Reverse Sural Fasciocutaneous Flap in Patient with crural Defect.
Reverse SuralFasciocutaneous Flap in Patient WithCrural Defect
1
I gede T. ElingTulus W , I.B Surya Wisesa
2
1
Surgery Department, Faculty Of Medicine Udayana University
2
Oncology Surgery Department- Sanglah Hospital, Denpasar
Abstract
background: Complex wounds and soft tissue defects in the distal third of the leg and foot remain difficult
problem to solve. Soft tissue defect management around the lower third of the leg presents a
considerable challenge to the reconstruction. The reverse suralfasciocutaneous flap is feasible option for
the soft tissue coverage of distal third of the leg. We reported a patient with recurrent squamous cell
carcinoma, with extensive defect after excision was done with improper procedure on the distal third of
the crural, so we decide to perform with reverse suralfasciocutaneous flap.
case : A 61 years old female, with local recurrent squamous cell carcinoma, came with extensive defect
after excision was done with improper procedure on the distal third of the crural. Further treatment for this
patient will be re-excision to remove the entire defect. Hence,the reverse suralfasciocutaneous flap
technique is conducted in managing the extensive defect.
conclusion : the reverse suralfaciocutaneous flap showed satisfactory outcome in reconstructing defects
that exist in the distal third of the leg. In the case report shows similar results to the research study.
Thereby, this flap can be used as the most feasible alternative to reconstruct existing defects especially in
the distal third of the leg.
Keywords :reverse suralfasciocutaneous flap, distal third leg defect
INTRODUCTION
Complex wounds and soft tissue defectsin the distal third of the leg, ankle, and foot
remain difficult problems to solve.Free tissue transfer could be the treatment of choice, but it
requires a team approach, andaccompanies long operative time, donor morbidity,and a risk of
complete failure1.Soft tissue defect management around the lower third of the leg and foot
present a considerable challenge to the reconstruction. This isbecause the tibia is subcutaneous
bone with almost no muscles around its lowerthird with tight skin and poor circulation.The
options in this region are limited.Durable flap is the preferred option for coverage of such
defects2.
Free flap surgery to cover defect is not possible in every center due the sophisticated
instruments, equipments and lengthy procedures. The Reverse suralfasciocutaneous flap is
feasible option for the soft tissue coverage of distal third leg and foot5.
There are many methods for covering soft tissue defect, although free flaps have
beenused to manage these defects, with good result, but their greater complexity requires,
specially trained surgeons who are not always available at hospital, and have a
highercomplication rate than loco regional flap. There has been a great deal of interest inthe use
of local tissue to cover lower limb defects, beginning with their description byponten,
fasciocutaneous flap have been attempted for defect of the lower third of the legbased on the axis
of major vessels of the leg, subsequently, however it was discoveredthat there existed vascular
axis along the path of cutaneous nerves of the body3.This allows elevation of the skin supplied
by this neurovascular axis as a flap forcoverage of leg wounds, this perhaps best exemplified by
the sural nerve flap describedby Masqueletet all6. The sural nerve as it pierces the fascial plane
to runsubcutaneously between the two heads of gastrocnemius muscle is generallyaccompanied
by one to three arteries, these run inferiorly to a region just above thelateral malleolus, where it
communicates with multiple perforators from the peroneal artery.Also running along this same
axis is the lesser saphenous vein, as such the skin overlying gastrocnemius muscle can be
elevated based distally on these perforators3.
Although cross leg fasciocutaneous flap are less frequently indicated for distal leg
andfoot defect due to the availability of other alternative it still useful as they continue toprove to
be the flap of choice in demanding situation3.
CASE REPORT
A 61 years old female patient with local recurrent squamous cell carcinoma, came with
extensive defect after excision was done with improper procedure on the distal third of thecrural
(Figure 1 and 2). Further treatment for this patient will be re-excision to remove the entire defect
to prevent reoccurrence of recurrent squamous cell carcinoma.It is not possible to reconstruct the
extensive defect in the anterior distal third of the cruralwith just a primary lid with suture or by
skin graft (Figure 3). Hence,the reverse suralfasciocutaneous flap technique is conducted in
managing the extensive defect. This technique is the most feasible option to cover extensive
defect especially in the distal third of the crural.
