ORIGINAL ARTICLE

Reverse pedicle-based greater saphenous neuro-veno-fasciocutaneous flap for reconstruction of lower leg and foot

Sandeep Kansal • Pradeep Goil • Vijay Agarwal •

Swarnima Agarwal • Shashank Mishra •

Deepak Agarwal • Pranay Singh

Received: 7 June 2012 / Accepted: 8 December 2012

� Springer-Verlag France 2013

Abstract

Introduction Paucity of soft tissue available locally for

reconstruction of defects in leg and foot presents a chal-

lenge for reconstructive surgeon. The use of reverse pedi-

cle-based greater saphenous neuro-veno-fasciocutaneous

flap in reconstruction of lower leg and foot presents a viable

alternative to free flap and cross-leg flap reconstruction. The

vascular axis of the flap is formed by the vessels accom-

panying the saphenous nerve and the greater saphenous

vein. We present here our experience with reverse saphe-

nous neurocutaneous flap which provides a stable cover

without the need to sacrifice any important vessel of leg.

Patients and methods The study is conducted from March

2003 through Dec 2009 and included a total of 96 patients

with defects in lower two-thirds of leg and foot. There are

74 males and 22 females. Distal pivot point was kept

approximately 5–6 cm from tip of medial malleolus, thus

preserving the distal most perforator, and the flap is turned

and inserted into the defect. Donor site is covered with a

split thickness skin graft. Postoperative follow-up period

was 6 weeks to 6 months.

Result The procedure is uneventful in 77 cases. Infection

is observed in 14 cases. Partial flap necrosis occurs in 2

cases. Total flap necrosis is noted in 3 cases.

Conclusion Reverse pedicle saphenous flap can be used

to reconstruct defects of lower one-third leg and foot with a

reliable blood supply with a large arc of rotation while

having minimal donor site morbidity.

Keywords Lower leg � Foot � Reverse saphenous flap �Great saphenous vein � Saphenous nerve

Introduction

Paucity of soft tissue available locally for reconstruction

of defects in leg and foot presents a challenge for recon-

structive surgeon. Reconstruction with free flap provides

healthy tissue for reconstruction, but many a times leads to

sacrifice of one of the major vessels of leg. Similarly,

peroneal flap [1], posterior tibial artery flap [2] and ante-

rior tibial artery flap [3] also lead to sacrifice of a vessel.

The use of reverse pedicle-based greater saphenous neuro-

veno-fasciocutaneous flap in reconstruction of lower leg

and foot presents a viable alternative to free flap and

cross-leg flap. The vascular axis of the flap is formed by

the vessels accompanying the saphenous nerve and the

greater saphenous vein. The flap can be raised up to the

knee, has minimal morbidity and can reach up to the distal

part of foot. We present here our experience with reverse

saphenous neurocutaneous flap which provides a stable

cover without the need to sacrifice any important vessel

of leg.

Patients and methods

The study was conducted from March 2003 through Dec

2009 in our hospital and included a total of 96 patients with

defects in lower two-thirds of leg and foot. There were 74

males and 22 females. Injury due to road traffic accident

was the main aetiology of the defect. Patients with defect

encroaching upon the territory of the saphenous nerve, vein

and the medial malleolus were excluded.

S. Kansal (&) � P. Goil � V. Agarwal � S. Agarwal �S. Mishra � D. Agarwal � P. Singh

A-27, Alok Park, Modinagar 201204, Ghaziabad, UP, India

e-mail: drsandeepkansal@gmail.com

123

Eur J Orthop Surg Traumatol

DOI 10.1007/s00590-012-1150-5

Regional anaesthesia (intrathecal or epidural) was pre-

ferred. The procedure was done under tourniquet control.

The wound was debrided, and planning in reverse was done.

