4
Use of Expanded Reverse Sural Artery Flap in Lower Extremity Reconstruction R us ¸t uK ose, MD 1 , Cengiz Mordeniz, MD 2 ,C ¸ os ¸ kun S ¸ anli, MD 3 1 Assistant Professor, Department of Plastic and Reconstructive Surgery, Rize University Medical School, Rize, Turkey 2 Assistant Professor, Department of Anesthesiology and Intensive Care, Harran University Medical School, Sanliurfa, Turkey 3 Orthopedist, Department of Orthopedics and Trauma, State Hospital, Trabzon, Turkey article info Level of Clinical Evidence: 4 Keywords: ankle foot ulcer leg necrosis surgery tissue expander wound abstract Coverage of defects of the distal third portion of the leg and foot remains a challenge for surgeons. The difculty results from the limited mobility and availability of the overlying skin, the weight-bearing requirements, and the relatively poor circulation of the skin. From January 2008 to December 2009, 10 patients had defects of the foot and ankle covered using the 2-stage expanded reverse sural ap. Of these 10 patients, 6 had at least 1 risk factor for compromised wound healing, such as diabetes mellitus, peripheral arterial disease, venous insufciency, tobacco smoking, or age older than 40 years. Flap necrosis was observed in only 1 patient (10%). Venous congestion was noted in 2 patients (20%) by the third postoperative day, 1 of whom responded to postural elevation of the extremity and 1 to medicinal leech therapy. Although it is a 2-stage procedure that requires wound dressing during the expansion, we strongly suggest the use of the expanded reverse sural ap for defects too large to be primarily closed, especially in patients older than 40 years with risk factors such as diabetes mellitus, peripheral arterial disease, or venous insufciency. Ó 2011 by the American College of Foot and Ankle Surgeons. All rights reserved. Despite advancements in microsurgical techniques, the coverage of defects of the distal third portion of the leg and those of the hindfoot and ankle remains a challenge for surgeons. The difculty comes from the limited mobility and availability of the overlying skin, weight- bearing and contact requirements, and relatively poor circulation of the skin (1,2). A wide range of reconstructive techniques, including skin grafting, cross-leg aps, muscle aps with skin grafting, adipo- fascial aps, and free aps have been reported for wound coverage in this difcult area (36). Nevertheless, the sural ap has gained popularity during the past decade as a versatile option for covering defects around the distal leg and ankle and hindfoot. Despite the need for a delayed procedure, the advantages of this technique include preservation of the major arteries in the distal leg, a constant blood supply to the ap, a relatively low rate of complications, and a short operative time without the need for microvascular anastomosis. Several reports have described low rates of failure in association with the sural ap, although these have pertained to use of the ap in a relatively young patient population (710). In contrast, Baumeister et al (11) used sural aps for soft tissue coverage of the distal leg and reported partial or complete ap necrosis in 36% of the patients with risk factors that included concomitant diabetes mellitus, peripheral arterial or venous disease, vasculitis, age older than 40 years, and the absence of the lesser saphenous vein. Because of these ndings, Baumeister et al (11) proposed the use of a sural ap delayproce- dure in an effort to diminish the risk of ap failure. As a general rule, closure of a ap donor site is best done using primary closure. However, if primary skin closure is not possible, the ap donor site can be covered with the use of a split-thickness skin graft. The ap skin can also be increased using soft tissue expansion before transfer of the ap to the recipient site. In diabetic patients, a primarily closed donor site is preferable to coverage using a split- thickness skin graft (Fig. 1). Furthermore, in diabetic patients, it is particularly important that the donor and recipient site wounds heal satisfactorily whenever a sural ap is used, because failure to heal is likely to result in the need for a below-the-knee amputation. Thus, many reconstructive surgeons are reluctant to use the sural ap for coverage of distal leg, ankle, and hindfoot wounds, especially in the presence of any risk factor known to threaten wound healing. A compromised cosmetic donor site and increased ap necrosis rate in high-risk patient groups have made many surgeons reluctant to use the sural ap. In the present report, we describe the use of the delayed sural artery ap, combined with tissue expansion, for coverage of distal leg, ankle, and hindfoot wounds, in a series of 10 patients. Patients and Methods We retrospectively procured and reviewed the records of consecutive patients who had undergone sural artery ap coverage of a distal leg, ankle, or hindfoot wound Financial Disclosure: None reported. Conict of Interest: None reported. Address correspondence to: Rus ¸tuKose, MD, Department of Plastic and Recon- structive Surgery, Rize University Faculty of Medicine, Rize 53100 Turkey. E-mail address: [email protected] (R. Kose). 1067-2516/$ - see front matter Ó 2011 by the American College of Foot and Ankle Surgeons. All rights reserved. doi:10.1053/j.jfas.2011.06.007 Contents lists available at ScienceDirect The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org The Journal of Foot & Ankle Surgery 50 (2011) 695698

