A modified technique for transposition of the reverse sural. The reverse sural artery flap is a reliable alternative for small to moderate size defects and can be used with modifications of the original technique. Use this flap for wounds around the knee and upper leg. Fascio cutaneous flap, foot and ankle, reverse sural artery, reverse sural flap, sural nerve 1. The success of the reverse sural flap is predicated on the ability to correctly incorporate its vascular supply which is based off the sural nerve and, to a greater extent, the sural artery which provides the true vascular network as it continues into the retromalleolar region and. The reverse flow sural flap is a good option for the treatment of the distal region of the legs and feet. The reverse sural artery flap eliminates the need for long and technically demanding free tissue transfers, which have become the gold standard for significant tissue defects in the distal third of the leg and ankle. The sural artery flap, which is fasciocutaneous, can be used for correcting softtissue defects of.
It is clinically relevant that the success rate of the reverseflow sural fasciocutaneous flap technique was of 87. Sshaped reverse sural flap for reconstruction of tissue. The flap consists of superficial and deep fascia, the sural nerve, lesser saphenous vein, and superficial sural artery. The reverse sural artery flap is a reliable alternative for treating small to moderate size defects of the lower tibia, ankle, and heel regions. Reverse sural fascio cutaneous flap for soft tissue. Fixation of the flap in the recipient area and use of a. Enhanced survival using the distally based sural artery. Masquelet et al created a distal pedicled reverseflow sural artery flap using the relation between the median superficial sural artery and the bottom perforator branch of the peroneal artery. Fasciocutaneous flap with wide pedicle in the late group.
Surgical anatomy of the medial sural artery perforator flap. Objective the present study aims to evaluate the use of the reverse flow sural fasciocutaneous flap to cover lesions in the distal third of the lower limb. Reverse sural artery flap has been proven to be an effective option to cover such defects. Pdf the reverse superficial sural artery flap revisited for. 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. The distally based superficial sural artery flap for coverage. Methods a total of 24 cases were analyzed, including 20 traumatic injuries, 3 sports injuries, and 1 case of tumor resection. Rbcp reverse sural flap of the fasciosubcutaneous pedicle. The defects were located at the ankle three cases, foot two cases, and heel six cases. The aim of this study is to analyze the demographic. Postoperative complications were defined as any untoward event that occurred within 30 days of the procedure and required either medical or. Despite various reported techniques, the coverage of the achilles tendon, malleoli, ankle and heel is still daunting and demanding procedure. A retrospective study of reverse flow sural flaps was per formed from january 2002. The reverse sural artery fasciomusculocutaneous flap for small lowerlimb defects.
The reverse sural artery flap is a generally accepted means of soft tissue reconstruction for defects of the distal third of the legs. The reverse superficial sural artery flap revisited for. In this report, we present our experience on the use of the reverse sural flap for traumatic foot and ankle reconstruction. Partial flap loss was found in 2 patients 8%, marginal flap necrosis in 2 patients 8% and complete loss in 1 patient 4%.
Our initial experience with this flap at multiple institutions resulted in a 50% failure rate, mostly because of critical venous congestion. Because of the patients smoking history, a 7day flap delay was undertaken before completion of both flap elevation procedures, matching the. Jul 01, 20 in this report, we present our experience on the use of the reverse sural flap for traumatic foot and ankle reconstruction. The reverse sural nerve flap is one of many versatile neurofasciocutaneous techniques available for staged reconstruction of lower limb and foot. This flap is commonly referred as reverse sural artery island flap and has become an acceptable and routine technique for reconstruction of difficult defects around the ankle, foot and lower leg.
The distallybased sural island flap was first described in the early 1990s and quickly gained popularity. The flap can measure 15 x 6 cm and may include the sural nerve as a neurosensory flap. A modified technique for transposition of the reverse sural artery flap. The reverse sural flap, initially described by masquelet et al 5 in 1992, is a good option for coverage of the distal third of the leg and the ankle owing to its proximity to the injured area. The reverse superficial sural artery flap revisited for comp. The reverse superficial sural artery flap revisited for complex. The flap offers the surgeon a simple and fast procedure to cover extensive defects either secondary to trauma or when conservative methods have failed to close chronic nonhealing wounds. Comparison between peroneus brevis flap and reverse sural. The flap was distally based, islanded and covered the area with vascularised. Reverse sural artery flap for the reconstruction of chronic. Delayed reverse sural flap for staged reconstruction of the foot and lower leg.
