In this report, we present our experience on the use of the reverse sural flap for traumatic foot and ankle reconstruction. From 2007 to 2010, 11 consecutive patients underwent modified reverse sural flap at the chang gung memorial hospital. Sural fl, preoperative and early postoperative photographs of a patient with cruris distal third defect. Risk analysis for the reverse sural fasciocutaneous flap. The versatile reverse flow sural artery neurocutaneous flap. Repeated reverse sural fasciocutaneous flap is an effective surgical strategy for repairing long segmental soft tissue defects of the tibia zelong cui1,2, xuemei zhang3, jiabao shou2 and guoqian yin1 abstract objective. The use of the reverse sural neurovenocutaneous flap in. Xiaohua li1,2,3, huidong wang2, chunlin xia1, lei zhuang3,shimin chang3, baozhi ding2, zelu li3 1department of anatomy and boxi institute of clinical anatomy, medical college of soochow university, suzhou. They concluded that there is an innate mechanical property that allows the sole to withstand weight bearing and shearing forces and that this is as important as the.
Pdf the reverse superficial sural artery flap revisited for. The main perforators of the medial sural artery are located on a line drawn from the midpoint of the popliteal crease to the midpoint of the medial malleolus. Pdf the reverse sural fasciocutaneous flap for the. This flap is based on perforators of the peroneal artery system. The sural flap procedure is a versatile technique that can be used to cover many types of defects about the lower extremity. This is a random type of flap, based on the reverse flow of the superficial sural artery, which mainly depends on the anatomy of the perforators of the peroneal artery system. Many articles have been written with some contrasting opinions regarding the anatomy, size of flap, location of the skin paddle, mode of transfer and overall survival. Patients and methods from march 2006 to march 2009, 32 distally based neurofasciocutaneous reverse sural flaps were used for. There was satisfactory flap healing in 17 patients 85%, while 3 patients 15% had complete flap necrosis. The reverse sural fasciocutaneous flap for the treatment of traumatic, infectious or diabetic foot and ankle wounds. Reverse sural artery flap for the reconstruction of chronic. Despite various reported techniques, the coverage of the achilles tendon, malleoli, ankle and heel is still daunting and demanding procedure. Pdf reverseflow medial sural artery perforator flap. The authors present their experience with the use of sural fasciocutaneous flaps for the treatment of various soft tissue defects in the lower limb.
B flap elevation and calcaneal defect after debridement. Factors which determine success of reverse sural artery. Jan 17, 2016 a pedicled flap for lower limb defect coverage. Reverse sural fascio cutaneous flap for soft tissue coverage. The flap consists of superficial and deep fascia, the sural nerve, lesser saphenous vein, and superficial sural artery. Traumatic limb injury is a prevalent lesion in iran. The distally based neurofasciocutaneous reverse sural flap, 11 x 12 cm in size was transferred to the defect through the subcutaneous tunnel. The reverse sural artery flap for the reconstruction of. We reconstructed the heel of a 41yearold male hemophilia b patient using a reverse sural artery flap operation. Factors which determine success of reverse sural artery flap for repair of lower limb defects. The reverse sural artery flap is a reliable alternative for treating small to moderate size defects of the lower tibia, ankle, and heel regions. The lateral supramalleolar skin flap offers a range of coverage similar to that of the sural flap, but the dissection is more difficult than for a sural flap and offers no advantages, the remaining nonsensitive area in sural flaps is smaller than the one left after the. The reverse superficial sural artery flap rssaf is a distally based fasciocutaneous or adipofascial flap that is increasingly being used for coverage of defects that involve the distal third of the leg, ankle, and foot. The reverse sural artery flap is an effective technique for closing these defects and saving the limb.
The reverse sural fasciocutaneous flap offers the surgeon a straightforward procedure that minimizes donorsite morbidity and preserves the major. The design of the desired flap is centered around the most distal perforator found to ensure the longest possible pedicle fig. The technique is based on the use of a reverse flow island sural flap combined with other flaps in three cases crossleg, peroneal, gastrocnemius. Success of reverse suralfasciocutaneous flap for coverage. Repeated reverse sural the authors 2019 fasciocutaneous. The versatile reverse flow sural artery neurocutaneous. It has the largest arc of rotation of all the regional flaps and does not require sacrifice of any major artery, and moderatetolargesized defects can be covered adequately. Recent modifications of distally based perforator sural flap overcame most of the drawbacks of the original technique. A significant advantage of this flap is a constant blood supply that does not require sacrifice of a major artery. Associated risk factors in the patients for the flap performance were diabetes five patients and cigarette smoking ten patients. Sshaped reverse sural flap for reconstruction of tissue. Risk analysis for the reverse sural fasciocutaneous flap in.
