INTRODUCTION
Reconstruction of the foot and ankle defects
represents a great challenge for the plastic surgeons.
This region characterized by lack of tissue availability
and relatively poor skin circulation and
frequent exposure to trauma. Different methods
for coverage involve: Skin grafts, local flaps, distant
flaps but their application is limited because of
their complications. Free flaps are considered the
standard for this region but they need microsurgical
experience and longtime procedure, [1].
However, fasciocutaneous flaps; first reported
by Ponten in 1981; are excellent option in the
repair of these soft-tissue defects, [2]. The distally
based sural fasciocutaneous flap was; first introduced
by Donski and Fogdestam in 1983; one of
the earliest fasciocutaneous flaps used. They described
the anatomy, offered a comprehensive
description of the surgical procedure and their
experience with the flap in three clinical cases, [3].
After this report the sural flap remained largely
unmentioned in the literature with only one publication
on its anatomical aspects between 1983 and
1992, [4].
Masquelet, et al., reintroduced again the sural
flap in 1992 with a complete condensed illustration
of the related anatomy and the surgical procedure.
After the work of Masquelet, et al., the distally
based sural fasciocutaneous flap has become a
mainstay in the lower leg, heel and foot reconstruction
[5]. The main advantage of the sural flap over
other flaps of the lower leg is that it does not utilize
any of the three major arteries to the distal extremity.
The greatest morbidity of the flap is division
of the sural nerve, which is usually very well
tolerated. The flap is valid in young healthy patients
[5].
However, in older patients; especially those
with medical comorbidities such as diabetes, neuropathy
or peripheral vascular disease; the flap is
less predictable. Venous congestion rather than
arterial ischemia tends to be a greater problem
with this flap especially if designed as an island
flap. In these patients, surgical delay procedure or
venous supercharging through microvascular venous
anastomosis may be considered [6].
In this study, two methods to overcome the
venous congestion in the distally based sural flap
were applied by supercharging the lesser saphenous
vein through venous anastomosis to a superficial
vein in the foot or by venous cannulation of the
proximal stump of the lesser saphenous vein.
PATIENTS AND METHODS
Demographic data:
A comparative study was performed on diabetic
patients with defects on the distal third leg and
foot at Plastic Surgery Department, Qena University
Hospital, from May 2017 to April 2019 (two years
duration). Twenty patients enrolled into the study
and were divided into two groups; Group (A):
Defects had reconstructed with super drainage
reversed sural flap technique (10 cases) and Group
(B): Defects had reconstructed with standard reversed
sural flap technique (10 cases).
Both sexes were reported: 14 (70%) males and
6 (30%) females; all from our outpatient clinic.
Ages ranged from 25-65 years old (mean 45 years).
Main etiological factor was diabetes with additional
factor like neuropathy in 11 cases and ischemia in
9 cases. Different sites of defect had encountered:
The heel in 15 cases (75%), the ankle in 3 cases
(15%) and the distal third leg in 2 cases (10%).
All patients with intact superficial and deep
venous system were included in the study. Patients
with chronic venous insufficiency and where the
zone of injury extends to the area of peroneal
138 Vol. 44, No. 1 / Superdrainage Reverse-Flow Sural Flap for Distal Leg & Foot Reconstruction
perforators were excluded from the study. Doppler
ultrasound and venography had done before selection
of the cases to insure the patency of peroneal
perforators and the venous system respectively.
Blood sugar level monitoring was mandatory before
surgery, and so controlled diabetic patients were
eligible for operation.
Every patient had data sheet with the following
parameters: Age, sex, etiology of the defect, site
and size of the defect, flap technique, and flap
dimensions, donor site closure and complications.
Informed consent was obtained from all patients.
The study was approved by the ethical committee
in our faculty for research in human studies.
Pre-operative preparation:
Procedures had performed under spinal anesthesia
with all patients in the prone position. A handheld
Doppler was used before flap marking to
predetermine the perforators of the peroneal artery.
