Langenbecks Arch Surg (2002) 387:320–325DOI 10.1007/s00423-002-0317-7

Received: 4 March 2002 Accepted: 26 August 2002Published online: 8 November 2002© Springer-Verlag 2002

Abstract Background: Soft tissuecovering on the lower leg is fre-quently a difficult challenge andcauses increasing problems for treat-ment in smaller hospitals. We intro-duce a plastic surgery method forcovering these soft tissue defects.Method: An island of skin, centeredabove the sural nerve, is cut out inthe middle dorsal area of the lowerleg. The subcutaneous vascular pedi-cle is prepared along the nerve. Thegained skin flap is rotated into thedefect site and fixed without tension.The wound of the donor-site defectis usually closed primarily, and theflap pedicle is covered with Mesh-craft. Results: In 18 of the 21 pa-tients treated by this method the flap

healed without functional impair-ment, one patient experienced a ne-crosis leading to the loss of the flap.And a partial loss of the skin islandwas recorded in two cases, completehealing was achieved by means ofMeshcraft transplantation. Conclusions: The superficial suralartery flap usually results in a reli-able and complete healing of soft tis-sue defects within the area of thelower legs with justifiable operation-al expenditures also for elderly pa-tients and those with vascular ail-ments.

Keywords Soft tissue defect · Superficial sural artery flap · Surgical flaps methods

O R I G I N A L A RT I C L E

Christof MeyerBernd HartmannUwe HorasOlaf KilianChristian HeissReinhard Schnettler

Reconstruction of the lower leg with the sural artery flap

Introduction

Soft tissue defects in the problematic zones of the lowerleg, tuberosity of the tibia, and distal part of the lowerleg frequently lead to problems in plastic wound closure.Due to the increasing age of patients and the associateddiabetogenetic or neurovascular modifications woundhealing impairments with therapy-resistant soft tissuedefects in these areas sometimes lead to amputation ofthe lower leg [10]. Anatomy studies by Masquelet et al.[8], which refer to the works of Salmon in 1936 and fur-ther investigations on vascularized nerve transplants [2,11], have shown that a vascular network with numerousanastomoses follows the sensitive nerves of the lowerlegs – the saphenous, sural, and superficial peronealnerves – to the suprafascicular vascular bed with nutri-tive branches to the skin. Proximally and distally basedfasciocutaneous flaps, island flaps, or adipofascial turn-

over flaps used to cover infected and trauma-inducedsoft tissue defects can be usually lifted without problemsalong these vascular axles [1, 4, 6, 7, 9]. The rotation ra-dius thereby includes the tibial tuberosity up to the ven-tral side of the knee joint, distally the region of the an-kle; the heel can also be covered with the help of thisflap technique. Elaborate free flaps with microvascularanastomosis are avoidable particularly in elderly and illpatients with special indications.

Material and methods

In the period between May 1997 and December 2001, 16 men and5 women aged between 28 and 80 years (average 62.8 years), suf-fering soft tissue defects received surgical treatment with a super-ficial sural artery flap at the Department of Trauma Surgery, JustusLiebig University Giessen, Germany. The defect size was between3×4 cm and 6×8 cm. Thirteen patients received distally based su-

C. Meyer (✉) · U. Horas · O. KilianC. Heiss · R. SchnettlerKlinik und Poliklinik für Unfallchirurgie,Justus-Liebig-Universität Giessen, Rudolf-Buchheim-Strasse 7, 35385 Giessen, Germanye-mail: christof.meyer@chiru.med.uni-giessen.deTel.: +49-641-9944601Fax: +49-641-9944609

B. HartmannZentrum für Schwerbrandverletzte mitPlastischer Chirurgie, Unfallkrankenhaus Berlin, Berlin, Germany

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ral island skin flaps, four distally based adipofascial turnoverflaps, and four the proximally based preparation (Table 1).

We standardized the following therapeutic concept for thetreatment of these defects. Firstly, primary radical wound débride-ment with removal of all necrotic soft tissue and necrosis of bone.In addition to intraoperative smears, samples of bones and tissuewere taken for microbiological testing. Supplementary to the anti-biogram and perioperative systemic antibiosis, local antibiotic de-livery systems (e.g., Septocoll) are applied in the defect area. Thewound is temporarily closed using synthetic skin replacements.Depending upon the development of the clinical and laboratorychemical findings, serial surgical débridements follow after3–6 days. If a covering with a neurovascular flap is planned, defi-nite soft tissue covering is carried out as early as possible with avital wound basis and repetitive negative smears results.