Jun, 2016 the distally based sural artery flap, which is perfused by reverse flow through the anastomosis between the superficial sural artery and the lowermost perforator of the peroneal artery, forms part of this group. Health, general flaps surgery usage leg surgery patient outcomes quality of life health aspects surgical flaps. Single patient with a full thickness soft tissue loss over the posterior calcaneal tuberosity requiring soft tissue coverage. Reverse sural artery adipofascial turndown flap for ulcerations with achilles exposure by david pougatsch, dpm and karen shum, dpm wound management continued on page the reverse sural artery flap is typically performed as a distally based fasciocutaneous flap. View enhanced pdf access article on wiley online library html view. The versatility and reliability of sural artery flap have made it an emerging popular option for the reconstruction of such defects.
Reverse sural fascio cutaneous flap for soft tissue. The sural artery flap is a distally based fasciocutaneous flap that has many advantages to offer for coverage in the foot and ankle area. However, this flaps versatility allows for the limits of its indications to be increased to include multiple areas of the posterior lower limb with small defects. Reverse sural artery flap for the reconstruction of. Reverse sural artery flap request pdf researchgate. In such patients, the reverse sural fasciocutaneous flap requires multiple operative revisions and. The routine sacrifice of the sural nerve with its consequential temporary loss of sensation on the lateral aspect of the foot can be of concern to early rehabilitation of some patients. The potential advantages are the relatively constant blood supply, ease of elevation and preservation of major vascular trunks in the leg. A comparison of fasciocutaneous and adipofascial methods in.
The potential disadvantages remain venous congestion, donor site morbidity and lack of sensation. Apr 02, 2016 the design of the desired flap is centered around the most distal perforator found to ensure the longest possible pedicle fig. This study was performed to highlight its reliability, safety and potential for large traumatized foot defect reconstruction. Soft tissue reconstruction of the foot with a reverse flow. Jan 12, 2011 the lateral supramalleolar skin flap offers a range of coverage similar to that of the sural flap, but the dissection is more difficult than for a sural flap and offers no advantages, the remaining nonsensitive area in sural flaps is smaller than the one left after the transection of the superficial peroneal nerve. Role of reversed sural artery flap in reconstruction of. Fasciocutaneous flap with wide pedicle in the late group.
The reverse sural artery flap is a generally accepted means of soft tissue reconstruction for defects of the distal third of the legs. Reverse flow sural neurocutaneous flap has been utilized more frequently during the past decade to cover vital structures around the foot and ankle area. Distally based perforator sural flaps for foot and ankle. Success of reverse suralfasciocutaneous flap for coverage of soft tissue defect of distal limb 1204 p j m h s vol. A case of heel reconstruction with a reverse sural artery. To overcome this, we have modified our operative technique, which has produced a more reliable flap. Sep 22, 2015 the reverse superficial sural artery flap rssaf is a distally based fasciocutaneous or adipofascial flap that is increasingly being used for coverage of defects that involve the distal third of the leg, ankle, and foot. This study was performed to introduce our surgical strategy and experience in. Distally based perforator sural flaps from the posterolateral or posteromedial lower leg aspect are initially a neurofasciocutaneous flap that can be transferred reversely to the foot and ankle region with no need to harvest and sacrifice the deep major artery. The lateral supramalleolar skin flap offers a range of coverage similar to that of the sural flap, but the dissection is more difficult than for a sural flap and offers no advantages, the remaining nonsensitive area in sural flaps is smaller than the one left after the transection of the superficial peroneal nerve.
Original article fasciocutaneous sural nerve flap for lower extremity reconstruction. In particular, guidelines for flap operations in hemophilia b patients have still not been defined, and case reports are rare. The patient presented with mild hemophilia, having 27% of the normal value of coagulation factor ix. The management of soft tissue defects of the lower extremity with underlying osteomyelitis is difficult. The reverse superficial sural artery flap revisited for. The reverse sural artery flap is utilized to reconstruct defects in the distal third of the lower leg, ankle, and heel. Sshaped reverse sural flap is a modified technique of reconstruction. Original research article, report by journal of evolution of medical and dental sciences.