Use of Expanded Reverse Sural Artery Flap in Lower Extremity Reconstruction

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lable at ScienceDirect

The Journal of Foot & Ankle Surgery 50 (2011) 695–698

Contents lists avai

The Journal of Foot & Ankle Surgery

journal homepage: www.j fas .org

Use of Expanded Reverse Sural Artery Flap in Lower Extremity Reconstruction

R€ust€u K€ose, MD 1, Cengiz Mordeniz, MD2, Coskun Sanli, MD 3

1Assistant Professor, Department of Plastic and Reconstructive Surgery, Rize University Medical School, Rize, Turkey2Assistant Professor, Department of Anesthesiology and Intensive Care, Harran University Medical School, Sanliurfa, Turkey3Orthopedist, Department of Orthopedics and Trauma, State Hospital, Trabzon, Turkey

a r t i c l e i n f o

Level of Clinical Evidence: 4Keywords:anklefoot ulcerlegnecrosissurgerytissue expanderwound

Financial Disclosure: None reported.Conflict of Interest: None reported.Address correspondence to: R€ust€u K€ose, MD, De

structive Surgery, Rize University Faculty of MedicineE-mail address: [email protected] (R. K€ose).

1067-2516/$ - see front matter � 2011 by the Americdoi:10.1053/j.jfas.2011.06.007

a b s t r a c t

Coverage of defects of the distal third portion of the leg and foot remains a challenge for surgeons. Thedifficulty results from the limited mobility and availability of the overlying skin, the weight-bearingrequirements, and the relatively poor circulation of the skin. From January 2008 to December 2009, 10patients had defects of the foot and ankle covered using the 2-stage expanded reverse sural flap. Of these 10patients, 6 had at least 1 risk factor for compromised wound healing, such as diabetes mellitus, peripheralarterial disease, venous insufficiency, tobacco smoking, or age older than 40 years. Flap necrosis was observedin only 1 patient (10%). Venous congestion was noted in 2 patients (20%) by the third postoperative day, 1 ofwhom responded to postural elevation of the extremity and 1 to medicinal leech therapy. Although it isa 2-stage procedure that requires wound dressing during the expansion, we strongly suggest the use of theexpanded reverse sural flap for defects too large to be primarily closed, especially in patients older than 40years with risk factors such as diabetes mellitus, peripheral arterial disease, or venous insufficiency.

� 2011 by the American College of Foot and Ankle Surgeons. All rights reserved.

Despite advancements inmicrosurgical techniques, the coverage ofdefects of the distal third portion of the leg and those of the hindfootand ankle remains a challenge for surgeons. The difficulty comes fromthe limited mobility and availability of the overlying skin, weight-bearing and contact requirements, and relatively poor circulation ofthe skin (1,2). A wide range of reconstructive techniques, includingskin grafting, cross-leg flaps, muscle flaps with skin grafting, adipo-fascial flaps, and free flaps have been reported for wound coverage inthis difficult area (3–6). Nevertheless, the sural flap has gainedpopularity during the past decade as a versatile option for coveringdefects around the distal leg and ankle and hindfoot. Despite the needfor a delayed procedure, the advantages of this technique includepreservation of the major arteries in the distal leg, a constant bloodsupply to the flap, a relatively low rate of complications, and a shortoperative time without the need for microvascular anastomosis.

Several reports have described low rates of failure in associationwith the sural flap, although these have pertained to use of the flap ina relatively young patient population (7–10). In contrast, Baumeisteret al (11) used sural flaps for soft tissue coverage of the distal leg andreported partial or complete flap necrosis in 36% of the patients withrisk factors that included concomitant diabetes mellitus, peripheral

partment of Plastic and Recon-, Rize 53100 Turkey.

an College of Foot and Ankle Surgeon

arterial or venous disease, vasculitis, age older than 40 years, and theabsence of the lesser saphenous vein. Because of these findings,Baumeister et al (11) proposed the use of a sural flap “delay” proce-dure in an effort to diminish the risk of flap failure.