Perioperative I.V. antibiotics (3rd generation Cephalosporins)
were injected. For easily dissection,
application of pneumatic tourniquet after exsanguination
and the use of (3.5X) loupe magnifications
were used.
Marking the flap:
As in the standard reversed sural flap technique,
firstly; the defect was debrided. Average size of
the defects ranged from (2 X 2.5cm) to (5 X 6cm).
Then; the flap was marked with a line drawn from
a point midway between the Achilles tendon and
the lateral malleolus to the midline between two
heads of the gastrocnemius muscle. This marks
the pathway of sural nerve and short saphenous
vein. After that; the larger peroneal perforator
detected by handheld Doppler was marked, which
is often located approximately 5cm superior to the
tip of the lateral malleolus.
Surgical technique:
A template of the defect was drawn and the
flap outlined and centered over line that marked
the sural nerve. Average size of flaps drawn ranged
from (5 X 6cm) to (10 X 14cm) with mean (7.5 X
10cm). Firstly, the proximal border of the flap is
incised. Then, the sural nerve and lesser saphenous
vein were identified at the mid-calf supra-fascially.
In the superdrainage technique, the sural nerve,
superficial median sural artery and lesser saphenous
vein were divided and ligated, with preservation
of long proximal vein stump which included within
the flap. The dissection was then resumed distally
in the subfascial plane. All musculocutaneous
perforators emerged from the gastrocnemius muscle
were recognized and cauterized. Distally; a narrow
Egypt, J. Plast. Reconstr. Surg., January 2020 139
longitudinal band of the fascia and subcutaneous
fascial pedicle, which involved the sural nerve and
lesser saphenous vein, elevated with a width of
4cm to protect the pedicle.
Laterally, the dissection was up to medial border
of the fibula and medially to the lateral border of
the Achilles tendon. The dissection discontinued
at the pivot point which is 5cm proximal to the
lateral malleolus where perforators from the peroneal
artery connect with the vascular plexus. Division
of the skin island between the donor site and
the defect had done to avoid the risk of compression
of the pedicle (no subcutaneous tunnel). After the
flap was inset into the defect, the tourniquet was
deflated and hemostasis had achieved.
In the superdrainage technique, end-to-end
anastomosis for supercharging had performed between
the free end of long stump of the lesser
saphenous vein and a superficial leg or foot vein
as a recipient vein; that found close to the defect;
under (3.5X) loupe magnification in six cases using
9/0 nylon sutures. Venous cannulation was carried
out in four cases with 20 or 24 gauge cannula
according to the caliber of the vein. Intermittent
drainage of the vein was done hourly in the first
six hours (golden hours), every two hours in the
next 18 hours at the first day and then every 4
hourly at the next 3 days.
The pedicle and the donor site were covered
with a split thickness skin graft. A well-padded
dressing had applied making sure that there is no
compression on the pedicle with a window left
exposed for observation, (Tables 1,2) shows the
data of the two groups of the patients.
Table (1): Group (A): Patients with superdrainage reverse flow sural flap technique.
Age
(yrs.)
42
25
62
39
45
28
40
60
53
36
1
2
3
4
5
6
7
8
9
10
No.
M
M
F
M
F
M
M
M
F
M
Sex
Diabetes + neuropathy
Diabetes + ischemia
Diabetes + neuropathy
Diabetes + neuropathy
Diabetes + ischemia
Diabetes + neuropathy
Diabetes + neuropathy
Diabetes + ischemia
Diabetes + neuropathy
Diabetes + ischemia
Etiology
Supercharged with superficial vein in foot
Venous Cannulation with 20 gauge cannula
Supercharged with superficial vein in foot
Venous Cannulation with 24 gauge cannula
Supercharged with superficial vein in foot
Venous Cannulation with 20 gauge cannula
Supercharged with superficial vein in foot
Venous Cannulation with 24 gauge cannula
Supercharged with superficial vein in foot
Supercharged with superficial vein in foot
Site and size Technique of flab
of defect
Right heel
3 X 4cm
Left heel
2 X 2.5cm
Right heel
2.5 X 3cm
Left ankle
4 X 5cm
Left heel
5 X 6cm
Right heel
3 X 4cm
Right ankle
4 X 5cm
Left heel
3 X 4cm
Right heel
2.5 X 4cm
Distal left leg
5.5 X 4.5cm
Flab size
5 X 6cm
3 X 4cm
3 X 4cm
5 X 5cm
6 X 7cm
5 X 6cm
3 X 4cm
5 X 5cm
6 X 7cm
5 X 6cm
Follow-up
(month)
7
8
6
12
10
7
11
14
18
15
Table (2): Group (B): Patients with standard reverse flow sural flap technique.