The flap was raised proximal to distal with the patient in

supine position. Anterior margin of the flap was kept just

medial to the medial border of tibia, and the posterior

margin did not cross the midline. Dissection proceeded in a

plane deep to the deep fascia. Care was taken to include

both the greater saphenous vein and the saphenous nerve in

the flap. Saphenous vein and saphenous nerve are ligated

and divided and included in the flap. Upper limit of the flap

was up to the insertion of the sartorius muscle, as it was the

point where nerve dips deep to the deep fascia. Distally,

pivot point was kept approximately 5–6 cm from the tip of

medial malleolus, thus preserving the distal most perforator

from the posterior tibial artery (present 5–6 cm proximal to

medial malleolus) as shown in Figs. 1 and 2. Doppler

should be used to locate the perforator preoperatively and to

plan the flap more accurately. The flap was turned and

insetted in the defect taking care not to twist the pedicle.

Donor site is covered with a split thickness skin graft. The

foot was immobilized for 3 weeks avoiding pressure over

the pedicle and the flap.

Postoperative follow-up of the patients ranged from

6 weeks to 6 months (Tables 1, 2, 3, 4).

Results

• Most of the cases were due to road traffic accidents

(65 %).

• Majority of patients were in the age group of

15–45 years (70 %).

• The procedure was uneventful in 77 (80.2 %) cases.

• Infection observed in 14 (14.58 %) cases.

Fig. 1 The marking of flap along with pivot point of flap. Markingincludes the great saphenous vein and saphenous nerve

Table 1 The agewise distribution of the patients

Age group (years) No. of patients Percentage

0–15 12 1.25

15–30 42 43.75

30–45 26 27.08

[45 16 16.66

Total 96

Fig. 2 The method of raising the flap keeping the great saphenous

vein and saphenous nerve in the flap

Eur J Orthop Surg Traumatol

123

• Partial flap necrosis occurs in 2 (2.1 %) cases, with

resulting need for complimentary minor surgery

(debridement and split thickness graft).

• Total flap necrosis noted in 3 (3.1 %) cases.

Discussion

Soft tissue defects of lower one-third tibia and foot used to

be enigma of orthopaedic and even plastic and recon-

structive surgeon. Trauma due to road traffic accidents

account for most of the cases. Various techniques have

been developed for the reconstruction of these defects.

Split skin graft remains the best option to cover superficial

defects over dorsum of foot due to its faster take and early

neurotization.

The coverage of wounds of the lower third of the leg is

usually best treated using microvascular free-tissue trans-

fer. These flaps provide reliable single-stage coverage of

these wounds. There are certain disadvantages of free flaps.

These are the need for a remote donor site, increased

operative time, use of a major vessel of the leg and the need

for micro vascular expertise (Figs. 3, 4, 5, 6, 7, 8, 9, 10).

Inferiorly based muscle flaps continue to be plagued by

a high failure rate [3]. The donor defect and bulk and

morbidity also added the disadvantage of this flap [4].

Fasciocutaneous flaps first introduced by Ponten in 1981

[5, 6] are in the use for the reconstruction of soft tissue

defects of lower one-third leg and foot. Reversed island

flap, for example, peroneal artery flap [1], anterior tibial

artery flap [7–9] and posterior tibial artery flap can be

transferred to the ankle or foot [2]. However, it needs

sacrifice of a major artery which constitutes a potentially

serious disadvantage. Masquelet et al. [10] in 1992 first

described distally based sural artery flap based on vascular

plexus around the sural nerve.

Saphenous nerve is the largest branch of the femoral

nerve and enters the leg between sartorius and tendon of

Fig. 3 Pre-operative photograph of patient 1 showing defect over

anteromedial aspect of foot

Fig. 4 Pre-operative photograph of patient 1 showing incision of the

marked reverse saphenous flap

Table 2 Aetiology of patients

Aetiology No. of patients Percentage

RTA 62 64.58

Nonhealing ulcer 12 12.5

Unstable area 13 13.54

Others (exposed pin, plates, etc.) 9 9.4

Table 3 The site of defect

Site of defect No. of patients Percentage

Ankle 21 21.9

Lower one-third leg 42 43.75

Foot 27 28.1

Heel 6 6.25

Table 4 The postop. results in study group

Postop. result No. of patients Percentage (%)

Uneventful 77 80.2

Discharge/infection 14 14.58

Partial flap necrosis 2 2.1

Total flap necrosis 3 3.1

Eur J Orthop Surg Traumatol

123

gracilis. It remains deep to the deep fascia proximally and

become suprafascial distal to insertion of sartorius muscle.

