Super sural neurofasciocutaneous flaps in acute traumatic heel reconstructions

Conventional reversed sural flaps have been used to cover heel defects; however, the experience of the authors indicates that the reach of these flaps falls just short of the critical area to be covered. With the limitation being the location of the flap (the middle third of the leg), the authors thought that if the flap territory were extended proximally, they would have a super flap with immense potential. Nevertheless, the critical question remained, "How far?" The massive earthquake in January of 2001 in Gujarat, India, made medical personnel pressed for time, manpower, resources, and other ancillary supports. The authors were forced to make some innovations in their management of extensive heel defects. On the basis of preexisting anatomic studies, they developed the possibility of using distally based neuroskin flaps of huge dimensions that extend well beyond the conventional confines. The versatility of this extended, reversed, neuro-fasciocutaneous flap in regard to its reliability and safety, despite its huge dimensions, is commendable. The hallmarks of this successful extended sural flap, which the authors used to cover large heel defects, were basically accurate understanding of the anatomy and the use of Doppler to map the perforators and the lesser saphenous vein for inclusion in the lie of the pedicle. The authors share their experience of five cases of difficult heel reconstructions salvaged with this flap, which made them attempt to define maximum flap dimensions that can be harvested. The authors learned that the flap can be extended proximally to include the entire upper one-third of the leg posteriorly, drastically improving its reach and size, without compromising safety. The largest flap used measured 17 x 16 cm, far more than ever reported in the literature. The flaps truly deserve the classification of "super," which is usually reserved for Ponten's flaps.     

Reverse-flow island sural flap

The reverse flow island sural flap is presented as an alternative to flaps currently used for reconstruction of small and medium substance losses in the distal third of the leg, ankle, and heel. 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.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. The skin island and the subcutaneous cellular tissue complement the flap proper. This skin island was demarcated at any point of the median or distal thirds of the leg, having the short saphenous vein and the sural nerve on its central axis. The distal dissection limit of the pedicle is located 5 centimeters above the lateral malleolus. This limit is established so as to ensure the integrity of the perforators from the principal arteries of the leg, mainly the peroneal artery, responsible for the reverse flow nourishing the flap. These perforators will affect anastomoses with the superficial sural artery in charge of irrigating the structures compounding the flap.A total of 71 patients were operated on with this technique, some of them with basic pathologic abnormalities limiting the distal blood flow, such as diabetes mellitus, and some others having proven vascular insufficiency or displaying unstable areas attributable to problems such as pseudarthrosis and osteomyelitis, which needed to be covered. Fifteen flaps (21.1 percent) suffered partial necrosis, which did not compromise the final result, and another three (4.2 percent) showed total loss. The flap in question has great mobility and versatility, allowing the treatment of specific areas of the lower limb, without sacrificing important arteries or mobilizing structures that might bring about functional deficits.     

The medial adiposofascial flap of the leg: anatomical basis and clinical applications

Despite recent advances in microsurgical techniques, coverage of lower leg defects by locoregional flaps remains indicated in selected cases. The interest in these types of flaps has improved because recent clinical work advocates that fascial and fasciocutaneous flaps can be well indicated for bone coverage. The anatomical study of the medial adiposofascial flap is presented in this article. The flap is based on the rich vascular network supplied by the saphenous artery and the posterior tibial artery perforators. This flap can be harvested on the anteromedial aspect of the leg and can be mobilized to cover defects located between the patella and the heel. This multiple blood supply makes it possible to harvest this flap in various ways, so various defects can be covered. To confirm and prove the versatility and clinical value of this flap, the authors have studied a series of 22 cases in which this flap was used for coverage of lower leg defects. For these defects, especially when situated in the lower third or around the heel and ankle, coverage by a free flap is most often the only proposed solution. However, the authors have obtained excellent results in the majority of these cases, avoiding a free flap procedure. Moreover, in this way, the option of using a free flap remains possible if needed. There is minimal donor-site morbidity and a high functional and aesthetic outcome, making this flap a first-choice flap in selected cases of lower leg defects.     