Age
(yrs.)
35
48
42
50
47
56
29
34
65
45
1
2
3
4
5
6
7
8
9
10
No.
F
M
M
M
F
M
M
F
M
M
Sex
Diabetes + neuropathy
Diabetes + ischemia
Diabetes + neuropathy
Diabetes + neuropathy
Diabetes + ischemia
Diabetes + ischemia
Diabetes + neuropathy
Diabetes + ischemia
Diabetes + ischemia
Diabetes + neuropathy
Etiology Site and size of defect
Left heel 3 X 4cm
Right heel 2.5 X 4cm
Left heel 3 X 4cm
Left heel 2 X 2.5cm
Right heel 2.5 X 3cm
Left heel 5 X 6cm
Distal right leg 5 X 6cm
Right ankle 4 X 5cm
Left heel 3 X 4cm
Left heel 2 X 4cm
Technique
of flab
Standard
Standard
Standard
Standard
Standard
Standard
Standard
Standard
Standard
Standard
Follow-up
(month)
11
15
9
12
14
12
8
9
11
10
Flab size
5 X 6cm
5 X 5cm
6 X 7cm
5 X 6cm
6 X 7cm
5 X 6cm
3 X 4cm
4 X 5cm
5 X 5cm
6 X 7cm
Follow-up:
A leg elevation is maintained at 45º to enhance
the venous return. The dressing is changed on 3th
post-operative day. All patients were followed-up
for a period from 6 to 18 months (mean=12
months). The flaps usually healed eventually by
3rd week, but full weight bearing on them postponed
up to 6th week and all patients were satisfied with
the good functional and aesthetic outcomes.
Statistical analysis:
Data was analyzed using the Statistical Package
for Social Sciences (SPSS) version 20. A p-value
<0.005 was considered significant.
RESULTS
In Group (A) patients with super drainage
technique: In the second day postoperatively, two
cases (20%) had venous congestion (cases no. 5
and no. 8). This congestion was not relived by
local subcutaneous injection of heparin and ended
with partial flap necrosis at the fifth day, then one
of the two flaps (no. 8) had complete flap necrosis
and flap loss (another flap reconstruction was
done). This case also showed wound dehiscence,
and graft loss at the pedicle and the donor site
areas. All other flaps showed complete healing
without complications.
In Group (B) patients with standard technique:
Venous congestion occurred in seven cases (70%)
which ended in partial flap necrosis in four cases
(40%) cases (no. 2, 3, 6 and 8) and complete flap
necrosis in three cases (30%) cases (no. 1, 5 and
9). Also, wound dehiscence was reported in the
three cases with complete flap loss that underwent
140 Vol. 44, No. 1 / Superdrainage Reverse-Flow Sural Flap for Distal Leg & Foot Reconstruction
secondary surgery for re-stitching. Skin regrafting
was performed in 2 (20%) cases at the pedicle and
the donor site area.
Comparison between these groups was statistically
significance for the above mentioned differences
(p<0.005), Figs. (1,2), and (Table 3) shows
the rate of complication between both techniques.
Table (3): Rate of complication between superdrainage and
standard technique.