It accompanies the great saphenous vein in the leg and foot

and ends in the skin of medial side of leg. According to

Masquelet et al. [10], a rich network of vessels is formed

around the nerve by the saphenous artery. Distally this

plexus has numerous anastomoses with perforators from

posterior tibial artery. The distal most of these anastomoses

is 5–6 cm proximal to medial malleolus.

The hemodynamic role of the large subcutaneous veins

in distally based flaps has been extensively discussed.

Timmons [11] suggested that flow could be reversed

against the denerved valves to drain the flaps. Torri et al.

[12] reported that the valves of the greater saphenous vein

become independent only with venous pressures of more

than 90 mmHg; therefore, it seems very unlikely that flow

reversal could occur in clinical situation. Imanshi et al. [13]

suggested that superficial vein included in the flap usually

get thrombosed in postoperative period. Chang [14]

observed that, when the large veins draining from the limb

were included in a reversed flap, they became extremely

Fig. 6 Post-operative photograph of patient 1 after reverse saphenous

flap insetting over the defect

Fig. 5 Pre-operative photograph of patient 1 showing raised reverse

saphenous flap

Fig. 7 Photograph of patient 2 showing defect over medial malleolus

and raised reverse saphenous flap

Fig. 8 Post-operative photograph of patient 2 after reverse saphenous

flap insetting over the defect

Fig. 9 Pre-operative photograph of patient 3 showing pressure ulcer

over heel

Eur J Orthop Surg Traumatol

123

engorged and the venous pressure inside the veins increased

to 42 mmHg, which was much higher than the capillary

pressure. Venous hypertension thus propagates and hinders

normal venous pressure through valveless small veins within

the flap. Cavadas [15] advocated to routinely ligated and

divide the vein at the base of the flap and taking care not to

disrupt other vascular structures. This significantly reduces

postoperative flap congestion and partial flap loss. In our

series, we have not ligated the saphenous vein at the base of

the flap and found no problem of engorgement of flap due to

venous hypertension.

Carriquiry et al. [4] reported their detailed anatomical

study of the septocutaneous vessels of the leg. They

reported that the lower leg perforator is 9–12 cm above the

tip of the medial malleolus. However, Amarante et al.

suggested that the lowest perforator of the posterior tibial

vessels is about 4 and 6.5 cm above the medial malleolus.

In all our cases, we found the lowest perforator 5–6 cm

from the medial malleolus.

Nayak et al. [16] in their study of the microneurovas-

cular structure of greater saphenous vein reported that the

vein is surrounded by a rich mixed vascular network from

ankle to knee.

Based on these networks, a flap can be raised over the

anteromedial aspect of the leg. Using only the neurocuta-

neous component restricts the length of the flap up to the

insertion of sartorius, that is, to a point where the nerve

dips deeper to the deep fascia. Inclusion of the vein enables

extension of the flap beyond this point.

Based on the vein, the pivot point of the flap can be

placed just proximal to the medial malleolus, but preser-

vation of the tibial perforator ensures better nourishment to

the flap.

Thus, inclusion of both the nerve and the vein enabled

raising of a long flap while ensuring its viability.

Amarante et al. [17] described a medial distally based

fasciocutaneous flap with a narrow pedicle and reported

four successful cases.

Cavadas [15] reported his experience of 5 cases of

reverse flow neurocutaneous saphenous flap with low

complication rate.