The role of the large superficial vein in survival of proximally based versus distally based sural veno-neuro-fasciocutaneous flaps in a rabbit model

A sural veno-neuro-fasciocutaneous flap in the New Zealand White rabbit was developed, and the role of the large subcutaneous lesser saphenous vein was investigated in proximally based versus distally based flaps. Retrograde dye injection showed that the lesser saphenous vein in rabbits has many valves with strong resistance against reflux. Twenty rabbits were randomly allocated into four groups of 10 flaps each. Group I consisted of proximally based flaps with the lesser saphenous vein intact (outflow) in the veno-neuro-adipofascial pedicle. Group II also consisted of proximally based flaps but the lesser saphenous vein was ligated at 1 cm proximal to the pedicle. Group III consisted of distally based flaps with the lesser saphenous vein intact (inflow) in the veno-neuro-adipofascial pedicle. Group IV also consisted of distally based flaps, but the lesser saphenous vein was ligated at 1 cm distal to the pedicle. The results showed that the mean flap survival area in group I (88.8 percent) was statistically higher than that in group II (62.6 percent, p < 0.001), and was higher in group IV (55.5 percent) than in group III (22.7 percent, p < 0.01). However, group II and group IV had no significant difference (p > 0.05). This experiment demonstrated that flap viability is determined by its intrinsic vascularization, both arterial and venous. The large superficial subcutaneous vein has a positive role (venous outflow) in proximally based flaps but a negative role (venous inflow) in distally based flaps. If the effect of the large subcutaneous vein is excluded, distally based flaps are not inherently inferior to proximally based flaps.     

The vasculature and clinical application of the posterior tibial perforator-based flap.

Use of the posterior tibial flap pedicled on the posterior tibial vessels has been described by several authors, but with it there is the major disadvantage of an unavoidable transection of the posterior tibial artery. To overcome this disadvantage, we anatomically studied the perforators from the posterior tibial artery and used posterior tibial perforator-based flaps clinically. Based on our anatomic study of 25 cadaveric legs, the cutaneous perforators were considered to be distributed from the distal to the proximal sides of the lower leg through the medial border of the tibia, and they were classified into three types: septocutaneous perforators mainly located in the distal third of the leg, muscle perforators located in the proximal half, and periosteal perforators in the proximal third of the leg. The average size and number of perforators was 0.8 mm and 3.1 in one leg, respectively. A considerable number were located at sites from 70 to 140 mm superior to the medial malleolus. Based on our clinical cases repaired with flaps, we consider this flap to be useful as a free flap for the repair of defects of the extremities and as an island flap for reconstruction of defects on the anteromedial aspect of the lower leg. The territory of the flap is relatively wide, being 19 x 13 cm. The long saphenous vein can be used safely as the venous drainage system in the case of free-flap transfer.     

Reconstruction of heel and sole defects by free flaps

One latissimus dorsi musculocutaneous flap and five radial forearm flaps were used in reconstruction of weight-bearing parts of the heel and sole, the follow-up period being 7 to 38 months. Additional injuries such as forefoot amputations or amputations of the other leg were present in four patients. There was no flap loss. The latissimus dorsi flap proved to be too bulky and showed recurrent ulcerations, several reoperations were necessary, and definite healing has not occurred. The five forearm flaps gave good results, with a walking range from 2 hours to unimpeded walking. Complications included fissuring at the edges of one large flap and a local infection which was successfully treated. Cutaneous sensation returned in all but one flap, where it was reduced preoperatively due to a meningomyelocele. The results indicate that the fasciocutaneous radial forearm flap should be taken into consideration for reconstruction of weight-bearing areas of the heel and sole. Shortcomings of this flap include an unsightly donor defect and possible hair growth on the flap.     

