Experience of 56 patients using a retrograde sural neurovascular flap to repair lower limb tissue defects

Hemodynamics in Distally Based Sural Flaps for Lower Leg Reconstruction: A Literature Review

Coverage of posttraumatic and chronic wounds at the distal leg is a difficult problem due to limited soft tissue available for local flaps. The sural flap is a versatile and effective method for reconstruction in this area since it does not need a significant amount of time or assistance to complete. Improving the survival of these flaps is critically dependent on understanding the basics of flap circulation and why recent modifications were introduced. This review will serve as a much-needed comprehensive analysis of these topics for surgeons looking to increase the reliability of their sural flaps.

Comparison of "complications" and functional outcome of anterolateral thigh flap and sural neurofasciocutaneus flap for foot and ankle reconstruction: A single center cohort study

BACKGROUND

Skin and soft-tissue defects around the foot and ankle remain a challenge for orthopedic and plastic surgeons. Anterolateral thigh (ALT) flap and sural neurofasciocutaneous (NFC) flap are both used to reconstruct lower-extremity soft-tissue defects. The purpose of this study was to compare outcomes of the two flaps and attempt to provide an optimal strategy.

METHODS

A retrospective study was conducted, reviewing data from 93 patients who underwent reconstruction of wounds around the foot and ankle with ALT flap (42 cases) or NFC flap (51 cases) from January 2014 to January 2020. Patients' demographics, characteristics of the defect, complications, cosmetic appearance, and functional outcome were analyzed, and statistical analysis was performed.

RESULT

There was no difference in gender and etiology; however, NFC flaps were more frequently used in elderly patients. Mean size of the flap in the ALT group was significantly larger in comparison with the NFC group. The ALT group had longer operation and hospitalization time than the NFC group (P < 0.05). The incidence of partial necrosis in ALT group was significantly lower than that in NFC group, while its general complications rate was higher. In long-term follow-up, esthetic appearance of the reconstructed site was comparable in both groups, the ALT group had a higher ratio of revision surgery. Moreover, the ALT group showed better overall esthetic outcomes in the donor site.

CONCLUSIONS

The study showed that anterolateral thigh flaps in wound coverage of foot and ankle achieved better outcomes than neurofasciocutaneous flaps in terms of recipient benefits and donor-site compromise with a special indication for larger and more distally located defects.

Coverage of exposed ankle and foot with the conjoined lower abdomen and groin flaps

BACKGROUND

Extensive soft-tissue defects around the ankle and foot pose a difficult challenge to surgeons. Considering that natural contour, the ideal solution should match a thin and pliable skin flap to allow shoe fitting and provide a functional move. As the conjoined flaps were increasingly utilized in covering various defects, we present our experience using the bipedicle conjoined flap on the lower abdomen and groin site.

METHODS

From May 2018 to September 2020, 36 patients (27 male and 9 female) with a mean age of 32 years (ranged, 21-54 years) underwent the one-stage coverage of ankle and foot defects with the bipedicle conjoined flap. A suitable "Y" bifurcation was dissected to enlarge vessel size or participated in intra-flap anastomosis. The mean dimension of the defect was 30 × 12 cm² (ranged, 20 × 8 cm² to 38 × 16 cm²). Primary donor-site closure was accomplished in all patients.

RESULTS

Thirty-six flaps survived completely without significant complications, and mild venous congestion was observed in one flap. The average flap size was 35 × 15 cm² (ranged, 22 × 10 cm² to 42 × 18 cm²). All flaps were available for a mean follow-up of 18 months (ranged, 12 to 24 months). Natural shape and walking function were successfully achieved with restored protective sensation.

CONCLUSIONS

Bipedicle conjoined flap harvested from the lower abdomen and groin is a great alternative, in selected patients seeking one-stage coverage for the exposed ankle and foot. Compared to single-pedicle flaps, the increased skin allows the wider coverage for the large defect with less morbidity and better outcomes.

How Safe Is Reverse Sural Flap?: A Systematic Review

BACKGROUND

Soft tissue reconstruction of the lower third of the leg, the ankle, and the foot is challenging for reconstructive surgeons. The options for reconstruction are limited. Reverse sural flap is relatively easy to perform and considered a good option for reconstruction. The complication rates are variable in studies. This study aims to systemically review all available articles based on reverse sural flap focusing on complications of the flap. The overall complication of the flap helps to better understand the reliability of the flap.

