearm) were raised according to standard techniques and wounds resurfaced accordingly. The outcome was considered 'excellent' when there was no flap necrosis and no donor site morbidity, 'good' when there was some infection, either at the donor or recipient site, but no necrosis, 'satisfactory' when partial flap necrosis and 'poor' when there was flap loss.

RESULTS

One-hundred and ten patients (86 males and 24 females) with post-traumatic leg defects underwent reconstruction with different fasciocutaneous flaps. The ages of the patients ranged from 6 years to 58 years, with a mean age of 28.2 +/- 11.5 years. Forty cases (37%) underwent immediate reconstruction within the first 72 hours and in 70 cases (63%) delayed reconstruction was done. Hospital stay of the patients ranged from 8 days to 54 days, with a mean of 20.2 +/- 1.9 days. There were no complications recorded at donor site. The overall results were considered excellent in 92 cases (84%), good in 12 (11%), satisfactory in four (3.6%) and poor in two cases (1.8%), where flap necrosis occurred.

CONCLUSION

Our results suggest fasciocutaneous flaps are convenient, simple, reliable and easy to manage. The majority of compound leg defects can be reconstructed with fasciocutaneous flaps either from the ipsilateral leg, contralateral leg or in the form of free flaps.

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.

Heel coverage using a distally based sural artery fasciocutaneous cross-leg flap: report of a small series

One of the goals in the management of severe open injuries of the foot is to obtain adequate soft tissue coverage. In extreme conditions of pedal soft tissue loss, in patients who are not satisfactory candidates for local or free-tissue transfer, the cross-leg flap remains an option for surgical reconstruction. We present the results of 7 patients with multiple lower limb open fractures associated with ipsilateral degloving injuries, and/or secondary pressure ulcers of the hindfoot with exposure of the calcaneus, in which a distally based sural artery island fasciocutaneous flap, elevated from the contralateral leg and crossed to the injured side, was used to repair the soft tissue defect of the recipient heel. All of the flaps survived and the soft tissues healed uneventfully, thereby providing satisfactory and stable coverage of the calcaneal tuberosity. To the best of our knowledge, this is the first report in which this technique has been used to repair hindfoot soft tissue defects associated with complex bone and vascular injuries of the lower limb in polytrauma patients.

LEVEL OF CLINICAL EVIDENCE

4.

Cross-leg flap: Its role in limb salvage

BACKGROUND

Pedicled cross-extremity flaps for lower limb wound coverage have been replaced by free tissue transfer in the last two decades. However, there are certain difficult situations where the free flap cannot be employed and alternative methods are needed. We describe our experience with cross-leg flap in 18 patients for the reconstruction of difficult leg defects in which no suitable recipient vessels were available for microvascular anastomosis in the vicinity of the defect.

MATERIALS AND METHODS

18 patients (17 men and 1 woman) with mean range 31.5 yrs(range 18-70 yrs) grade III B tibial fractures were included in the study. fasciocuteneous cross leg flap was employed and extremities were immobilized by external Fixator.

RESULTS

Fifteen flaps were completely available with two had marginal necrosis and one supsficial epidermal necrosis. No complications were related to the donor site, flap, or by immobilization are noted. Each patient resumed essentially normal gait and activity without any stiffness of joints related with the flap or external fixator.

CONCLUSION

The addition of external fixator stabilization aids greatly in wound care, as well as for general ease of the patient mobility and positioning. Cross-leg flap offers the possibility of salvaging limbs that are otherwise nonreconstructable.

Distally based adipofascial flaps for dorsal foot and ankle soft tissue defects

Soft tissue defects of the dorsal foot and ankle are difficult to reconstruct because the contour of the foot must be maintained for shoe fitting. The adipofascial flap, covered with a skin graft, is a suitable method of reconstruction that fulfills this important requirement. Twelve patients with soft tissue defects of the dorsal foot and at the ankle were treated in our unit with this method. Ten (83%) were children, 2 (17%) were adults. All defects were due to road traffic accidents. Three (25%) patients were women; 9 (75%) were men. The right foot was affected in 10 (83.4%) patients, with 2 (16.6%) patients having the left foot involved. The flaps used were the peroneal artery perforator flap (distally based lateral adipofascial flap) in 9 (75%) patients, the superficial sural artery flap in 2 patients (17%), and the posterior tibial artery perforator flap (distally based medial adipofascial flap) in 1 patient (8%). All flaps were successful, providing adequate contour of the foot for wearing ordinary shoes. There were 2 partial skin graft necroses, and, in 1 patient, the tips of the donor site skin flaps were necrosed. In conclusion, the distally based adipofascial flap, covered with skin graft, is a suitable method for reconstruction of soft tissue loss of the dorsal foot and ankle and provides optimum functional and aesthetic outcome with minimum donor site morbidity.

