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J Reconstr Microsurg 2021; 37(03): 227-233
DOI: 10.1055/s-0040-1716744
Original Article

A Retrospective Study of an Updated and Traditional Surgical Approach of the Distally Based Sural Flap

Heng Xu   *
1   Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
,
Xuexin Cao   *
2   Department of Orthopedics, Center of Reconstructive and Microsurgery, Suqian Third Hospital, Anhui, People's Republic of China
,
Sally Kiu-Huen
3   Department of Plastic Surgery, Austin Health, Melbourne, Australia
,
Zhu Zhu
1   Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
,
Jun Chen
1   Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
,
Zhenglin Chi
2   Department of Orthopedics, Center of Reconstructive and Microsurgery, Suqian Third Hospital, Anhui, People's Republic of China
,
Yixin Zhang
1   Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
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Abstract

Background The distally based sural flap (DBSF) is one of the armamentarium in the lower limb reconstruction. However, the flap has not gained popularity due to concerns about its reliability and donor site morbidity. Based on the anatomy characterization, we combined and developed five modifications to improve the vascular supply and reduce donor site morbidity.

Patients and Methods The authors performed a comparison of retrospective study that included patients who underwent either traditional distally based sural flap (tDBSF) or modified distally based sural flap (mDBSF) surgery approach for ankle, heel, and dorsal foot coverage between January 2007 and May, 2019. The five modifications developed to improve the reliability of the flap include: 1. shift the pivot point more proximally 7.0 cm above the lateral malleolus, 2. preserve the lesser saphenous vein and include branches that communicates with the flap, 3. harvest thinner fascial pedicle, 4. change the skin incision to “S” shape, 5. closure of the donor site with a propeller flap.

Results Thirty-one patients underwent mDBSF, and 23 received tDBSF. There were no significant differences in the size of the DBSF. Mean pedicle width was significantly narrower in mDBSF (1.63 ± 0.52 cm vs. 3.81 ± 0.70 in tDBSF). The pivot point was also found to be higher in mDBSF (8.01 ± 0.63 cm vs. 5.46 ± 0.56 cm) above the lateral malleolus. In mDBSF, the size of the propeller flap required for donor site closure was 53.45 ± 19.06 cm2 (range 33–80 cm2). The rate of partial necrosis between mDBSF and tDBSF was significantly different (9.68 vs. 34.78%). While the other complications had no difference.

Conclusion The modifications applied to the harvesting of the DBSF have achieved higher survival rate, lower dehiscence rate, and shorter hospital stay time in comparison with traditional approach in our retrospective study.

Keywords

distally based sural flap - modification - sequential flap

* These are first two authors and have contributed equally to this study.




Publication History

Received: 10 April 2020

Accepted: 10 August 2020

Article published online:
17 September 2020

© 2020. Thieme. All rights reserved.