Our experience with combined procedures in aesthetic plastic surgery

The instep flap needs neither muscle nor a transposition base for survival or innervation. It can be transposed as an island fasciocutaneous flap either on the medial or lateral plantar neurovascular bundles or both, and it can be transferred also as a free flap from the opposite foot. Four cases demonstrating the use of the flap as an island and free flap are presented with follow-up ranging from 1 to 2 years. The absence of muscle in the flap provides greater stability of the heel reconstruction and results in a lesser secondary defect. Sensation in the flaps is diminished but adequate for long-term function, but hyperkeratotic reaction remains an unpredictable problem. The ability to transfer the flap as a free transfer widens the scope of the flap to reconstruct both heel and forefoot defects where local instep tissue or vascularity are inadequate for local reconstruction. The secondary defect, particularly when no muscle is included in the flap, has been minimal.     

Fasciocutaneous island flap based on the medial plantar artery: clinical applications for leg, ankle, and forefoot

Soft-tissue deficits over the plantar forefoot, plantar heel, tendo calcaneus, and lower leg are often impossible to cover with a simple skin graft. The previously developed medial plantar fasciocutaneous island flap has been adapted to cover soft-tissue defects over these areas. This fasciocutaneous flap based on the medial plantar neurovascular bundle is capable of providing sensate and structurally similar local tissue. Application of this fasciocutaneous island flap is demonstrated in 12 clinical cases. Successful soft-tissue cover was achieved on the plantar calcaneus (four patients), tendo calcaneus (four patients), lower leg (two patients), and plantar forefoot (two patients). Follow-up ranged from 6 months to 5 years. All flaps were viable at follow-up. Protective sensation was present in 11 of 12 flaps evaluated at 6 months. In addition, all 11 patients were able to ambulate in normal footwear. The medial plantar island flap seems to be more durable than a skin graft, and the donor site on the non-weight-bearing instep is well tolerated. This study demonstrates that the medial plantar fasciocutaneous island flap should be considered as another valuable tool in reconstructive efforts directed at the plantar forefoot, plantar heel, posterior ankle, and lower leg.     

Clinical applications of free soleus and peroneal perforator flaps

Clinical applications of two free lateral leg perforator flaps are described: a free soleus perforator flap that is based on the musculocutaneous perforator vessels from one of the three main arteries in the proximal lateral lower leg, and a free peroneal perforator flap that is based on the septocutaneous or direct skin perforator vessels from the peroneal artery in the distal and middle thirds of the lateral lower leg. The authors applied free soleus perforator flaps to 18 patients and free peroneal perforator flaps to five patients with soft-tissue defects. The recipient site was the great toe in 14 patients, the hand and fingers in five patients, the leg in two patients, and the upper arm and the jaw in one patient each. The largest soleus perforator flap was 15 x 9 cm, and the largest peroneal perforator flap was 9 x 4 cm. Vascular pedicle lengths ranged from 6.5 to 10 cm in soleus perforator flaps and from 4 to 6 cm in peroneal perforator flaps. All flaps, except for the flap in one patient in the peroneal perforator flap series, survived completely. Advantages of these flaps are that there is no need to sacrifice any main artery in the lower leg, and there is minimal morbidity at the donor site. For patients with a small to medium soft-tissue defect, these free perforator flaps are useful.     

A realistic complication analysis of 70 sural artery flaps in a multimorbid patient group

The popularity of the sural artery flap has increased markedly throughout the years, and favorable results are reported almost uniformly. Previous publications have mainly presented results of small groups and of predominantly younger patients with posttraumatic defects, or they have reported technical modifications of the sural artery flap. The authors have increasingly used the reversed sural artery flap in a high-risk, critically multimorbid, and older patient population, and in contrast to the results of other authors, a considerable necrosis rate of 36 percent was seen. For the first time, a detailed, critical, retrospective complication analysis of 70 sural artery flaps is presented. The results reveal the following risk factors, which can potentially impair successful defect coverage and thus contribute to flap complications: concomitant diseases, particularly diabetes mellitus; peripheral arterial disease or venous insufficiency, which increase the risk of flap necrosis five-fold to six-fold; and patient age of over 40 years, because of an increased rate of comorbidity, underlying osteomyelitis, and the use of a tight subcutaneous tunnel. However, age alone did not seem to represent a risk factor by itself. Given the results of the analysis, the operative procedure was altered, as follows. In cases in which a lesser saphenous vein cannot be found, a delay procedure is recommended, or the flap is not utilized. In addition, an external fixation device seems to facilitate postoperative care markedly without adding specific complications; it is recommended in most patients. This analysis emphasizes specific risk factors that result in higher complication rates of the sural artery flap, and it leads to more realistic and appropriate expectations for this flap.     