The surgical techniqueattention is directed to the posterior central third of the proximal
leg where a skin island is created based on the dimensions and distance of the recipient site
(Figure 4). The flap should be created slightly larger than the defect needing to becovered and
when establishing the margins of the flap, it isvital to maintain enough overall length to prevent
tensionor kinking during rotation of the flap. Located superior to the lateralmalleolus, the course
of these vessels will influence theoverall path of the pedicle and it is imperative to establishthese
vessels beforehand in order to preserve the majorcirculation and subsequent survival of the
island flap.The flap is fashioned in the shape of an ellipse with thedistal aspect tapered into a
teardrop design to aid in finalclosure (Figure 4).
Dissection is begun proximally andcarried down through to the deep fascial level until
the suralnerve, artery, and lesser saphenous vein are identified (Figure 5). At this point, theisland
flap including the skin, subcutaneous tissue, and thedeep fascial tissues containing the
neurovascular structures,are elevated off the surface of the gastrocnemius musclebellies (Figure6
and 7). Thepivot point is dependent upon the location of the recipientsite and is roughly 5 to 8
cmabove the lateralmalleolus. Thepedicle is approximately 2 to 3 cm in width once
dissectedfreely from the surrounding tissues. Once the flap is mobile,it is repositioned via
working space andsutured to the recipient sitewith care to not kink the flap as it is folded back
upon itself (Figure8). The donor site is primary suture(Figure9). The patient is maintained
nonweight bearing 4 to6 weeks until it is established that the flap has survivedwithout any major
complications and the surgical woundshave healed (Figure 10,11 and 12).
Figure 1.Extensive defect after excision
Figure 2.Re-excision to remove the entire defect to prevent reoccurrence of recurrent squamous
cell carcinoma
Figure 3.It is not possible to reconstruct the extensive defect in the anterior distal third of the
cruralwith just a primary lid with suture or by skin graft
Figure 4.The flap is fashioned in the shape of an ellipse with thedistal aspect tapered into a
teardrop design to aid in finalclosure
Figure 5.Dissection is begun proximally andcarried down through to the deep fascial level until
the suralnerve, artery, and lesser saphenous vein are identified
Figure 6.At this point, theisland flap including the skin, subcutaneous tissue, and thedeep fascial
tissues containing the neurovascular structures,are elevated off the surface of the gastrocnemius
musclebellies
Figure 7.Indentified of the sural nerve
Figure 8.Flap is mobile,it is repositioned via working space and sutured to the recipient sitewith
care to not kink the flap as it is folded back upon itself
Figure 9. The donor site is primary suture
Figure 10. Wound in 3 days, necrotizing (-), hiperemis (+) pus (-)
Figure 11. Wound in 1 week, necrotizing (-), hiperemis (+) pus (-)
Figure 12.Wound in 2 weeks, necrotizing (-), hiperemis (-) pus (-).until it is established that the
flap has survivedwithout any major complications and the surgical wounds have healed.
DISCUSSION
As mention in Hassanpour,et all.2008 with 25 samples that the result such as: Complete
failure 0 (0%), Marginal, necrosis 1 (3.6%), Venous congestion 6 (21.4%), Suture rupture 2
(7.1%), Superficial epidermolysis 2 (7.1%), Hypertrophic scar at donor site 3 (10.7%). The result
of this study showedextension of reversed suralisland flaps to the proximal third of the leg
wassafe and reliable, and the results of medium sized flaps to very large ones were quite
acceptable1.
In 2011,Mohammadkhah, et all. Mentionsabout their studyin13 patients who had large
defects on their foot. The results showed low rates of ischemia, venous congestion, dehiscence,
infection and flap necrosis. Proximal extended and large distally based sural flap is an alternative
to free tissue transfer for large defect reconstruction of the foot2.