Two of these patients had significant comorbidities of haemoglobinopathy and poorly controlled diabetes mellitus. The distally based sural artery flap, which is perfused by reverse flow through the anastomosis between the superficial sural artery and the lowermost perforator of the peroneal artery, forms part of this group. The reverse superficial sural artery flap rssaf is a popular option for many of these difficult wounds. The reverse sural fasciocutaneous flap for the treatment. The length of the pedicle is identical to the distance between the rotation point of the flap and the wound. Although the reverse sural fasciocutaneous flap is reliable in young healthy patients, it has significant complication rates in patients with comorbidities, especially smokers. Medial sural artery perforator flap plastic surgery key. During a 3year 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. The distally based sural artery flap for ankle and foot. Original article fasciocutaneous sural nerve flap for lower. The patient selection and surgical refinement are discussed. This is a case report of a 24 years old male who had gustillo and anderson. Reverse sural artery adipofascial turndown flap for. When contraction was released by an operation, a wide defect was created.
Figure 4 from the reverse superficial sural artery flap. Motorcycle accidents are responsible for most of these traumatic lesions. Partial flap loss was found in 2 patients 8%, marginal flap necrosis in 2 patients 8% and complete loss in 1 patient 4%. Among the options available for surgical repair, the use of the reverse sural flap of the fasciosubcutaneous pedicle 3, 6, 7 or adipofascial reverse flap has been reported in the literature as a viable option since more than 20 years 7, 8. The reverse superficial sural artery flap rssaf is a distally based fasciocutaneous or adipofascial flap that is used for coverage of defects that involve the distal third of the leg, ankle, and foot. In such patients, the reverse sural fasciocutaneous flap requires multiple operative revisions and a surgical delay should be considered. Defects at this site will often require flap cover. The aim of this study is to analyze the demographic variables of affected individuals, technical aspects of reverse sural artery flap, quantify the effectiveness of reverse sural artery flap among various treatment options available, and to study the outcome of injury. The reverse sural artery flap rsaf and distal peroneus brevis flap dpbf have gained popularity for lower third leg defects among surgeons. Surgical anatomy of the medial sural artery perforator flap wong et al. Distally based sural fasciocutaneous flap was used for coverage in all cases and its survival, successful coverage of the defect and donor site morbidity studied. However, this flap s versatility allows for the limits of its indications to be increased to include multiple areas of the posterior lower limb with small defects. In lower limb surgery, the sural flap is based on this principle and this flap is becoming increasingly popular.
Introduction wounds around the lower third of the leg and foot are difficult to manage because of the composite tissue defects, inadequate and tight local tissues and poor circulation. Alqattan 19 described a modified technique for harvesting a reverse sural artery flap from the upper part of the leg, and he included a gastrocnemius muscular cuff around the sural nerve where it perforated from deep to superficial. Original article fasciocutaneous sural nerve flap for. Free flap is ideal for these defects and gives good results but with its own limitations. Success of reverse suralfasciocutaneous flap for coverage of soft tissue defect of distal limb. Our initial experience with this flap at multiple institutions resulted in a 50% failure rate, mostly because of critical venous congestion. Distallybased sural flap nattakul yamprasert, md department of orthopaedics, maharat nakhon ratchasima hospital regional hand meeting 2015 the diversity of the hand and upper extremity surgery august 20th. He suggested that this muscular cuff provided superior venous drainage of the flap. Surgical anatomy of the medial sural artery perforator flap. Increasing the success of reverse sural flap from proximal. Comparison between peroneus brevis flap and reverse sural. Rbcp reverse sural flap of the fasciosubcutaneous pedicle. Pdf the reverse superficial sural artery flap revisited.
Fascio cutaneous flap, foot and ankle, reverse sural artery, reverse sural flap, sural nerve 1. One of the advantages of this thin fasciocutaneous flap is that it permits skin coverage with ideal contouring. Posttraumatic wounds and soft tissue defects in the distal third of the leg and ankle remain a challenge. Aug 11, 2009 an defect on the posterior ankle exposing the tendoachilles and a fractured calcaneum covered with a sural artery flap. Cureus effectiveness of reverse sural artery flap in the. The flap was distally based, islanded and covered the area with vascularised. Reverse sural fasciocutaneous flap, preoperative and postoperative 2nd year photographs of a patient with skin defect on achilles tendon. Dec 31, 2016 the reverse sural artery flap is utilized to reconstruct defects in the distal third of the lower leg, ankle, and heel. Soft tissue reconstruction of foot and ankle defects with. The distally based superficial sural artery flap for. Sural flap use for the treatment of wounds with underlying.
The reverse sural artery flap for the reconstruction of distal third of the leg and foot. To demonstrate the technical aspects of a reverse sural artery rsa flap. An defect on the posterior ankle exposing the tendoachilles and a fractured calcaneum covered with a sural artery flap. Figure 5 from the reverse superficial sural artery flap. The anatomic structures that constitute the pedicle are the superficial and deep fascias, the sural nerve, the short saphenous vein, and the superficial sural artery. Reverse sural flap for ankle and heel soft tissues.