The extended dorsalis pedis flap.

An extended dorsalis pedis island flap was used to cover the heel in two patients. The arterial predicles were extended by cutting and bridging with vein grafts to allow the flaps to reach the defects. By this method, excellent coverage is obtained and the protective sensation may be retained or restored by preservation or extension of the sensory nerves.     

Survival and blood flow evaluation of canine venous flaps

Using a canine model, we compared postoperative viability of saphenous venous flaps, cephalic venous flaps, and composite-tissue grafts without vascular connections. Of the saphenous flaps, 14 percent survived. Of the flaps based on the cephalic vein, 75 percent survived. Cephalic composite-tissue grafts were 13 percent successful. The presence of a more intricate venous plexus in a flap seems to increase its chances of success. Arterial injections of radioisotope-labeled microspheres were used to chart revascularization in cephalic flaps. These flaps demonstrated arterial blood flow by day 3, while the composite grafts showed no flow until day 7. Venous injections of microspheres distal to the flap were used to test vein-to-capillary blood flow. No significant entrapment of microspheres within the flaps occurred at any time, suggesting such flow to be inadequate.     

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

Skin defects over the lower one-fourth of the leg and over the foot are difficult to cover. Two types of pedicled fasciocutaneous flaps used to cover such defects were studied: the lateral supramalleolar flap and the distally based sural neurocutaneous flap. The series consisted of 27 and 36 cases, respectively. The lateral supramalleolar flap was used 27 times: for skin defects over the ankle (4), foot (16), and leg (7). The distally based sural neurocutaneous flap was used 42 times: over the foot (24), ankle (13), and leg (5). Fourteen of these patients were 65 years of age or older, and local vascularity was diminished in 16 cases. The flaps were evaluated clinically twice: in the immediate postoperative period for survival or for partial or total flap necrosis, and again to determine the presence of pain at the donor or recipient sites and the cosmetic appearance. Thirty-nine patients (62 percent) were reviewed subsequently, with a mean follow-up of 5 years for the supramalleolar flap and 2 years for the sural neurocutaneous flap. The results were evaluated for the presence or absence of pain, the appearance of the flap, the disability due to the insensate nature of the flap, and the presence or absence of secondary ulceration. Painful neuromata were noted in three cases with the sural neurocutaneous flap, whereas complete necrosis of the supramalleolar artery flap occurred in three patients. The distally based sural neurocutaneous island flap is very reliable, even in debilitated patients. Though the lateral supramalleolar artery flap offers the possibility of covering the same areas as the sural neurocutaneous flap, it is much less reliable in the presence of diminished local vascularity (18.5 percent failure rate as compared with 4.8 percent for the sural neurocutaneous flap). Because the procedure can cover extensive defects and is easy to perform, the distally based sural neurocutaneous flap was the method of choice for covering skin defects over the foot, heel, ankle, and the lower one-fourth of the leg. The lateral supramalleolar artery flap is indicated only when the sural neurocutaneous flap is contraindicated.     

The nutrient flap: a new concept of the role of the flap and application to the salvage of arteriosclerotic lower limbs

The nutrient flap is a new concept of the role of the flap. It has three functions: (1) it provides supplementary blood flow to ischemic zones, (2) it assists venous drainage in regions of venous insufficiency, and (3) it induces the formation of a capillary network. Its skin covering role is only accessory. We have applied this principle to osteitis, pseudoarthrosis, and arteriosclerosis. The nutrient flap constitutes a new type of treatment for stage IV arteriosclerosis of the lower limbs when classical revascularization techniques cannot be performed and when high amputation is indicated. Four clinical cases and the surgical techniques used are described. The flap, usually raised from the latissimus dorsi, is anastomosed to the popliteal artery by means of an inverted saphenous vein graft. It is applied to the distal extremity of the limb after excision of the necrotic tissues. The nutrient flap preserves weight-bearing by maintaining the heel.     