Maazil, et all.2012 as well studied about reverse suralfaciocutaneous flap in22
patients.Their ages ranged between 5-42years. (Average age was 17 years), with soft tissue
defect in the distal leg and foot. The conclusion of this study, that the distally based sural flap is
a versatile and reliable flap for the coverage of soft tissue defects of the distal third of the leg and
foot. It is safer to apply the flap from contralateral limb rather than its extension proximally, if
micro vascular surgical facilities arenot available3.
Bista, et all 2013 showed Out of 11cases, 10 cases had uneventful postoperative course.
In one case, weencountered complete necrosis of the flap due to venous congestion that occurred
in 3rd post op day. In all othercases, the flap survived completely without any marginal necrosis.
Split thickness skin graft was well taken indonor site in all other cases. The sural artery
fasciocutaneous flap is versatile and reliable procedure, easy and quick to elevate, due to the long
pedicle, distalization up to the dorsum of the mid foot can be achieved and also a good
alternative to microsurgical procedures where such facilities are not available and the surgeon
isnot well familiar with the procedure5.
Based on the results of the above study researchers, thereverse suralfaciocutaneous flap
showed satisfactory outcome in reconstructing defects that exist in the distal third of the leg and
foot. In the case report shows similar resultsto the above-mentioned research study. Thereby, this
flap can be used as the most feasiblealternative to reconstruct existing defects especially in the
distal third of the leg and foot.
CONCLUSION
The case reported a difficulty in reconstructing defect existing on distal third of the leg
with conventional procedure. Based on the results of the above study researchers, thereverse
suralfaciocutaneous flap showed satisfactory outcome in reconstructing defects that exist in the
distal third of the leg and foot. In the case report shows similar resultsto the above-mentioned
research study. Thereby, this flap can be used as the most feasiblealternative to reconstruct
existing defects especially in the distal third of the leg and foot.
REFERENCES
1. Hassanpour, S.E., Mohammadkhah, N., Arasteh, E. Is It Safe to Extract the Reverse Sural
Artery Flap from the Proximal Third of the Leg?.Arch Iranian Med. 2008;11(2):179– 185.
2. Mohammadkhah, N., Hossein, S.N., Hallajmofrad, H.R.,Abdolzadeh, M., Borujeni, L.A.,
Mousavinasab, S. Complex Technique of Large Sural Flap: An Alternative Option for
Free Flap in Large Defect of the Traumatized Foot. ActaMedicaIranica. 2011;49(4):195200
3. Maazil, A.A. Distally Based SuralFasciocutaneous Flap For Soft Tissue Reconstruction
Of The Distal Leg, Ankle And Foot Defects. Kufa MedJournal. 2012;15(1):232
4. Sever,C., Kulahci, Y., Oksuz, U. Fasciocutaneous Flap Choices Totreat Dorsal Surface Of
Foot Defects.J Clin Anal Med. 2012;3(1):21-25
5. Bista, N., Shrestha, K.M., Bhattachan, C.L. The reverse suralfasciocutaneous flap for the
coverage of soft tissue defect of lower extremities (distal 1/3 leg and foot). Nepal Med
Coll J. 2013; 15(1): 56-61.
6. Masquelet, A.C., Romana, M.C., Wolf, G. Skin island flaps supplied by the vascular axis
of the sensitive superficial nerves: anatomic study and clinical experience in the leg.