Shalby et al. [18] reported their experience of 7 cases of

distally based medial island septocutaneous flap for repair

of soft tissue defect of lower leg.

Rajacic et al. [19] reported their experience of using

distally based saphenous island flap in 14 patients. Nine

flaps survived completely. Two had marginal flap necrosis

while one flap lost completely.

Flap is indicated in defect of lower one-third leg, mid

foot and defect of heel. However, it is contraindicated in

venous disease of leg and in suspected trauma of perforator

and in peripheral arterial disease of leg. This flap has many

advantages. It can be raised with the patient in supine

position, does not require sacrifice of any major artery of

the leg and can be used to cover areas like tendo achilles.

The flap has wide arc of rotation, and it can reach up to

lower one-third leg, ankle and midfoot level. Moreover, it

is easy to execute and transpose. The donor site morbidity

is also minimal compared with the reverse sural flap, and

tendo achilles is not exposed. And also saphenous nerve

sacrifice has not been a problem, since most of the defect to

be reconstructed involved the area supplied by the nerve.

The elevation of large retrograde flow flap in the

saphenous region inevitably implies the elevation of pre-

tibial skin. We have modified the technique by elevating

the flap at the medial border of the shin preserving the

pretibial skin and taking care to include the great saphe-

nous vein in the flap. As the flap did not encroach upon the

subcutaneous part of tibia, the donor site defect required

only a split skin graft for coverage.

Any venous pathology like varicose vein and venous

thrombosis should be ruled out, as with sacrificing the

superficial veins venous congestion occurs.

Other options for reconstruction of lower leg and foot

include microvascular flaps, cross-leg flaps and reverse

flow island flaps. Microvascular flaps introduce healthy

tissue with its blood supply in the area. However, they

require sophisticated instruments and availability of a

microvascular team. Moreover, long-standing infection and

oedema alter the physical characteristics of the recipient

vessels and increase the possibility of anastomotic prob-

lems. Cross-leg flaps though feasible require the patient to

maintain an uncomfortable position for a long time. Thus, a

reverse saphenous flap scores over the other modalities of

treatment available for management of the leg and foot

defects.

The distally based medial septocutaneous flap, based on

one vascular pedicle with a very wide arc of rotation, can

Fig. 10 Post-operative photograph of patient 3 showing reverse saphe-

nous flap coverage over heel defect

Eur J Orthop Surg Traumatol

123

be transposed 90� or 180� to cover the defects of the lower

third of the leg successfully. There is no bulk or pedicle

kink of the flap. However, this flap is not recommended in

cases of venous ulcers or stasis because this might com-

prise the venous drainage of the flap.

In our series, we have used both pedicle as well as island

flap to cover the defect. Procedure is carried out in two

stages, first being flap elevation and coverage of defect.

Second stage is being flap detachment and insetting. Donor

site scar and loss of sensation at medial aspect of leg and two-

stage procedure are the main disadvantages. Our series shows

that majority of patients are males and got injured due to road

traffic accident, implicating that usually males are going out

for earning their living. Our series shows the complications

like discharge and infection, which may be due to inadequate

debridement or cross-infection and is controlled by antibi-

otics and dressing. Our series shows that partial flap necrosis

that may be due to kinking of pedicle or pressure over flap

due to improper position and controlled by giving proper

position and relieving the kinking or tension at the suture line

by removing sutures. Later the flap resettled. In our series 3,

patient showed total flap necrosis, which may be due to

pressure over pedicle for a prolong period and secondary

procedure like free flap have to be done to cover the defect.

Conclusion

Reverse pedicled saphenous flap is a versatile flap which

can be used to reconstruct defects of lower one-third leg

and foot with a reliable blood supply, easy elevation and

long vascular pedicle with a large arc of rotation can be

transposed up to base of the toes. Also, it preserves the

major arteries of the leg and also dispenses off with the

need of executing a free-tissue transfer while having min-

imal donor site morbidity.

Conflict of interest None.

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