One of the major challenging problems, facing the reconstructive. A 47yearold man with a calcaneal defect from chronic osteomyelitis. The inthecrease inferior gluteal artery perforator flap from the buttock is now the authors primary alternative to the deep inferior epigastric perforator flap from the abdomen for breast reconstruction. Use of expanded reverse sural artery flap in lower. Distally based sural fasciocutaneous flap was used for coverage in all cases and its survival, successful coverage of the defect and donor site morbidity studied. In an attempt to find a more ideal alternative, we present our initial experience using the medial sural artery perforator msap flap in intraoral reconstruction. The reverse sural artery flap is utilized to reconstruct defects in the distal third of the lower leg, ankle, and heel. The reverse sural artery flap is an effective technique for closing these defects and saving the limb. The length of the pedicle is identical to the distance between the rotation point of the flap and the wound.
In the present report, we describe the use of the delayed sural artery flap, combined with tissue expansion, for coverage of distal leg, ankle, and hindfoot wounds, in a series of 10 patients. It allows rapid and reliable coverage of defects from the distal third of the lower leg to the. Reverse radial artery flap perforator anatomy and clinical. The reverse superficial sural artery flap revisited for complex. The distally based sural artery flap, first described as a distally based neurocutaneous flap by masquelet et al. Sural artery use popliteal artery, right use popliteal artery, left. An defect on the posterior ankle exposing the tendoachilles and a fractured calcaneum covered with a sural artery flap. Large when taken up to the thoracodorsal or subscapular system. A total of 71 patients were operated on with this technique, some of them with. Soleus used for wounds over middle third of tibia supplied by b ranches of the popliteal artery trunk, the posterior tibial artery medial, and the peroneal artery proximal.
Surgical anatomy of the medial sural artery perforator flap. Supraclavicular artery island flap for reconstructing defects in the head and neck region. Placement of reverse sural fasciocutaneous pedicle flap. This flap is a suitable choice for difficult gunshot wounds in distal of the leg and hindfoot when peroneal artery is patent. Reverse sural artery flap christopher finkemeier, md on. The rotation point is 5 cm above the lateral malleolus the limit for dissection of the pedicle. The reverse superficial sural artery flap revisited for. The defect, plot, execution and final result shown. Vy flap raised subfascially and advanced into defect. Two median sural artery perforators were identified and dissected on the lateral aspect of the flap. A distally based superficial sural artery flap was performed in each patient.
Attingerce,etalangiosomesofthefootandankleandclinical implications for limb salvage. It joins the sural nerve coursing between the two heads of the gastrocnemius and follows the lateral edge of the achilles tendon. The modified reverse sural artery flap lower extremity. We document the number, emerging diameter, length from origin, course, and location of all perforators of the radial artery in a series of 6 fresh human cadavers after whole body lead oxide and gelatin injection to confirm and. Video shows the technique for a reverse sural artery flap used to cover a full thickness skin loss over the calcaneal tuberosity from delay in treatment of a severely. Proximal extension of the distally based large sural flap 196 acta medica iranica, vol. This artery is found within a triangle limited anteriorly by the vastus lateralis muscle, posteriorly by the short head of the biceps femoris muscle. The reverse flow sural flap was used in the reconstruction of 18 defects. The venous network of the superficial sural vein, the short saphenous vein, and the associated veins of the peroneal artery provide the venous return for. The age and sex of each patient, cause, dimension of flap, transposition of pedicle through a tunnel or laid open and covered with a skin graft, postoperative results and. Medial gastroc flap used for medial and midline defects over proximal third of tibia pedicle supplied by medial sural artery. The versatile reverse flow sural artery neurocutaneous.
Sample video from surgical treatment of orthopedic trauma, 2nd edition by james p. This is usually done in selected cases, and is typically used for augmenting the volume or perfecting the contour of alreadyreconstructed breasts. Caveats for success complex open wounds of the distal third of the leg and ankle remain a reconstructive challenge. Surgical anatomy of the medial sural artery perforator flap wong et al. This is a thin, pliable flap with a lengthy reliable pedicle.
Supraclavicular artery island flap iowa head and neck. The medial sural artery muscle perforator flap would be called the msap flap using the canadian terminology 9, or the ms medial gastrocnemius muscle perforator flap if one prefers to include both the source vessel and the muscle intermediary as part of the nomenclature 10. Neurological deficit caused by division of nerve is minimal and tends to improve with time. Medial sural artery perforator free flap msap british.
The pedicled reverse radial forearm flap is a wellknown option for the treatment of a variety of soft tissue wounds including dorsal hand wounds. The reverse sural artery flap eliminates the need for long and technically demanding free tissue transfers, which have become the gold standard for significant tissue defects in the distal third of the leg and ankle. To overcome this, we have modified our operative technique, which has produced a more reliable flap. The reverse sural artery fasciocutaneous flap is a versatile soft tissue coverage procedure for traumatic soft tissue defects of the. One excellent option for reconstruction of these defects is the distally based neurofasciocutaneous sural flap. The flap vascularization is supplied by the skin perforator of the lateral superior genicular artery lsga, the right branch of the popliteal artery 11,14.