1- No complications:
Count
%
2- Venous congestion:
Count
%
3- Partial flap necrosis:
Count
%
4- Complete flap necrosis:
Count
%
5- Wound dehiscence:
Count
%
6- Donor site morbidity:
Count
%
7- Pedicle morbidity:
Count
%
Complications pvalue
2 0.005s
20.0%
2
20.0%
2
20.0%
1
10.0%
1
10.0%
1
10.0%
1
10.0%
Group A Group B
0
.0%
7
70%
4
40%
3
30%
3
30%
2
20%
2
20%
Group
15% 20%
15%
20%
20%
30%
45%
No complications
Venous congestion
Partial flab necrosis
Complete falp necrosis
Wound dehiscence
Donor site morbidity
Pedicle morbidity
Fig. (1): Percentage of complications in both techniques.
7
6
5
4
3
2
1
0
No
complications
Donor site
morbidity
Complete
falp necrosis
Venous
congestion
Partial
flab necrosis
Wound
dehiscence
Pedicle
morbidity
Group A Group B
Fig. (2): Rate of complications in both techniques.
Egypt, J. Plast. Reconstr. Surg., January 2020 141
Case presentations:
Case 1: (Patient no. 1): A 42-years-old man
with chronic ulcer right heel. Supercharged sural
flap with superficial vein in the foot was done.
There were no complications; the patient began
walking with silicon heel after 8 weeks with no
complications, Fig. (3).
Case 2: (Patient no. 6): A 28-years-old male
had chronic trophic ulcer at right heel. Sural flap
with lesser saphenous cannulation was done. Normal
flap monitoring signs during follow-up and
flap healed within 4 weeks. There were no complications
and patient began walking with silicon heel
after 7 weeks with no complications, Fig. (4).
Fig. (3): (A) Pre-operative marking of the flap. (B) Shows the free proximal end of short saphenous vein and
superficial vein. (C) Shows the anastomosis between the two veins. (D) Post-operative of the flap
after 3 months.
Fig. (4): (A) Pre-operative marking of the flap. (B) Shows the long proximal stump of short saphenous vein.
(C) Cannulation of the vein (D) Post-operative after 3 months.
(A) (B)
(C) (D)
(A) (B)
(C) (D)
DISCUSSION
The distally based sural artery fasciocutaneous
flap has become a workhorse in the soft tissue
reconstruction of difficult defects in the lower leg,
ankle, and foot. Its success in appropriately selected
patients is well documented. However, complications
such as venous congestion, flap necrosis, and
other complications are still significant [7].
The largest published data to critically review
the flap complication rate found that an overall
complication rate of 59% (41 of 70 flaps) [8] age;
greater than 40 years; and significant medical
comorbidities were both significant risk factors
for complications. Specific medical comorbidities
that were found to be risk factors included diabetes,
peripheral arterial disease and venous insufficiency
[8].
Another more recent review by Parrett et al.,
[9] found an overall complication rate of 50% (29
out of 58 flaps). Risk factors for these complications
were the same: Older age, history of smoking,
obesity, diabetes, and peripheral arterial disease
[9].
Many modifications have been performed to
achieve the safe and reliable flaps from reconstructing
the distal leg. Baumeister et al., [8] proposed
the use of a sural flap ''delay'' procedure in an
effort to diminish the risk of flap failure. Dragu et
al., [10] performed a supercharged venous anastomosis
of the proximal end stump of the sural flap
vein (lesser saphenous) with a subcutaneous vein
found locally in the recipient site to reduce the risk
of venous congestion.
Yao et al., [11] included the distal part of the
peroneal artery and its cutaneous branches in the
sural flap to augment the supply of the flap. Al-
Qattan [12] harvested a midline ''cuff '' of gastrocnemius
muscle containing the buried sural pedicle
with the flap. This modification maintains a ''mesenteric''
connection between the sural pedicle and
the overlying fascia in the proximal part of the leg.
Ayyappan and Chadha [13] also named the vascular
plexus around the sural nerve, sural artery,
and lesser saphenous vein between the 2 heads of
the gastrocnemius muscle mesentery-like structure,
which were kept intact in their flaps. The large
reversed sural fasciocutaneous flaps with sites
extending beyond the proximal one third of the
leg were harvested successfully.