PlastReconstr Surg. 1992;89:1115–21
7. Awerani, S.T., Ansari, M.N.U.R.A., Siddiqui, N. Minimizing complications in reverse
Sural Artery flaps. Pak J Surg. 2011; 27(1):2-7
8. Ajmal, S., Khan, M.A., Khan, R.A., Shadman, M., Yousof, K., Iqbal, T. Distally Based
SuralFasciocutaneous Flap For Soft Tissue Reconstruction Of The Distal Leg, Ankle And
Foot Defects. J Ayub Med CollAbbottabad. 2009;21(4)
1
I gede T. ElingTulus W , I.B Surya Wisesa
2
1
Surgery Department, Faculty Of Medicine Udayana University
2
Oncology Surgery Department- Sanglah Hospital, Denpasar
Abstract
background: Complex wounds and soft tissue defects in the distal third of the leg and foot remain difficult
problem to solve. Soft tissue defect management around the lower third of the leg presents a
considerable challenge to the reconstruction. The reverse suralfasciocutaneous flap is feasible option for
the soft tissue coverage of distal third of the leg. We reported a patient with recurrent squamous cell
carcinoma, with extensive defect after excision was done with improper procedure on the distal third of
the crural, so we decide to perform with reverse suralfasciocutaneous flap.
case : A 61 years old female, with local recurrent squamous cell carcinoma, came with extensive defect
after excision was done with improper procedure on the distal third of the crural. Further treatment for this
patient will be re-excision to remove the entire defect. Hence,the reverse suralfasciocutaneous flap
technique is conducted in managing the extensive defect.
conclusion : the reverse suralfaciocutaneous flap showed satisfactory outcome in reconstructing defects
that exist in the distal third of the leg. In the case report shows similar results to the research study.
Thereby, this flap can be used as the most feasible alternative to reconstruct existing defects especially in
the distal third of the leg.
Keywords :reverse suralfasciocutaneous flap, distal third leg defect
INTRODUCTION
Complex wounds and soft tissue defectsin the distal third of the leg, ankle, and foot
remain difficult problems to solve.Free tissue transfer could be the treatment of choice, but it
requires a team approach, andaccompanies long operative time, donor morbidity,and a risk of
complete failure1.Soft tissue defect management around the lower third of the leg and foot
present a considerable challenge to the reconstruction. This isbecause the tibia is subcutaneous
bone with almost no muscles around its lowerthird with tight skin and poor circulation.The
options in this region are limited.Durable flap is the preferred option for coverage of such
defects2.
Free flap surgery to cover defect is not possible in every center due the sophisticated
instruments, equipments and lengthy procedures. The Reverse suralfasciocutaneous flap is
feasible option for the soft tissue coverage of distal third leg and foot5.
There are many methods for covering soft tissue defect, although free flaps have
beenused to manage these defects, with good result, but their greater complexity requires,
specially trained surgeons who are not always available at hospital, and have a
highercomplication rate than loco regional flap. There has been a great deal of interest inthe use
of local tissue to cover lower limb defects, beginning with their description byponten,
fasciocutaneous flap have been attempted for defect of the lower third of the legbased on the axis
of major vessels of the leg, subsequently, however it was discoveredthat there existed vascular
axis along the path of cutaneous nerves of the body3.This allows elevation of the skin supplied
by this neurovascular axis as a flap forcoverage of leg wounds, this perhaps best exemplified by
the sural nerve flap describedby Masqueletet all6. The sural nerve as it pierces the fascial plane
to runsubcutaneously between the two heads of gastrocnemius muscle is generallyaccompanied
by one to three arteries, these run inferiorly to a region just above thelateral malleolus, where it
communicates with multiple perforators from the peroneal artery.Also running along this same
axis is the lesser saphenous vein, as such the skin overlying gastrocnemius muscle can be
elevated based distally on these perforators3.
Although cross leg fasciocutaneous flap are less frequently indicated for distal leg
andfoot defect due to the availability of other alternative it still useful as they continue toprove to
be the flap of choice in demanding situation3.
CASE REPORT
A 61 years old female patient with local recurrent squamous cell carcinoma, came with
extensive defect after excision was done with improper procedure on the distal third of thecrural
(Figure 1 and 2). Further treatment for this patient will be re-excision to remove the entire defect
to prevent reoccurrence of recurrent squamous cell carcinoma.It is not possible to reconstruct the
extensive defect in the anterior distal third of the cruralwith just a primary lid with suture or by
skin graft (Figure 3). Hence,the reverse suralfasciocutaneous flap technique is conducted in
managing the extensive defect. This technique is the most feasible option to cover extensive
defect especially in the distal third of the crural.