As a general rule, closure of a flap donor site is best done usingprimary closure. However, if primary skin closure is not possible, theflap donor site can be covered with the use of a split-thickness skingraft. The flap skin can also be increased using soft tissue expansionbefore transfer of the flap to the recipient site. In diabetic patients,a primarily closed donor site is preferable to coverage using a split-thickness skin graft (Fig. 1). Furthermore, in diabetic patients, it isparticularly important that the donor and recipient site wounds healsatisfactorily whenever a sural flap is used, because failure to heal islikely to result in the need for a below-the-knee amputation. Thus,many reconstructive surgeons are reluctant to use the sural flap forcoverage of distal leg, ankle, and hindfoot wounds, especially in thepresence of any risk factor known to threaten wound healing. Acompromised cosmetic donor site and increased flap necrosis rate inhigh-risk patient groups have made many surgeons reluctant to usethe sural flap. In the present report, we describe the use of the delayedsural artery flap, combined with tissue expansion, for coverage ofdistal leg, ankle, and hindfoot wounds, in a series of 10 patients.

Patients and Methods

We retrospectively procured and reviewed the records of consecutive patients whohad undergone sural artery flap coverage of a distal leg, ankle, or hindfoot wound

s. All rights reserved.

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Fig. 1. View of donor site flap repaired with skin graft. Fig. 2. Tissue expander inserted.

R. K€ose et al. / The Journal of Foot & Ankle Surgery 50 (2011) 695–698696

during the study period from January 2008 to December 2009. All the patientsunderwent surgery by the senior author (R.K.), and all of us reviewed the records andabstracted the data of interest.

Flap Design

Before the operation, the lesser saphenous vein and the perforators of the peronealartery on the lateral aspect of the distal leg were detected using a Doppler ultrasoundprobe. Thereafter, the flap was approached with the patient in the prone position. Tovisualize the lesser saphenous vein without exsanguinating the limb, we useda pneumatic tourniquet equipped with an Esmarch bandage. The flap axis was drawnfrom the lateral malleolus to the midline of the popliteal fossa, outlining the pedicle.The skin island was then marked, with its center along the axis of the lesser saphenousvein. Because of the thicker subcutaneous tissue of the donor site relative to theplanned recipient site, the skin islandwas usually designed to be slightly larger than thedefect to facilitate subsequent skin-to-skin closure at the recipient site (10).

Tissue Expansion and Flap Delay

Only the upper border of the flap was incised in the shape of a “half moon.” Thelesser saphenous vein, median sural nerve, and superficial sural artery were thendivided and ligated. Using long scissors, the subfascial planewas cut downward on bothsides, which can be a difficult dissection, because care is needed to preserve theadventitial attachment of the nerve to the deep fascia. Use of a lighted retractor helpedwith this step and minimized the risk of injuring the deep pedicle. Hemostasis wastypically achieved with bipolar cautery after the tourniquet was deflated, and thevascularity to the overlying skin was assessed. Thereafter, a 100- to 200-ml tissueexpander was inserted (Fig. 2), and the fascia and skin at the upper (proximal) border ofthe incision was closed. Low doses of normal sterile saline were used to expand thedonor flap, beginning at the first operation and then twiceweekly starting after the firstpostoperative week (Fig. 3) and continued until the flap was of adequate size to coverthe recipient wound.

Fig. 3. Expansion completed within 25 days.

Flap Transfer

After a 30-day delay, the patient returned to the operating room for flap elevationand transfer. In all cases, the incision started at the proximal border of the flap, thepedicle of which contained the superficial and deep fascia, sural nerve, lesser saphe-nous vein, and superficial sural artery. To elevate the flap, subfascial dissection wasdirected toward the pivot point, which was typically localized at a point 5 to 6 cmproximal to the lateral malleolus, with care taken to preserve most of the communi-cating perforator vessels. In all cases, a 3- to 4-cm-wide adipofascial pedicle withoutoverlying skin was used. After preparation of the pedicle, the flap was transposedthrough a subcutaneous tunnel from the donor site to the recipient site. To minimizerisk of pedicle compression, the skin bridge was divided over the subcutaneous tunnel.Hemostasis was achieved with bipolar cautery after the tourniquet was deflated, andthe fascia was sutured to the skin with 4-0 silk sutures. After securing the flap at therecipient site, the flap donor site was primarily closed (Fig. 4).

