Reverse-Flow Island Sural Flap

Abstract

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.

Soft Tissue Reconstruction of the Foot Using the Distally Based Island Pedicle Flap after Resection of Malignant Melanoma

“…The peroneal artery, in turn, makes other anastomoses, notably through its descending branch, and especially with the anterior tibial artery. Several authors have stated that the principal anastomosis occurs at above to 5 centimeters from the lateral malleolus 2,11-13). Although there are some reports of a preoperative lesser saphenous vein mapping method that used Doppler ultrasound4) or using a simple rubber tourniquet for making the superficial vessels prominent,2) we did not use these techniques.…”

“…The distally based island sural flap2,3) is raised on the posterior aspect of the calf, and the anatomical structures that constitute the pedicle are the superficial and deep fascias, the sural nerve, the lesser saphenous vein and the superficial sural artery. This flap is especially indicated for coverage of the hindfoot and the region of the lateral malleolus.…”

Soft Tissue Reconstruction around the Ankle with Sural Artery Flap

“…In a smaller percentage of cases, it remains hidden inside the muscle along most of its path. 7,8 The superficial sural artery originates from the popliteal or sural arteries and reaches the sural nerve at 2 to 3 cm after it's emergence, then subdivides into the medial, median and lateral superficial sural arteries. The median superficial sural artery follows the course of the sural nerve, then emits numerous branches toward the skin at the lower half of the leg along its subfascial path.…”

Reconstruction of Traumatic Defect of the Lower Third of the Leg Using a Combined Therapy: Negative Pressure Wound Therapy, Acellular Dermal Matrix, and Skin Graft

“…A random flap has an indistinct perfusion pattern which requires a careful assessment of length-to-width ratio to ensure viability. These features make random flaps difficult to perform in the lower leg and anyway associated with a high rate of necrosis [2]. Musculocutaneous flaps are widespread in leg reconstruction for their reliability.…”