The surgical techniqueattention is directed to the posterior central third of the proximal
leg where a skin island is created based on the dimensions and distance of the recipient site
(Figure 4). The flap should be created slightly larger than the defect needing to becovered and
when establishing the margins of the flap, it isvital to maintain enough overall length to prevent
tensionor kinking during rotation of the flap. Located superior to the lateralmalleolus, the course
of these vessels will influence theoverall path of the pedicle and it is imperative to establishthese
vessels beforehand in order to preserve the majorcirculation and subsequent survival of the
island flap.The flap is fashioned in the shape of an ellipse with thedistal aspect tapered into a
teardrop design to aid in finalclosure (Figure 4).
Dissection is begun proximally andcarried down through to the deep fascial level until
the suralnerve, artery, and lesser saphenous vein are identified (Figure 5). At this point, theisland
flap including the skin, subcutaneous tissue, and thedeep fascial tissues containing the
neurovascular structures,are elevated off the surface of the gastrocnemius musclebellies (Figure6
and 7). Thepivot point is dependent upon the location of the recipientsite and is roughly 5 to 8
cmabove the lateralmalleolus. Thepedicle is approximately 2 to 3 cm in width once
dissectedfreely from the surrounding tissues. Once the flap is mobile,it is repositioned via
working space andsutured to the recipient sitewith care to not kink the flap as it is folded back
upon itself (Figure8). The donor site is primary suture(Figure9). The patient is maintained
nonweight bearing 4 to6 weeks until it is established that the flap has survivedwithout any major
complications and the surgical woundshave healed (Figure 10,11 and 12).
Figure 1.Extensive defect after excision
Figure 2.Re-excision to remove the entire defect to prevent reoccurrence of recurrent squamous
cell carcinoma
Figure 3.It is not possible to reconstruct the extensive defect in the anterior distal third of the
cruralwith just a primary lid with suture or by skin graft
Figure 4.The flap is fashioned in the shape of an ellipse with thedistal aspect tapered into a
teardrop design to aid in finalclosure
Figure 5.Dissection is begun proximally andcarried down through to the deep fascial level until
the suralnerve, artery, and lesser saphenous vein are identified
Figure 6.At this point, theisland flap including the skin, subcutaneous tissue, and thedeep fascial
tissues containing the neurovascular structures,are elevated off the surface of the gastrocnemius
musclebellies
Figure 7.Indentified of the sural nerve
Figure 8.Flap is mobile,it is repositioned via working space and sutured to the recipient sitewith
care to not kink the flap as it is folded back upon itself
Figure 9. The donor site is primary suture
Figure 10. Wound in 3 days, necrotizing (-), hiperemis (+) pus (-)
Figure 11. Wound in 1 week, necrotizing (-), hiperemis (+) pus (-)
Figure 12.Wound in 2 weeks, necrotizing (-), hiperemis (-) pus (-).until it is established that the
flap has survivedwithout any major complications and the surgical wounds have healed.
DISCUSSION
As mention in Hassanpour,et all.2008 with 25 samples that the result such as: Complete
failure 0 (0%), Marginal, necrosis 1 (3.6%), Venous congestion 6 (21.4%), Suture rupture 2
(7.1%), Superficial epidermolysis 2 (7.1%), Hypertrophic scar at donor site 3 (10.7%). The result
of this study showedextension of reversed suralisland flaps to the proximal third of the leg
wassafe and reliable, and the results of medium sized flaps to very large ones were quite
acceptable1.
In 2011,Mohammadkhah, et all. Mentionsabout their studyin13 patients who had large
defects on their foot. The results showed low rates of ischemia, venous congestion, dehiscence,
infection and flap necrosis. Proximal extended and large distally based sural flap is an alternative
to free tissue transfer for large defect reconstruction of the foot2.