Results

A statistical description of the case series is depicted in Table 1. Themean age of the 10 patients in the present series was 42 (range 10 to72) years. Of the 10 patients, 6 (60%) were males and 4 (40%) werefemales. Six patients (60%) had at least 1 risk factor for delayed orfailed wound healing, including 4 (40%) older than 40 years, 2 (20%)with diabetes mellitus, 2 (20%) who were cigarette smokers, and 1(10%) with peripheral arterial disease. Three of the patients (30%) had2 co-morbidities that threatened wound healing, including 2 (20%)with diabetes and aged older than 40 years and 1 (10%) who wasa cigarette smoker and aged older than 40 years. The etiology of thedefect was trauma in 5 (50%), diabetic ulcer in 2 (20%), burnwound in2 (20%), and osteomyelitis in 1 patient (10%). A neurofasciocutaneousflapwas used in all 10 patients, and these ranged in size from 4� 5 cmto 15 � 11 cm. In 6 patients (60%), the skin bridge between the defectand the donor site was “tunnelized,” and in 4 (40%), the flaps weretransferred to the defect through an incision between the donor areaand defect. Flap expansion and the delay required amean of 30 (range20 to 35) days, and a flap tunnel was used to convey the flap from thedonor site to the recipient site in all 10 patients. The mean duration of

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Fig. 4. Flap donor site closed primarily.

R. K€ose et al. / The Journal of Foot & Ankle Surgery 50 (2011) 695–698 697

follow-up was 9 (range 4 to 24) months. Partial flap necrosis wasobserved in only 1 patient (10%), and venous congestionwas observedby the third postoperative day in 2 patients (20%). Of these 2 patients,1 responded well to elevation of the extremity and 1 healed satis-factorily after application of medical leech therapy. Medical leechtherapy was applied 3 times a day for the first 3 days. The following 2days it was applied twice a day. We did not have to use any medica-tion. We kept the extremity in such a position that the flap did notstay under pressure. In this way, the venous congestion was furtherprevented.

Discussion

A distally based fasciocutaneous flap harvested in the sural regionwas first described by Donski and Fogdestam (12) in 1983. After beingpopularized by Masquelet et al (13), this flap has often been used asa donor site to cover the defects of the distal portion of the leg, as wellas of the ankle and hindfoot. The obvious advantages to this flapinclude preservation of the major arteries of the leg, constant flapperfusion, a relatively short operative time, no need for microvascularanastamosis, and, historically, a relatively low rate of complications. Anumber of reports have described good results using the sural arteryflap, with rates of flap necrosis (partial and total) ranging from 0% to17% (7–10). Because of these satisfactory outcomes, the distally basedsural flap has been recognized as safe and effective (14, 15). A recentreview of a series of 70 sural flaps in a population of patients olderthan 40 years of age, with a number of associated comorbidities and

Table 1Statistical description of case series (N ¼ 10 procedures in 10 patients)

Pt. No. Age (y) Sex Comorbidity Defect Etiology Defect Location

1 34 Male None Burn Ankle2 10 Female None Osteomyelitis Lateral malleolu3 63 Female Age >40 y, diabetic Diabetic ulcer Heel4 54 Male Age >40 y Trauma Ankle5 30 Female None Trauma Medial malleolu6 72 Male Age >40 y, diabetic Diabetic ulcer Heel7 48 Male PAD Trauma Dorsal foot8 19 Male None Burn Distal leg9 65 Male Age >40 y, smoker Trauma Heel

10 25 Female Smoker Trauma Medial malleolu

Abbreviation: PAD, peripheral arterial disease.* Length by width.

risk factors such as peripheral arterial disease, venous insufficiency,and diabetes mellitus, showed the partial or complete flap necrosisrate to be 36%. In an effort to minimize flap necrosis, implementationof the delay procedure has been recommended in conjunction withthe sural artery pedicle flap (11). This combination has been shown tobe useful even in patients at high risk of wound healing complications(16–18). It is also interesting to note that Tan et al (19) reported theabsence of flap congestion and necrosis by anastomosing the flap toa superficial leg or foot vein.

The use of a delay procedure is also known to minimize the risk ofpartial or total flap necrosis after transposition. Aky€urek et al (20)described the use of a 2-week surgical delay after designing thesural artery and nerve island flap and recommended its use to mini-mize the risk of failure. The improved viability of flaps attributed tothe delay phenomenon has been studied extensively in experimentaltransverse rectus abdominis muscle flap models (21–23). Experiencehas led to the general understanding that flap delay is a useful tool toimprove the random pattern perfusion within the flap, which resultsin permanent and irreversible dilation of the existing vessels ofthe flap by induction of hyperplasia and hypertrophy in the cells of the“choke” artery wall. This results in increased perfusion in even themost distal parts of the flap (24).