The reversed fasciosubcutaneous flap in the leg

A reversed fasciosubcutaneous tissue flap in the leg is described. This distally based flap is vascularized by the perforating cutaneous branches of the peroneal and tibialis posterior arteries. It must carry all its subcutaneous tissue. A study on the vascularization of the subcutaneous tissue reveals the predominance of the vascular network in this layer with regard to the dermal or fascial plane. The dermal vascular network at the donor site is sufficient to let the skin survive without its underlying subcutaneous vascular support. The flap can reach the malleolar and heel region. The advantages of this technique are (1) easy dissection, (2) preservation of the major vascular pedicles of the lower limb, (3) skin preservation at the donor site, thus preserving the shape of the limb, and (4) versatility (it is supple and can adapt to every surface, and it can be grafted on the deep or the superficial side). The addition of this technique to the armamentarium of the reconstructive surgeon has proved to be very useful in repairing soft-tissue defects in the lower limb. Often it can replace the classical fasciocutaneous flap or even a free flap.     

Leg repairs with an island flap from the dorsum of the foot, based on the anterior tibial vessels.

We report 20 chronic leg ulcers successfully treated by rotating an anterior tibial flap, which is a modification of the dorsalis pedis flap. The sizes of the flaps ranged from 6 x 6 cm up to 15 x 13 cm; the largest ones are not recommended, for fear of development of persistent lymphedema of the foot. These flaps are dissected upward through the leg and pedicled on the anterior tibial vessels, so they can be rotated to any site on the anterior, lateral, or medial side of the leg.     

Fat necrosis in free transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flaps

A series of 310 breasts reconstructed by a single surgeon using free transverse rectus abdominis myocutaneous (TRAM) and deep inferior epigastric perforator (DIEP) flaps was reviewed to see if there were any differences in the incidence of fat necrosis and/or partial flap loss between the two techniques. During the study period, 279 breasts were reconstructed with free TRAM flaps and 31 breasts were reconstructed with DIEP flaps. In the breasts reconstructed with free TRAM flaps, the incidence of partial flap loss was 2.2 percent and the incidence of fat necrosis was 12.9 percent. The DIEP flaps were divided into two groups. For the first eight flaps, patients were selected using the same criteria normally used to choose patients for free TRAM flaps. In this unselected early group, the incidence of partial flap loss was 37.5 percent and the incidence of fat necrosis was 62.5 percent. Because of the high incidence of partial flap loss and fat necrosis in the first eight flaps, subsequent selection was modified to limit the use of DIEP flaps to patients who had at least one sufficiently large perforator in each flap (a palpable pulse and a vein at least 1 mm in diameter) and who did not require more than 70 percent of the flap to create a breast of adequate size. In this later (selected) group, fat necrosis (17.4 percent) and partial flap loss (8.7 percent) were reduced to a level only moderately higher than that found in the free TRAM flap group. From these data, it can be concluded that the incidence of partial flap loss and fat necrosis is higher in DIEP flaps than in free TRAM flaps, probably because the blood flow to the former flap is less robust. This difficulty can be circumvented to some extent, however, by careful patient selection. Factors that should be considered include tobacco use, size of the perforators (especially the vein), and (in unilateral reconstructions) the amount of flap tissue across the midline needed to create an adequately sized breast. If these factors are properly considered when planning the operation, fat necrosis and partial flap loss can be reduced to an acceptable level. For selected patients, the DIEP flap is an excellent technique that can obtain a successful, autologous tissue breast reconstruction with minimal donor-site morbidity. For patients who are not good candidates for reconstruction with this flap, the free TRAM flap remains a good alternative.     