Maazil, et all.2012 as well studied about reverse suralfaciocutaneous flap in22
patients.Their ages ranged between 5-42years. (Average age was 17 years), with soft tissue
defect in the distal leg and foot. The conclusion of this study, that the distally based sural flap is
a versatile and reliable flap for the coverage of soft tissue defects of the distal third of the leg and
foot. It is safer to apply the flap from contralateral limb rather than its extension proximally, if
micro vascular surgical facilities arenot available3.
Bista, et all 2013 showed Out of 11cases, 10 cases had uneventful postoperative course.
In one case, weencountered complete necrosis of the flap due to venous congestion that occurred
in 3rd post op day. In all othercases, the flap survived completely without any marginal necrosis.
Split thickness skin graft was well taken indonor site in all other cases. The sural artery
fasciocutaneous flap is versatile and reliable procedure, easy and quick to elevate, due to the long
pedicle, distalization up to the dorsum of the mid foot can be achieved and also a good
alternative to microsurgical procedures where such facilities are not available and the surgeon
isnot well familiar with the procedure5.
Based on the results of the above study researchers, thereverse suralfaciocutaneous flap
showed satisfactory outcome in reconstructing defects that exist in the distal third of the leg and
foot. In the case report shows similar resultsto the above-mentioned research study. Thereby, this
flap can be used as the most feasiblealternative to reconstruct existing defects especially in the
distal third of the leg and foot.
CONCLUSION
The case reported a difficulty in reconstructing defect existing on distal third of the leg
with conventional procedure. Based on the results of the above study researchers, thereverse
suralfaciocutaneous flap showed satisfactory outcome in reconstructing defects that exist in the
distal third of the leg and foot. In the case report shows similar resultsto the above-mentioned
research study. Thereby, this flap can be used as the most feasiblealternative to reconstruct
existing defects especially in the distal third of the leg and foot.
REFERENCES
1. Hassanpour, S.E., Mohammadkhah, N., Arasteh, E. Is It Safe to Extract the Reverse Sural
Artery Flap from the Proximal Third of the Leg?.Arch Iranian Med. 2008;11(2):179– 185.
2. Mohammadkhah, N., Hossein, S.N., Hallajmofrad, H.R.,Abdolzadeh, M., Borujeni, L.A.,
Mousavinasab, S. Complex Technique of Large Sural Flap: An Alternative Option for
Free Flap in Large Defect of the Traumatized Foot. ActaMedicaIranica. 2011;49(4):195200
3. Maazil, A.A. Distally Based SuralFasciocutaneous Flap For Soft Tissue Reconstruction
Of The Distal Leg, Ankle And Foot Defects. Kufa MedJournal. 2012;15(1):232
4. Sever,C., Kulahci, Y., Oksuz, U. Fasciocutaneous Flap Choices Totreat Dorsal Surface Of
Foot Defects.J Clin Anal Med. 2012;3(1):21-25
5. Bista, N., Shrestha, K.M., Bhattachan, C.L. The reverse suralfasciocutaneous flap for the
coverage of soft tissue defect of lower extremities (distal 1/3 leg and foot). Nepal Med
Coll J. 2013; 15(1): 56-61.
6. Masquelet, A.C., Romana, M.C., Wolf, G. Skin island flaps supplied by the vascular axis
of the sensitive superficial nerves: anatomic study and clinical experience in the leg.
PlastReconstr Surg. 1992;89:1115–21
7. Awerani, S.T., Ansari, M.N.U.R.A., Siddiqui, N. Minimizing complications in reverse
Sural Artery flaps. Pak J Surg. 2011; 27(1):2-7
8. Ajmal, S., Khan, M.A., Khan, R.A., Shadman, M., Yousof, K., Iqbal, T. Distally Based
SuralFasciocutaneous Flap For Soft Tissue Reconstruction Of The Distal Leg, Ankle And
Foot Defects. J Ayub Med CollAbbottabad. 2009;21(4)