METHODS

A comprehensive literature search was performed using MEDLINE, EMBASE, and Google Scholar to identify cases of reverse sural artery flap.

RESULTS

A pooled analysis of 89 articles was performed, which yielded 2575 patients (2592 flaps) over a period of 19 years. Most of the cases were performed in Asian countries (1540 flaps, 59.4%) with the majority being performed in China (746 flaps, 28.8%). The most common cause for reverse sural flap surgery was trauma/postsurgical (1785/2592) followed by burn/scarring. Flap complications were recorded in 653 of 2592 flaps (25.20%). The most common complication was partial flap loss, which was recorded in 204 flaps (7.85%) followed by venous congestion (79 flaps, 3.05%). Complete flap loss was observed only in 66 participants (2.5% of all the flaps performed).

CONCLUSIONS

Reverse sural flap is reliable flap for the reconstruction of lower leg, ankle, and foot. It can give a comparable outcome as free flap when meticulously performed and, in many cases, a better result.

Heel Reconstruction With Bipedicled Flap: A Salvage Procedure

Reconstruction of the heel region poses great challenge to plastic surgeons not only due to calcaneal bone lying just deep to the subdermal fat pad but also due to easily exposed Achilles tendon. In order to achieve permanent closure of the heel defect, exposed bone or tendon-or both-should be covered with durable, preferably sensate, well-vascularized, thin skin flaps. Even though fasciocutaneous free flaps remain the gold standard in the reconstruction of heel defects with exposed bone or tendon, a significant number of these patients are older individuals with multiple comorbidities such as diabetes mellitus, hypertension, atherosclerosis, and peripheral vascular disease. In this study, with a clinic series consisting of 6 patients (1 female, 5 males), we present a new technique of reconstruction with a bipedicled flap as a safe, reliable, and efficient reconstructive modality in the treatment of heel defects in cases where free flaps and other more sophisticated reconstructive options are either not feasible or have failed. Achieving complete reconstruction of defects in all 6 patients, this technique proves to be successful as a salvage procedure in reconstruction of heel defects.

Repeated reverse sural fasciocutaneous flap is an effective surgical strategy for repairing long segmental soft tissue defects of the tibia

Objective

This study was performed to introduce our surgical strategy and experience in applying a repeated reverse sural fasciocutaneous flap (RSFF) to repair large areas of tibial exposure.

Methods

During a 3-year period, 10 patients with a large area of tibial exposure and intact posterior skin and soft tissue after trauma were treated in our hospital using a repeated RSFF. First, most of the area of proximal tibial exposure was covered by an RSFF. Three weeks later, another smaller RSFF was designed from the original flap and rotated to repair the remaining exposed area of the tibial wound.

Results

All 10 patients’ wounds were completely healed after 2 to 4 operations. The wounds had healed well after 6 months. The patients were satisfied in terms of both appearance and function.

Conclusion

The repeated RSFF is a good treatment strategy for patients with large areas of tibial exposure with intact posterior skin and soft tissue.

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.

[Long-term functional evaluation of complex traumatic heel defects reconstructed by flap in children]

INTRODUCTION

Complex heel injuries in children are rare and their management requires coverage combining resistance and thinness, to allow walking and footwear. The objective of this study was to create a decision-making algorithm for heel defect in children.

MATERIALS

Children received for heel defect, reconstructed with flap in our plastic surgery unit of Bordeaux with a follow-up greater than 10 years were investigated. Three children operated between 1999 and 2003 were included. A free contralateral reinnervated medial plantar flap, a free latissimus dorsi flap and a lateral supramalleolar flap were performed. Patients were reviewed in consultation to assess quality of reconstruction and functional outcomes. Three scores were used, the Foot Function Index (FFI), the AOFAS Ankle and Hindfoot Scale and the Maryland Foot Score.

RESULTS

No growth disorder has been found. Scores greater than 80 for the Maryland Foot Score and AOFAS Ankle and Hindfoot Scale and less than 10 for the FFI were very satisfactory in cases 1 and 3. We found pain and greater functional impairment in the second case.

CONCLUSIONS

"Like-with-like" reconstruction remains the gold standard, whether in loco-regional or free flap. The fasciocutaneous flaps allow custom reliable coverage with little donor site morbidity. Loco-regional flaps remain easily accessible but donor site sequelae are not negligible.