Skin island flaps supplied by the vascular axis of the sensitive superficial nerves: anatomic study and clinical experience in the leg.

An anatomic study performed on 64 fresh injected legs has shown the role of the vascular axis that follows the superficial sensitive nerves in supplying the skin. Three nerves were studied: the saphenous nerve, the superficial peroneal nerve, and the sural nerve. Conclusions are the same for the three nerves: The vascular axis, which can be either a true artery or an interlacing network, ensures the vascularization of the nerves, gives off several cutaneous branches in the suprafascial course of the nerve, and anastomoses with the septocutaneous arteries issuing from a deep main vessel. The superficial nerves that course the leg can therefore be considered as vascular relays owing to their neurocutaneous arteries. The concept of a neuroskin island flap has been developed and applied to six clinical cases for coverage of some specific areas of the knee and of the lower part of the limb.     

Popliteal-based filleted lower leg musculocutaneous free-flap coverage of a hemipelvectomy defect.

A 33-year-old man suffered from locally recurrent malignant fibrous histiocytoma of his left thigh unresponsive to previous excision, radiation therapy, chemotherapy, and hyperthermic treatment. He underwent radical hemipelvectomy for cure. Because of extensive tumor involvement, a free flap consisting of his distal left leg based on the popliteal artery was utilized to close the defect. Both the tibia and fibula were removed from their periosteal sheaths, and the foot was excised from the flap. The popliteal artery and vein were anastomosed to the iliac vessels. The flap survived, and the patient was discharged home after physical rehabilitation. We suggest that uninvolved portions of the distal leg may be utilized as a free flap to successfully close hemipelvectomy defects in selected patients when conventional pedicle flaps are unavailable.     

Easy tissue expansion of prelaminated mucosa-lined flaps for cheek reconstruction in a canine model

In head and neck reconstruction, there is sometimes the need for a skin flap lined with mucosa. The object of this study was to determine whether small pieces of mucosa grafted onto the undersurface of a skin flap can be expanded in a reasonable time to provide the material required to reconstruct a full-thickness cheek defect as a free flap. The study consisted of two phases: prelamination and expansion of the flap, and vascularized free-tissue transfer of the flap. Six adult mongrel dogs were used. First, a 5 x 10-cm flap based on the saphenous vessels was elevated on the lower leg, and then four 1 x 2-cm pieces of mucosa harvested from the tongue were grafted onto the undersurface of the flap. A tissue expander (5 x 10 cm) was then placed under the flap, and the incision was closed primarily. The expanders were initially filled with just enough normal saline to obliterate dead space immediately after surgery. The expansion was continued twice weekly for 3 weeks until sufficient expansion was obtained. Two of six flaps were followed for an additional 6 weeks after the 3-week expansion period to observe whether additional mucosa could be obtained. After measurement of the mucosal area, each flap was transferred as free flap to reconstruct an iatrogenic cheek defect. The increase of mucosal surface area was compared with the original graft, and differences were analyzed using the paired t test. All flaps were successfully expanded without any complications. Histologic evaluation revealed that grafted mucosa took well without evidence of graft necrosis, and the intergraft area was covered with histiocytes. Angiography revealed well-defined vascular structures covering the entire area of the flap. The new mucosal area (23.5 +/- 2.4 cm2) was significantly larger than the original mucosal graft (8.7 +/- 0.9 cm2) (p < 0.001). The net increase of the mucosal area was 172.9 +/- 32.4 percent. The increase of mucosal area in two flaps, following a 6-week consolidation period after 3 weeks of expansion, was only slightly greater (25.9 +/- 1.3 cm2) than those without the consolidation period (22.3 +/- 1.8 cm2). This increase of the mucosal area appears to be related to the amount of expansion, and not to the length of the consolidation period. The flaps were successfully transferred as free flaps to reconstruct the full-thickness cheek defects without major complications. Although a staged operation to allow flaps to mature is needed, the present procedure has the advantages of providing a mucosa-lined flap and allowing primary closure of the donor site. The authors conclude that expansion of this flap has great potential in reconstructive surgery.