Delayed reverse sural flap for staged reconstruction of. The reverse flow sural flap has been featured as a relevant option for recons truction of. The flap was distally based, islanded and covered the area with vascularised. The skin paddle can be from 18 cm wide and up to 55 cm long can be harvested on a single perforator. Reverse sural artery flap for the reconstruction of. Reverse sural artery flap for reconstruction of blast injuries of the foot and ankle. Department of otorhinolaryngology, head and neck surgery.
Placement of reverse sural fasciocutaneous pedicle flap subscription required. Download as an information leaflet pdf medial sural artery perforator free flap msap a medial sural artery perforator free flap is also known as an msap flap. The flap consists of superficial and deep fascia, the sural. Reverse sural artery flap christopher finkemeier, md 4 years ago video shows the technique for a reverse sural artery flap used to cover a full thickness skin loss over the calcaneal tuberosity from delay in treatment of a severely displaced tongue type calcaneus fx. Softtissue defects of the foot and lower leg caused by traumatic injury, tumor ablation, or infection associated with osteomyelitis often require coverage by flaps. Comparison between peroneus brevis flap and reverse sural. Reverse sural flap can be an alternative method for free tissue transfer in reconstruction of the lower extremity defects. Experience with reverse sural flap to cover defects of the. Tong, a clinical professor and chairman of department of otorhinolaryngology, head and neck surgery, as well as the director of the institute of human communicative research at the chinese university of hong kong cuhk, is specialized in the fields of otology, neurotology and skull base surgery.
The flap inset into the defect after rotation with excellent coverage. Lateral flap of the thigh based upon the lateral superior. Island reverse sural artery flap 0001 surgery video. Anteromedial thigh flap femoral artery lies in subsartorial canal for its lower 23, and in this portion gives off muscular and fasciocutaneous branches perforators pass around both borders of sartorius to form a plexus at the level of the deep fascia with an axis along the border of sartorius range in size from 0. Icd10cmpcs codes version 201620172018, icd10 data search engine. Several publications in recent years have proven popularity of superficial sural artery flaps and lateral supramalleolar flaps for the coverage of defects of the foot and ankle. Figure 6 a a 22yearold male presented with a left foot degloving injury with exposure of the. The sural artery flap is contraindicated in patients with destruction of the vascular pedicle or the lowermost perforator of the peroneal artery see table 292. A sensate lateral sural artery muscle perforator flap. Nugent m, endersby s, kennedy m, burns a 2015 early experience with the medial sural artery perforator flap as an alternative to the radial forearm flap for reconstruction in the head and neck. The reverse flow sural artery flap is an important skin flap that can be used for reconstruction of tissue defects of the distal third of the leg, heel and proximal plantar region. The sural artery is intimately connected with the sural nerve and plays an important role in supplying the skin of the lower and middle.
An anatomical basis for the flap using a pedicle containing a cervical, nonperforating cutaneous branch of. A reverse superficial sural artery flap rssaf raised as an adipofascial flap was used for coverage of the wound. Thoracodorsal artery perforator tdap flap harvests upper back skin and fat to create the breasts. Partial flap loss was found in 2 patients 8%, marginal flap necrosis in 2 patients 8% and complete loss in 1 patient 4%. P erforator free flaps harvested from the abdomen or buttock have been shown to be. Adipofascial flap with wide pedicle in the late group. It yields a relatively long, thin and pliable skin flap and a good aesthetic result. The inthecrease inferior gluteal artery perforator flap. The reverse sural artery flap is a generally accepted means of soft tissue reconstruction for defects of the distal third of the legs. This flap is based on perforators of the peroneal artery system. Reverse sural artery flap for reconstruction of blast.
The flap was distally based, islanded and covered the area with vascularised tissue well. Medial sural artery perforator flap 4 months postoperatively. In addition, the flap chosen should be easy to execute quickly with minimal discomfort to the patient and should provide durable coverage for the defect. A compromised cosmetic donor site and increased flap necrosis rate in highrisk patient groups have made many surgeons reluctant to use the sural flap.
Main demerit of distal based sural artery flap is a scar on calf which can be reduced by making use of fascia flap wherever possible. The routine sacrifice of the sural nerve with its consequential temporary loss of sensation on the lateral aspect of the foot can be of concern to early rehabilitation of some patients. The distally based superficial sural artery flap for. The reverse flow island sural flap is presented as an alternative to flaps. This is a random type of flap, based on the reverse flow of the superficial sural artery. A outline of the flap and the calcaneal defect before debridement. The reverse flow sural artery neurocutaneous flap is being rotaed through an arc 180 degrees on its pedicle. This technique had not been mentioned in the literature before as far as we know. Lateral gastroc flap used for lateral defects over proximal third of tibia. Large soft tissue defects around the lower third of the leg, ankle and foot always have been challenging to reconstruct. Reverse flow sural flap al azhar assiut medical journal.
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