Soft Tissue Reconstruction of the Foot with a Reverse Flow Sural Artery Neurofasciocutaneous Flap
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Coskunfirat et al14 performed 11 reverse neurofasciocutaneous flaps for coverage of soft tissue defects in the lower extremities. Six flaps were saphenous and five were sural; all survived completely. Bocchi et al8 used a reverse sural flap in 14 patients to successfully cover larger defects of the leg and ankle and a reverse adipofascial sural flap in 11 patients to cover moderate-size wounds in heel areas. Ferreira et al15 reported that in 36 distally-based superficial sural artery flaps, only six partially necrosed and no major complications occurred.
In a larger study, Almeida et al16 performed a reverse flow island sural flap on 71 patients; 15 partially necrosed and three experienced total loss. Fraccalvieri et al17 described their experience with 18 distally-based superficial sural flaps. Only one superficial necrosis had to be surgically revised. Singh and Naasan18 used the reverse sural artery flap to treat acute open fractures of the lower leg associated with soft tissue loss. Two out of seven patients had a partial necrosis of the distal tip of the flap. Al-Qattan19 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. He suggested that this muscular cuff provided superior venous drainage of the flap.
The use of reverse flow flaps raised from the lower leg in patients with diabetes and peripheral vascular disease may be questioned; however, in a series of patients with diabetes, the outcomes reported were quite favorable.20
Methods and Materials
A chart review was conducted of seven patients who underwent a distally-based neurofasciocutaneous sural artery flap for ankle or heel defects who had failed conservative treatment between 1999 and 2003. Chart abstraction included demographics, comorbitities, wound etiology and location, procedure performed, perioperative complications, time to return to shoes, and average healing time (see Table 1 and Table 2).
Five of the patients had diabetes and two had a history of chronic nonhealing ulcers. The presence of a patent peroneal artery was a requirement for the patients in this study; this was determined by Doppler examination, angiogram, or magnetic resonance angiography (MRA).
Seven patients underwent repair of ankle and heel ulcers with a reverse flow sural artery neurofasciocutaneous flaps. Five patients had diabetic ulcers of the heel; one patient had developed a nonhealing ulcer of the lateral malleolus; and one patient, suffering from multiple sclerosis, had developed a chronic traumatic ulcer of the posterior heel. One of the patients with diabetes had received a renal transplant and was on immunosuppressive therapy. The flaps were raised from the posterolateral calf. In two patients, donor sites were closed primarily; in the other five patients, skin grafts were employed. All patients were discharged from the hospital with their flaps viable. One flap failed during postoperative week 2 from ischemia (in the renal transplant patient). Patients were permitted to bear weight in shoes when the flap margins were completely healed.
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