Other modifications included a wider-thanusual
pedicle, subcutaneous transposition with the
aid of soft tissue expander, the inclusion of subcu-
142 Vol. 44, No. 1 / Superdrainage Reverse-Flow Sural Flap for Distal Leg & Foot Reconstruction
taneous tissue in the pedicle, and exteriorizing the
pedicle [14].
In this study, a superdrainage technique for the
short saphenous vein had performed to overcome
venous congestion. This superdrainage was
achieved by two methods: The first one by supercharging
the proximal stump of the short saphenous
vein to a superficial vein in the foot with microvascular
anastomosis in six cases and the other
method through intermittent drainage of the proximal
stump of the vein by using venous cannulas
in four cases.
Although this study enrolled high risk patients;
with diabetes, neuropathy and ischemic vascular
disease, this superdrainage modification had been
helpful in these patients to guarantee against venous
congestion.
By supercharging the sural flap, the venous
load; having also normal reverse venous drainage
through the suprafascial venous network in the
pedicle; decreases and the venous drainage associated
with the angulation or compression of the
pedicle; that leading to lack of reverse venous
flow; is only maintained antegradely because the
lesser saphenous vein is less affected than the
suprafascial venous network. This also allowed
harvesting flaps of large sizes [15].
In this technique of supercharging, a superficial
vein in satisfactory size around the recipient site
was sufficient, and a major vein in the leg was not
sacrificed. Thus, the method may be applied in
cases with peripheral venous insufficiency in the
lower limb comfortably. Also, microsurgical experience
was not required for end-to end anastomoses.
So, this modification can be easily practiced and
taught.
This modification greatly improves the venous
return as it provides an alternative pathway for
venous drainage that blocked by venous valves.
The unique disadvantage of this modification was
an increase in procedure time of 30 minutes on
average. Sometimes, it may be difficult to find a
satisfactory recipient vein with sufficient caliber.
Another method to overcome venous congestion
in this study was venous cannulation of the proximal
stump of the lesser saphenous vein with large
pore cannula (20/24 gauges). This method had an
effective way for intermittent venous drainage of
the vein and prevented the occurrence of congestion.
Post-operative close follow-up was planned
for these cases to drain the vein through the cannula
every one hour in the first six golden hours then
Egypt, J. Plast. Reconstr. Surg., January 2020 143
every two hours in the next 18 hours at the first
day and then every 4 hourly at the next 3 days.
Rate of complication in cases superdrainage
technique was fewer than cases reconstructed with
standard flap technique, there were only two cases
that had slight venous congestion This congestion
was not relived by local subcutaneous injection of
heparin and ended with partial flap necrosis at the
fifth day, then one of the two flaps (no. 8) had
complete flap necrosis and flap loss (another flap
reconstruction was done). All other flaps showed
complete healing without complications. In contrary
to cases reconstructed with standard flap technique,
venous congestion occurred in seven cases which
ended in partial flap necrosis in four of them and
complete flap necrosis in three cases. Wound dehiscence
reported in three cases that underwent
secondary surgery for re-stitching and skin regrafting
was performed in two cases at the pedicle and
the donor site area.
Dragu et al., [10] recommended supercharging
a proximal end of lesser saphenous vein to a subcutaneous
vein around the defect if the venous
congestion of the flap was diagnosed during operation.
Tan et al., [15] attempted to increase the
venous outflow by performing an anastomosis
between the stump of the lesser saphenous vein at
the proximal end of the flap and a superficial vein
in the leg but claimed that such veins could not
always be identified.
Wong and Tan [16] proposed that harvesting the
reverse sural flap with an extra length of lesser
saphenous vein for supercharging or intermittent
drainage to overcome flap congestion could enhance
the flap success rate. Loonen et al., [17] also
advised that if venous congestion occurred during
operation or even postoperatively, anastomosing
the lesser saphenous vein to other subcutaneous
veins found locally in the defect site may increase
venous return.
Conclusion:
In this study venous super-drainage could dramatically
reduce the incidence of venous congestion
by augmenting the venous output, thereby increasing
flap reliability and allowing for larger flap
sizes with lower rates of complications related to
venous congestion.
View on SCiNiTO