Surgery is usually performed with the patient lying in an ab-dominal position. After skin disinfection and sterile covering theskin island flap to be extracted is marked above the middle thirdpart of the lower leg. The marking for the distally based flap be-gins from the acute-angled tapered distal island pole towards thelaterally easily swung course of the sural nerve up to the rotation

Fig. 1 Diagram of the sural nerve with the short saphenous veinand sural artery

Fig. 2 Defect over the lateral ankle, intraoperative marking of thecutting line

Fig. 3 Presentation and disconnection of the sural nerve withinthe proximal area

Fig. 4 Preparation of the skin island with fixing seams betweendeep fascia, subcutis, and skin

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point, which is approximately 5 cm above the lateral peak of theankle (Figs. 1, 2). Preparation begins at the proximal edge of theskin island with a short transverse skin cut and a sharp incision ofthe deep fascia. Now the sural nerve with its accompanying arte-ries can be easily located and subsequently severed (Fig. 3). Next,it is imperative to fix the subcutis and muscle fascia with absorb-able threads, which can be used as fixation sutures. This preventsdissection and ensure the blood supply to the skin. Following thisthe marked skin island is cut around and adapted to the deep fasciaby further adapting fixation sutures (Fig. 4).

The incision within the area of the distal edge of the flap andover the course of the sural nerve severs only the cutis. The furtherpreparation of the sural nerve is carried out en bloc, including thesubcutaneous fat tissue up to the marked rotation point. This isdone strictly including the fascia, which can be pushed awaybluntly from the bulge of the gastrocnemius muscle (Figs. 5, 6).

Table 1 Patient characteristics (DPL distally based sural flap, TO turnover technique, PPL proximally based sural flap)

Case Age Sex Cause Defect location Flap type Flap size Complicationsno. (years) (cm2)

1 61 M Fracture, infection Lateral malleolus DPL 3×4 None2 58 M Fracture, infection Lateral malleolus DPL 3×4 None3 72 M Ulcus Medial malleolus DPL 4×4 None4 64 M Fracture, infection Tibial tuberosity PPL 4×5 None5 38 M Open fracture Anteromedial tibia DPL 3×5 None6 75 F Fracture, infection Lateral malleolus DPL 3×4 None7 68 M Ulcus Heel DPL, TO 5×5 None8 63 M Open fracture Anteromedial tibia PPL 3×4 None9 75 M Ulcus Lateral sura PPL 5×7 None

10 45 M Postop. infection Achilles tendon DPL, TO 4×4 None11 67 F Ulcus Lateral sura DPL 4×5 Superficial skin necrosis12 52 M Ulcus Heel DPL, TO 4×5 None13 80 M Open fracture Lateral malleolus DPL 5×8 None14 78 F Open fracture Medial malleolus DPL 6×8 Superficial skin necrosis15 79 F Ulcus Lateral sura DPL 3×4 None16 67 M Fracture, infection Tibial tuberosity PPL 3×4 None17 64 M Open fracture Medial malleolus DPL 3×6 None18 28 M Ulcus Heel DPL, TO 6×8 Flap loss19 60 F Fracture, infection Lateral malleolus DPL 6×8 None20 57 M Fracture, infection Lateral malleolus DPL 4×7 None21 67 M Open fracture Lateral malleolus DPL 4×4 None

Fig. 5 The skin island is raised with the deep fascia. The subcuta-neous fascial pedicle is elevated, keeping a width of 2 cm to in-clude the sural nerve, the concomitant artery and the short saphe-nous vein

Fig. 6 Preparation of the neurovascular pedicle taking along themuscle fascia

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After horizontal incision of the skin from the rotation point up tothe proximal edge of defect the elevated island flap is now movedwithout tension into the soft tissue defect area. To avoid venouscongestion and thus a possible flap necrosis, attention must bepaid that the flap pedicle is not torqued or too strongly crinkledwhen swiveling into the defect site (Figs. 7, 8). After refreshingand mobilizing the defective wound edges the skin island is fixedsecurely by loosely tied seams (Fig. 9). An absorbable local anti-biotic delivery system (e.g., Septocoll) under the transplanted flapis useful as a reliable local infection prophylaxis. Furthermore, itis recommended to insert latches under the flaps for the drainage.

Finally, a primary wound closure on the lower leg dorsal sideis usually possible after mobilization of the edges of the donor-sitedefect and a Meshcraft transplantation for covering the flap pedi-cle finalizes the surgery (see Fig. 10). After the operation anycompression of the flap must be avoided; the consistent side posi-tion of the patient proves favorable for this. Alternatively, theplacement in a preoperative manufactured special cast is possible,which protects the area of the flap and its pedicle against compres-sion.

Fig. 7 The flap is placed into the former defect

Fig. 8 Unstressed position of the flap pedicle, by adapting singleseams before bending or torquing secured

Fig. 9 Insert the island flap into the soft tissue defect

Fig. 10 Postoperative findings after primary closing of the donorsite defect and Meshcraft covering of the flap pedicle

ea [5]. However, due to the thickness of the shifted tissuethey lead to both functional and cosmetic problems.

