Soft Tissue Reconstruction of the Foot with a Reverse Flow Sural Artery Neurofasciocutaneous Flap
- 1 Comments
- 11324 reads
T he loss of soft tissue from the foot, either from trauma or as the result of a diabetic foot ulcer, can be a difficult problem to resolve. When tissue is lost from the weight-bearing surface of the foot, the result may be catastrophic. The plantar soft tissues have unique functional properties integrated into the biomechanics of weight-bearing that allow them to resist external stress and protect the skeletal architecture. A full-thickness tissue loss from weight-bearing areas requires replacement with tissues whose physical properties are similar to those that were lost. Unfortunately, simple solutions such as skin grafting are unable to address problems of such complexity, and healing by secondary intention usually leads to an unstable scar in the insensate foot and a painful scar/callus complex in patients whose sensorium is intact.1-3
As an alternative to healing by secondary intention, several flaps have been described that can be raised on the foot and leg and used to repair defects on the weight-bearing and non-weight-bearing surfaces of the foot. These flaps have advantages over healing by secondary intention - ie, their tissue properties closely resemble those of the lost tissue and they will move harmonically with the surrounding soft tissue during weight-bearing.
Sural artery flaps are useful in covering defects on the ankle, lower leg, and heel - areas that historically have been difficult to treat. Fasciocutaneous islands of tissue can be raised from the posterolateral surface of the leg and are based on the arteries that accompany the median branch of the sural nerve and the arterial commitantes of the lesser saphenous vein that anastomose with septocutaneous perforators from the peroneal artery.4-7 The most distal perforator, and subsequently the most distal pivot point, is usually found approximately 5 cm proximal to the lateral malleolus.7,8 The donor sites may be closed primarily or with a split-thickness skin graft depending on the size of the flap (see Figure 1a-1f). Other reverse flow flaps based on the major arteries of the legs have been described,1,3 but because they required the sacrifice of a major vascular axis, they are seldom performed, even in patients without vascular disease.
The distally-based sural island flap was first described in the early 1990s and quickly gained popularity.8-10 Flaps that are raised on a distally-based pedicle are said to possess retrograde or reverse flow; hence, the terms reverse flow sural artery and distally-based neurofasciocutaneous sural artery are interchangeable. The technique is comparatively simple, especially as compared to a microsurgical free flap: The pedicle is raised on a wide strip of fascia, making the skeletonization rather quick. Jeng and Wei11 used this technique to cover exposed Achilles tendons and soft tissue defects of the ankle and the heel. Of the 22 patients described, 20 had complete success with two minor complications that were treated uneventfully. Huisinga et al12 used this flap on 15 patients for soft tissue coverage in the lower leg, malleolar, and heel regions; 12 flaps survived, two partially survived, and one flap failed due to persistent infection. Jeng et al13 reported their experience with the use of the distally-based sural artery flap for salvage of the distal foot. In seven out of eight patients, the flaps survived completely and only one patient had a partial necrosis of the flap.
1. Jolly GP, Zgonis T. Pedicle flaps for replacement of soft tissue defects of the foot. Chir del piede. 2003;27:1-10.
2. Zgonis T, Jolly GP, Blume P. A guide to closure techniques for open wounds. Podiatry Today. 2003;16(7):41-48.
3. Jolly GP, Zgonis T, Blume P. Soft tissue reconstruction of the diabetic foot. Clin Podiatr Med Surg. 2003;20:757-781.
4. 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;89:1115-1121.
5. Nakajima H, Imanishi N, Fukuzumi S, et al. Accompanying arteries of the lesser saphenous vein and sural nerve: anatomic study and its clinical applications. Plast Reconstr Surg. 1999;103:104-120.
6. Le Fourn B, Caye N, Pannier M. Distally based sural fasciomuscular flap: anatomic study and application for filling leg or foot defects. Plast Reconstr Surg. 2001;107:67-72.
7. Yilmaz M, Karatas O, Barutcu A. The distally based superficial sural artery island flap: clinical experiences and modifications. Plast Reconstr Surg. 1998;102:2358-2367.