Although the specific delay procedure for the reverse sural flap isunusual, the options for delay include the use of small skin incisionsand ligature of the vasculature to complete the skin incision and flapelevation (16–18). The use of tissue expanders has also been describedfor use in conjunction with the reverse sural flap (25). The delayprocedure performed with tissue expansion enables the surgeon toincrease the size, primarily of the turning surface of the flap. In ourseries, tissue expansion enabled us to primarily close the turningsurface of all 10 of the flaps, which we believe was particularlyimportant in young and female patients. To ease primary closure ofthe turning surface of the flap, the use of a purse-string suture (10,26)T-shape skin paddle preparation have been recommended (15). Weused these methods in our series of 10 patients. Despite the use ofthese techniques, it can be difficult to primarily close the donor sitewound of a large flap, and secondary coverage of the donor site oftenrequires use of a split-thickness skin graft (25). Because necrosis ofa sural flap can result in below-the-knee amputation, skin graftcoverage of the donor site could complicate subsequent transtibialamputation, should it become necessary.

Delay procedures have the disadvantage of an additional operationand extend the hospital stay. In some clinical situations, a 2-stage (ormore) surgical approach is warranted. These include excision ofmalignant tumors to await histologic examination with tissuemargins free of tumor, debridement of severely traumatized andinfected wounds, and debridement of bone after manifestation ofosteomyelitis. In these cases, a flap delay procedure is a veryreasonable option that increases the likelihood of success with large

Defect Size* (cm) Flap Transport Donor Site Closure Complication

5 � 5 Tunnel Primary Nones 4 � 5 Tunnel Primary Venous congestion

5 � 6 Skin incision Primary None7 � 8 Tunnel Primary Venous congestion

s 6 � 6.5 Tunnel Primary none15 � 11 Skin incision Primary Partial flap necrosis7 � 7 Skin incision Primary None5 � 5.5 Tunnel Primary None

6.5 � 7.4 Skin incision Primary Nones 4.5 � 5 Tunnel Primary None

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sural flaps (16). During the delay procedure, negative pressure woundtherapy can be used to improve adherence and minimize surfaceexudate before definitive closurewith the delayed reverse sural arteryflap.

Tunneling of the flap pedicle, although cosmetically helpful,threatens the vitality of the flap. Also, kinking or compression of theflap pedicle predisposes the flap to venous congestion. To overcomethis problem, the use of a 1- to 2-cm teardrop-shaped excision of skinwithin the flap has been recommended (10), although we did not usethis technique in any of the present 10 patients. Venous congestionwas noted in the flap in 2 of our patients.

In conclusion, expansion and delay of the reverse sural artery flap,transferred from the donor to recipient site using tunneling, has, inour experience, been useful and safe, although 1 patient (10%) expe-rienced partial flap necrosis and 2 (20%) experienced venouscongestion that responded to supportive therapy. Also, although it isa 2-stage procedure that requires wound inspection and dressingduring the expansion period, we strongly recommend its use, espe-cially in young females with defects too large to be primarily closed orin patients older than 40 years of agewith risk factors such as diabetesmellitus, peripheral arterial disease, venous insufficiency, and ciga-rette smoking. To better understand just how this particular flapcompares with other methods of wound coverage in the distal leg,ankle, and hindfoot, a prospective cohort study or randomizedcontrolled trial is needed.

References

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22. Cederna PS, Chang P, Pittet-Cuenod BM, Razaboni RM, Cram AE. The effect of thedelay phenomenon on the vascularity of rabbit rectus abdominis muscles. PlastReconstr Surg 99:194–205, 1997.

23. Restifo RJ, Ahmed SS, Isenberg JS, Thomson J. Timing, magnitude, and utility ofsurgical delay in the TRAM flap: I. Animal studies. Plast Reconstr Surg 99:1211–1223, 1997.

24. Dhar SC, Taylor GI. The delay phenomenon: the story unfolds. Plast Reconstr Surg104:2079–2091, 1999.

25. Afifi AM, Mahboub TA, Losee JE, Smith DM, Khalil HH. The reverse sural flap:modifications to improve efficacy in foot and ankle reconstruction. Ann Plast Surg61:430–436, 2008.

26. Almeida MF, da Costa PR, Okawa RY. Reverse-flow island sural flap. Plast ReconstrSurg 109:583–591, 2002.