Operation procedures of free flap plastics requirehigh-standard operative resources and are therefore con-ditioned to prerequisites which are not available in allhospitals. These are, among other things, the equipmentand above all the trained personnel necessary for micro-surgical operations. In particular it must be ensured thatany operational interventions and revisions needed canbe carried out competently at any time. Freely trans-ferred, microvascular attached transplants affect the arte-rial blood circulation of the foot [5] via the connection toone of main vessels of the lower legs. Particularly in dia-betics and patients with existing arteriosclerosis insertionof pedicled flap plastics must be avoided, for example,an dorsal pedis artery flap and a medial plantar flap, be-cause of the associated iatrogenic impairment of theblood circulation of the foot. The long operation timemay be a contraindication in elderly patients. Cross-legflaps, for example, possible as neuroskin flap of the sa-phenous nerve, require long-lasting immobilization andentail a threat of thrombosis and the development of adecubital ulcera. However, considering the possible al-ternatives to local plastic covering, these are indicatedonly in rare exceptional cases.

The anatomical studies of Masquelet et al. [8] showskin areas supplied by the accompanying vascular net-works of the three suprafascially running, sensitivenerves of the lower leg (sural, saphenous, superficialperoneal nerves). The vascular nerve network is embed-ded into the surrounding fat tissue including the adjacentmuscle fascie, depending on whether type A or type B ofthe classification of fasciocutaneous flaps according toCormarck and Lamberty [3]. The separation from vesselsand nerve is impossible without impairment of the ve-nous discharge [3, 5, 8]. Proximally or distally based fas-ciocutaneous flaps, island flaps, and adipofascial turn-over flaps up to 10×13 cm can be lifted above these ves-sels to cover soft tissue defects at the lower leg, includ-ing the knee joint and heel region [2, 4, 6, 7, 8, 9]. Thesural artery arises from behind the lateral ankle, in two-thirds of the cases from the peroneal artery and in one-third from the retromalleolar arterial vascular network[8]. This vessel is regularly available, even with existingarteriosclerosis.

In agreement with other authors [6, 10], we do not seethe necessity of the pre- and intraoperative presentationof the accompanying vessels of the sural nerve. We thusrefrain from applying duplex sonography or angiogra-phy. It should be underlined that a further crucial advan-tage of neurovascular flap plastics is that a preparation oran impairment of the main vessels of the lower leg doesnot occur. The surgery takes up a relatively short opera-tion time of 30–60 min. These characteristics of the suralartery flap make it applicable even in elderly patientsand those with vascular ailments [6, 10]. Due to a threat-

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Results

The inserted sural artery flaps healed properly in 18 of21 cases without functional impairment (see Fig. 11). Intwo patients the transplanted suralis flap was partiallylost due to superficial skin necroses with vital subcutis.After renewed reduced débridement and temporary vacu-um sealing the area was covered secondarily with Mesh-craft plastic, which healed without problems in both pa-tients. In another case a flap necrosis developed postop-eratively. After radical débridement there was a second-ary renewed covering of the defect area with a microvas-cular radialis flap defect covering followed secondarilywith a microvascular radialis flap. The lifting defectswere closed primarily in 17 patients, while the remainingfour patients received a Meshcraft skin transplantation.Healing was achieved in all patients. The postoperativehospital stay of the 20 patients with healed sural arteryflap averaged at 19.8 days.

Discussion

The treatment of chronic ulcerations and superficial softtissue defects is usually conservative. Most patients canbe treated successfully with various methods of woundtreatment, for example, hydrocolloid wound dressing. Ifconservative treatment fails, plastic surgeries are indicat-ed. Numerous techniques for the plastic surgery are pos-sible.Movable flap plastics are available for local soft tissuecovering. These are useful for covering very small de-fects; therefore the indication spectrum is only a verylimited one. Compared to the neurocutaneous flaps, mus-cle flap plastics, for example, the soleus flap and theflexor digitorum longus flap, offer the advantage of bet-ter blood circulation and thus stronger resistance. This isan advantage in preexisting infections in the recipient ar-

Fig. 11 Result 9 months later

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ening postoperative venous congestion with consecutiveflap loss we prefer free Meshcraft-covered placing of theflap pedicle and avoid the so-called “tunneling” and sub-cutaneous placing. The postoperative edema of the skinisland is usually less marked than with pedicled flapplastics and can be observed for approximately 4 weeks[1, 6]. Concerning the morbidity of the operation, it mustbe mentioned that a possible hypesthesia at the lateraledge of the foot can occur due to the disconnection of

the sural nerve. The operation does not result in func-tional restrictions since the gastrocnemious muscle is notimpaired by the elevation of the fasciocutaneous flap.Also, in agreement with the results of other authors (e.g.,[3]), we have not observed formation of neuromas.

The sural artery flap can thus be recommended as themethod of choice for successful healing of soft tissue de-fects in the lower leg, even in elderly patients and thosewith vascular ailments.

References

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