Soft Tissue Reconstruction of the Foot with a Reverse Flow Sural Artery Neurofasciocutaneous Flap
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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.
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