The reverse superficial sural artery flap rssaf is a distally based fasciocutaneous or adipofascial flap that is increasingly being used for coverage of defects that involve the distal third of the leg, ankle, and foot. The modified reverse sural artery flap lower extremity. The reverse sural fasciocutaneous flap for the treatment of. The reverse sural artery flap rsaf and distal peroneus brevis flap dpbf have gained popularity for lower third leg defects among surgeons. The anatomic basis of the reverse sural flap has been well documented in the literature. Distally based perforator sural flaps for foot and ankle. Aug 11, 2009 an defect on the posterior ankle exposing the tendoachilles and a fractured calcaneum covered with a sural artery flap. The reverse sural nerve flap is one of many versatile neurofasciocutaneous techniques available for staged reconstruction of lower limb and. Reverse sural flap delayed technique, a novelty approach to stepwise algorithm utilizing skin substitute bilayer the reverse sural nerve flap is one of many versatile neurofasciocutaneous techniques available for staged reconstruction of lower limb and foot. Caveats for success article in annals of plastic surgery 485. The sural flap procedure is a versatile technique that can be used to cover many types of defects about the lower extremity. Increasing the success of reverse sural flap from proximal.
Nov 04, 20 the various modifications of the flap included reverse sural island flap with a subcutaneous tunnel or externally placed pedicle, sural peninsular flap, sural fasciocutaneous flap, extended sural fascio musculocutaneous flap and delayed sural flap depending on the size and location of the defect. Reverse sural artery flap christopher finkemeier, md on vimeo. Dissection of the fascia of the sural muscle and rotation of the flap 180 degrees on the axis of the fasciosubcutaneous pedicle, covering the exposed area. Because of the patients highrisk profile, a reverse sural flap was elevated in a delayed fashion, leaving intact the proximal skin margin and the short saphenous vein axial delay technique. The preferred perforator was the one figure 1 the medial sural artery divides into two. A reverse superficial sural artery flap rssaf raised as an adipofascial flap was used for coverage of the wound. We hypothesized that delaying the flap the delay time ranged from 48 hours to 2 weeks and using a 4cm wide pedicle would decrease the amount of partial flap necrosis that commonly occurs with this flap. In practice, the flap size and pivot point position are determined by the geometric contour of the defects. The reverse sural fasciocutaneous flap for the treatment of traumatic, infectious or diabetic foot and ankle wounds.
Experience with this technique and the additional cautions described herein may contribute to even better results. Ota video library reverse sural artery flap christopher. Jun 18, 20 traumatic limb injury is a prevalent lesion in iran. The patient selection and surgical refinement are discussed. This kind of injury commonly occurs when lower limbs get stuck in between the spokes of the wheel. This video demonstrates via cadaver dissection the technique for using a fasciocutaneous flap based upon the sural artery reverse flow and the distal peroneal artery. Traumatic limb injury is a prevalent lesion in iran.
Limb salvage approaches are based on careful preoperative evaluation, surgical technique, and postoperative care. The distal dissection is located 5 cm above the lateral malleolus to preserve the peroneal artery. Introduction wounds around the lower third of the leg and foot are difficult to manage because of the composite tissue defects, inadequate and tight local tissues and poor circulation. The reverse sural artery flap is an effective technique for closing these defects and saving the limb. At combined military hospital rawalpindi we frequently use the reverse sural artery flap to cover defects around the ankle and proximal foot. The routine sacrifice of the sural nerve with its consequential temporary loss of sensation on the lateral aspect of the foot can be. A realistic complication analysis of 70 sural artery flaps in a multimorbid patient group.
Reverse sural artery flap christopher finkemeier, md 4 years ago video shows the technique for a reverse sural artery flap used to cover a full thickness skin loss over the calcaneal tuberosity from delay in treatment of a severely displaced tongue type calcaneus fx. Reverse sural flap with bifocal ilizarov technique for tibial. Seven distally based reverse sural artery flaps were performed on ambulatory patients between 2001 and 2002. Reverse sural flap is a useful and versatile reconstructive method in patients with soft tissue defects of the lower leg and foot. Sshaped reverse sural flap is a modified technique of reconstruction. Reverse flow sural flap al azhar assiut medical journal. For those two patients, the ipsilateral sural nerve was harvested for grafting of the posterior tibial nerve defects.