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  • References

  • 1 Yilmaz M, Karatas O, Barutcu A. The distally based superficial sural artery island flap: clinical experiences and modifications. Plast Reconstr Surg 1998; 102 (07) 2358-2367
    CrossrefPubMedGoogle Scholar
  • 2 Jeng SF, Wei FC. Distally based sural island flap for foot and ankle reconstruction. Plast Reconstr Surg 1997; 99 (03) 744-750
    CrossrefPubMedGoogle Scholar
  • 3 Donski PK, Fogdestam I. Distally based fasciocutaneous flap from the sural region. A preliminary report. Scand J Plast Reconstr Surg 1983; 17 (03) 191-196
    CrossrefPubMedGoogle Scholar
  • 4 Akhtar S, Hameed A. Versatility of the sural fasciocutaneous flap in the coverage of lower third leg and hind foot defects. J Plast Reconstr Aesthet Surg 2006; 59 (08) 839-845
    CrossrefPubMedGoogle Scholar
  • 5 Masquelet AC, Romana MC, Wolf G. Skin island flaps supplied by the vascular axis of the sensitive superficial nerves: anatomic study and clinical experience in the leg. Plast Reconstr Surg 1992; 89 (06) 1115-1121
    CrossrefPubMedGoogle Scholar
  • 6 Follmar KE, Baccarani A, Baumeister SP, Levin LS, Erdmann D. The distally based sural flap. Plast Reconstr Surg 2007; 119 (06) 138e-148e
    CrossrefPubMedGoogle Scholar
  • 7 Tajsic N, Winkel R, Husum H. Distally based perforator flaps for reconstruction of post-traumatic defects of the lower leg and foot. A review of the anatomy and clinical outcomes. Injury 2014; 45 (03) 469-477
    CrossrefPubMedGoogle Scholar
  • 8 Rajacic N, Darweesh M, Jayakrishnan K, Gang RK, Jojic S. The distally based superficial sural flap for reconstruction of the lower leg and foot. Br J Plast Surg 1996; 49 (06) 383-389
    CrossrefPubMedGoogle Scholar
  • 9 Touam C, Rostoucher P, Bhatia A, Oberlin C. Comparative study of two series of distally based fasciocutaneous flaps for coverage of the lower one-fourth of the leg, the ankle, and the foot. Plast Reconstr Surg 2001; 107 (02) 383-392
    CrossrefPubMedGoogle Scholar
  • 10 Baumeister SP, Spierer R, Erdmann D, Sweis R, Levin LS, Germann GK. A realistic complication analysis of 70 sural artery flaps in a multimorbid patient group. Plast Reconstr Surg 2003; 112 (01) 129-140 , discussion 141–142
    CrossrefPubMedGoogle Scholar
  • 11 Erdmann D, Gottlieb N, Humphrey JS, Le TC, Bruno W, Levin LS. Sural flap delay procedure: a preliminary report. Ann Plast Surg 2005; 54 (05) 562-565
    CrossrefPubMedGoogle Scholar
  • 12 Zhang FH, Chang SM, Lin SQ. et al Modified distally based sural neuro-veno-fasciocutaneous flap: anatomical study and clinical applications. Microsurgery 2005; 25 (07) 543-550
    CrossrefPubMedGoogle Scholar
  • 13 Chang SM, Wang X, Huang YG, Zhu XZ, Tao YL, Zhang YQ. Distally based perforator propeller sural flap for foot and ankle reconstruction: a modified flap dissection technique. Ann Plast Surg 2014; 72 (03) 340-345
    CrossrefPubMedGoogle Scholar
  • 14 Chang SM, Hou CL. Role of large superficial veins in distally based flaps of the extremities. Plast Reconstr Surg 2000; 106 (01) 230-231
    CrossrefPubMedGoogle Scholar
  • 15 Finkemeier CG, Neiman R. Reverse sural artery pedicle flap. J Orthop Trauma 2016; 30 (Suppl. 02) S41-S42
    CrossrefPubMedGoogle Scholar
  • 16 Chai Y, Zeng B, Zhang F, Kang Q, Yang Q. Experience with the distally based sural neurofasciocutaneous flap supplied by the terminal perforator of peroneal vessels for ankle and foot reconstruction. Ann Plast Surg 2007; 59 (05) 526-531
    CrossrefPubMedGoogle Scholar
  • 17 Kansal S, Goil P, Agarwal V. et al Reverse pedicle-based greater saphenous neuro-veno-fasciocutaneous flap for reconstruction of lower leg and foot. Eur J Orthop Surg Traumatol 2014; 24 (01) 67-72
    CrossrefPubMedGoogle Scholar
  • 18 Wei JW, Ni JD, Dong ZG, Liu LH, Luo ZB, Zheng L. Distally based perforator-plus sural fasciocutaneous flap for soft-tissue reconstruction of the distal lower leg, ankle, and foot: comparison between pediatric and adult patients. J Reconstr Microsurg 2014; 30 (04) 249-254
    Article in Thieme ConnectPubMedGoogle Scholar
  • 19 Karinja S, Riesel J, Iorio ML. Evaluating venous drainage in reverse flow pedicles: available evidence and mechanisms. J Reconstr Microsurg 2019; 35 (02) 90-96
    Article in Thieme ConnectPubMedGoogle Scholar
  • 20 Herlin C, Bekara F, Bertheuil N. et al Venous supercharging reduces complications and improves outcomes of distally based sural flaps. J Reconstr Microsurg 2017; 33 (05) 343-351
    Article in Thieme ConnectPubMedGoogle Scholar
  • 21 Imanishi N, Nakajima H, Fukuzumi S, Aiso S. Venous drainage of the distally based lesser saphenous-sural veno-neuroadipofascial pedicled fasciocutaneous flap: a radiographic perfusion study. Plast Reconstr Surg 1999; 103 (02) 494-498
    CrossrefPubMedGoogle Scholar
  • 22 Liu Y, Zang M, Song B. et al The 'buddy flap' concept of soft-tissue-defect reconstruction. J Plast Reconstr Aesthet Surg 2011; 64 (11) 1475-1482
    CrossrefPubMedGoogle Scholar
  • 23 Song D, Pafitanis G, Reissis D. et al A sequential thoracoacromial artery perforator flap for reconstructing the donor site of sternocleidomastoid myocutaneous flaps: extended indications and technical modifications. Ann Plast Surg 2020; 84 (06) 657-664
    CrossrefPubMedGoogle Scholar