8. Bocchi A, Merelli S, Morellini A, Baldassarre S, Caleffi E, Papadia F. Reverse fasciosubcutaneous flap versus distally pedicled sural island flap: two elective methods for distal-third leg reconstruction. Ann Plast Surg. 2000;45:284-291.
9. Donski PK, Fogdestam I. Distally based fasciocutaneous flap from the sural region: a preliminary report. Scand J Reconstr Surg. 1983;17:191-196.
10. Hasegawa M, Torii S, Katoh H, Esaki S. The distally based superficial sural artery flap. Plast Reconstr Surg. 1994;93:1012-1020.
11. Jeng SF, Wei FC. Distally based sural island flap for foot and ankle reconstruction. Plast Reconstr Surg. 1997;99:744-750.
12. Huisinga RL, Houpt P, Dijkstra R, Storm van Leeuwen JB. The distally based sural artery flap. Ann Plast Surg. 1998;41:58-65.
13. Jeng SF, Wei FC, Kuo YR. Salvage of the distal foot using the distally based sural island flap. Ann Plast Surg. 1999;43:499-505.
14. Coskunfirat OK, Velidedeoglu HV, Sahin U, Demir, Z. Reverse neurofasciocutaneous flaps for soft-tissue coverage of the lower leg. Ann Plast Surg. 1999;43:14-20.
15. Ferreira AC, Reis J, Pinho C, Martins A, Amarante J. The distally based island superficial sural artery flap: clinical experience with 36 flaps. Ann Plast Surg. 2001;46:308-313.
16. Almeida MF, Robero da Costa P, Okawa RY. Reverse flow island sural flap. Plast Reconstr Surg. 2002;109: 583-591.
17. Fraccalvieri M, Verna G, Dolcet M, et al. The distally based superficial sural flap: our experience in reconstructing the lower leg and foot. Ann Plast Surg. 2000;45:132-139.
18. Singh S, Naasan A. Use of distally based superficial sural island artery flaps in acute open fractures of the lower leg. Ann Plast Surg. 2001;47:505-510.
19. Al-Qattan MM. A modified technique for harvesting the reverse sural artery flap from the upper part of the leg: inclusion of a gastrocnemius muscle "cuff" around the sural pedicle. Ann Plast Surg. 2001;47:269-278.
20. Isenberg JS. When less is more: revascularization and sural artery fasciocutaneous flaps in ischemic limb salvage. J Reconstr Microsurg. 2003;19:235-240.
21. Malokov S, Casanova D, Magalon G, Branchereau A. Sural flap vascularization in arteritic patients: an anatomic study of 24 amputation specimens. Surg Radiol Anat. 2003;25:372-378.
22. 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;112:129-140.
23. Raveendran SS, Perera D, Happuharachchi T, Yoganathan V. Superficial sural artery flap - a study in 40 cases. Br J Plast Surg. 2004;57(3):266-269.
24. Meyer C, Hartmann B, Horas U, Kilian O, Heiss C, Schnettler R. Reconstruction of the lower leg with the sural artery flap. Langenbecks Arch Surg. 2002;387(7-8):320-325.
25. Sharma GN, Nepram SS. Sural artery flap: a dependable solution in lower leg and foot soft tissue reconstruction. Int Surg. 2001;86(3):144-150.
26. Price MF, Capizzi PJ, Watterson PA, Lettieri S.Reverse sural artery flap: caveats for success. Ann Plast Surg. 2002;48(5):496-504.
27. Rashid M, Hussain SS, Aslam R, Illahi I.A comparison of two fasciocutaneous flaps in the reconstruction of defects of the weight-bearing heel. J Coll Physicians Surg Pak. 2003;13(4):216-218.
28. Angel MF, Ramasastry SS, Swartz WM, Basford RE , Futrell JW. The causes of skin ulcerations associated with venous insufficiency: a unifying hypothesis. Plast Reconstr Surg. 1987;79:289-297.