Sécurisation des lambeaux fasciocutanés de jambe à pédicule distal par l'anastomose saphène externe–saphène interne. À propos de 15 cas cliniques

PURPOSE

The distally based fasciocutaneous flaps of the leg are very useful for the treatment of skin defects at the lower third of the leg and the foot, but the venous congestion due to the reverse flow can be responsible of necrosis at the distal part of the flap. The anastomosis of the lesser saphenous vein which is included in the flap's dissection to the greater saphenous vein near the defect avoid this venous congestion and the necrosis of the most useful part of the flap for the coverage of these defects.

MATERIAL AND METHODS

From January 1999 to June 2005, 15 patients aged between 22 and 64 years old have benefited for the treatment of soft tissue defects secondary to trauma with a mean diameter of 7 x 10 cm and located in 7 cases at the lower third of the leg and in 8 cases at the posterior side of the heel, from distally based posterior fasciocutaneous flaps where the venous reverse flow has been changed in a physiological one by the terminolateral anastomosis between the lesser and greater saphenous vein. The dissection of these flaps was classical except that the lesser saphenous vein was dissected 6 cm beyond the proximal part of the flap in the popliteal region.

RESULTS

In all these flaps, there was no venous congestion and no arterial problems. With a mean follow-up of 40 months, the coverage's quality of these defects was very satisfactory. No sequellae are reported.

CONCLUSION

The anastomosis between the lesser and the greater saphenous veins seems to eliminate the main source of failure of the distally based fasciocutaneous flap of the leg and can reinforce the indications of these flaps for the treatment of such defects.

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.

Distally Based Sural Fasciomusculocutaneous Flap for Chronic Calcaneal Osteomyelitis in Diabetic Patients

Chronic calcaneal osteomyelitis is a difficult surgical problem, especially in diabetic patients. After aggressive surgical eradication of nonviable soft tissue and infected bone, there will be a large soft-tissue and bony defect. A distally based sural fasciomusculocutaneous flap including the sural nerve and a midline cuff of the gastrocnemius muscle can be useful for covering the defect. This flap is designed on the proximal half of the posterior calf and has an adequate blood supply derived from retrograde perfusion of the vascular axis of the sural nerve to the musculocutaneous perforators of the gastrocnemius muscle. The patency of the peroneal artery should be confirmed by Doppler ultrasound or angiography before surgery. If there are any vascular problems, this flap will not be used to avoid complications resulting from poor flap circulation. This approach has been used for 11 diabetic patients in the past 2 years. All flaps survived completely and all wounds healed uneventfully. The authors found that the flap was reliable and technically simple to design and execute. This 1-stage procedure not only preserves the major arteries of the injured leg but has also proved valuable for filling bony defect and treating bony infection because it provides a well-vascularized muscle fragment. Compared with other tissue transfers, this flap has special characteristics for use on diabetic patients with chronic calcaneal osteomyelitis.

Comparison of different managements of large superficial veins in distally based fasciocutaneous flaps with a veno-neuro-adipofascial pedicle: An experimental study using a rabbit model

The role of large superficial veins in the survival of a distally based fasciocutaneous flap with a veno-neuro-adipofascial pedicle was studied in a rabbit model. A sural veno-neuro-fasciocutaneous flap model (6 x 2 cm) with a distally based lesser saphenous veno-neuro-adipofascial pedicle (1.5 cm) was established. Fifteen rabbits were randomly divided into three groups with 10 flaps in each group. In group I, the distal lesser saphenous vein was left open (venous inflow remained) after the flap was raised. In group II, the lesser saphenous vein was ligated in the pedicle (no venous inflow). In group III, the venous pedicle was left open in the pedicle, and the proximal end was microsurgically anastomosed to the recipient vein (outflow established). Intravenous pressure, flap survival, and histology were examined. The results showed that the values of intravenous pressure in group I were significantly higher than in group II (P < 0.001). The mean flap survival rate of group III (94.5%) was significantly higher (P < 0.001) than of groups I (22.7%) and II (55.5%). Histology showed that the lesser saphenous vein in group I was extremely dilated and filled with thrombosis. This experiment demonstrated that establishing a superficial venous outflow channel by anastomosis at the proximal end, or interrupting the inflow channel by ligation at the distal pedicle, may significantly improve the survival rate of distally based veno-neuro-fasciocutaneous flaps.

Use of distally based saphenous neurofasciocutaneous and musculofasciocutaneous cross-leg flaps in limb salvage

Neurocutaneous island flaps have been very popular in soft-tissue coverage of the lower extremities. These flaps are based on the arterial network around the superficial sensory nerves. The advantages of these flaps are easy and quick dissection (hence a time-saving operation), acceptable donor site morbidity, and preservation of major arteries of the leg. The authors used five neurofasciocutaneous and three musculofasciocutaneous flaps successfully as cross-leg flaps for the coverage of relatively large defects of the lower two thirds of the leg and foot in 8 patients. They conclude that reverse saphenous neurofasciocutaneous and musculofasciocutaneous flaps as a cross-leg flap in patients who cannot be reconstructed with other flap alternatives have many advantages over traditional cross-leg procedures, such as short vascularization time, minimal patient discomfort, wide arc of rotation and great versatility, and a safe vascular pattern.