Preoperatively, the medial calf was examined with the handheld doppler. We did a retrospective study on 64 patients admitted between 2011 and 20 with posttraumatic moderate size defects of. Baek 2 was the first to report its clinical applications along with anatomical observations regarding medial and lateral femoral free flaps. We did a retrospective study on 64 patients admitted between 2011 and 20 with posttraumatic moderate size defects of lower onethird leg who underwent rsafs and dpbfs. Kocaeli, turkey from the departments of orthopedics and traumatology and plastic and reconstructive surgery. Objective the present study aims to evaluate the use of the reverseflow sural fasciocutaneous flap to cover lesions in the distal third of the lower limb. The routine sacrifice of the sural nerve with its consequential temporary loss of sensation on the lateral aspect of the foot can be of concern to early rehabilitation of some patients. A 47yearold man with a calcaneal defect from chronic osteomyelitis. The most common usage of the flap is for the distalthird defects of the leg. This is a viable and effective alternative in the therapeutic arsenal for. Study of various modifications of reverse sural artery flap. A outline of the flap and the calcaneal defect before debridement. In this report of 6 patients underwent surgical reconstruction by this modi.
From 2007 to 2010, 11 consecutive patients underwent modified reverse sural flap at the chang gung memorial hospital. Cureus effectiveness of reverse sural artery flap in the. Sample video from surgical treatment of orthopedic trauma, 2nd edition by james p. Sural flap use for the treatment of wounds with underlying. We describe an interpolation flap technique of simply avoiding a subcutaneous tunnel and exteriorizing the pedicle with no other alterations to flap design or elevation techniques. The reverse superficial sural artery flap rssaf is a popular option for many of these difficult wounds. The medial sural perforator flap was described in a very similar fashion in cadaver dissections by taylor and daniel as a potential free flap donor site as early as 1975. A modified technique for harvesting the reverse sural artery flap from the upper part of the leg. Venous congestion did not occur in any of the flaps.
Objective soft tissue injuries at the level of lower extremities, plantar, and dorsal foot pose a surgical challenge for reconstructive surgeons. The various modifications of the flap included reverse sural island flap with a subcutaneous tunnel or externally placed pedicle, sural peninsular flap, sural fasciocutaneous flap, extended sural fascio musculocutaneous flap and delayed sural flap depending on the size and location of. An defect on the posterior ankle exposing the tendoachilles and a fractured calcaneum covered with a sural artery flap. Experience with this technique and the additional cautions described herein may.
Distally based sural fasciocutaneous flap was used for coverage in all cases and its survival, successful coverage of the defect and donor site morbidity studied. Figure 2 intraoperative preparation of the reverse sural flap using the fasciosubcutaneous pedicle. Sep 22, 2015 adipofascial flap with wide pedicle in the late group. Dec 31, 2016 the reverse sural artery flap is utilized to reconstruct defects in the distal third of the lower leg, ankle, and heel. Reverse sural flap for ankle and heel soft tissues. This flap is based on perforators of the peroneal artery system. The management of soft tissue defects of the lower extremity with underl. Kocaeli, turkey from the departments of orthopedics and traumatology and plastic and reconstructive surgery, kocaeli university school of medicine.
Soft tissue reconstruction of the foot with a reverse flow. Lower limb reconstruction fasciocutaneous sural flap. Medial sural artery perforator flap plastic surgery key. Adipofascial flap with wide pedicle in the late group. Experience with reverse sural flap to cover defects of the. Versatility of delayed reverseflow islanded sural flap for. Apr 02, 2016 the medial sural perforator flap was described in a very similar fashion in cadaver dissections by taylor and daniel as a potential free flap donor site as early as 1975. Reverse sural flap for distal one third tibial wounds vumedi. Reverse sural fascio cutaneous flap for soft tissue coverage. Reverse sural artery flap for the reconstruction of.
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