Distally-Based Sural Flap

Nattakul Yamprasert, MD Department of Orthopaedics,

Maharat Nakhon Ratchasima Hospital

Regional Hand Meeting 2015 “The Diversity of the Hand and Upper Extremity Surgery”August 20th - 21st, 2015 At Ubon Ratchathani, THAILAND

Anatomy

• Vascular supply:

• Median superficial sural artery (along with medial sural nerve)

• Lesser saphenous vein and its arteries

• Pivot Point : about 5 cm proximal to lateral malleolus

Midpoint between posterior border of lateral malleolus

and Achilles tendon

Midpoint between 2 heads of Gastrocnemius muscle

Pivot point : 5 cm proximal to lateral malleolus

IndicationResurfacing of soft tissue defect in

• Middle third of leg

• Distal third of leg

• Anterior ankle

• Heel

• Dorsal foot

Preoperative Planning

• Posterolateral skin

• Flap size (Max. diameter 15 cm)

• Flap composition (including/excluding skin)

• One-stage/ two-stage (delayed) procedure

Patient Position

Prone

Lateral Position

Flap Composition

• Fasciocutaneous flap

• Fasciomusculocutaneous flap

• Adipofascial flap

• Adipofasciomuscular flap

Flap Dissection

Source : https://www.youtube.com/watch?v=eFwzbbYdAMQ

Pedicle Dissection

Source : https://www.youtube.com/watch?v=eFwzbbYdAMQ

Assessment of Vascularity

• Deflate tourniquet

• Observe bleeding from elevated flap

Subcutaneous Tunneling

Subcutaneous Tunneling

Subcutaneous Tunneling

Avoid Subcutaneous Tunneling?

• Not necessary unless there are certain risk factors such as HT, DM, peripheral vascular disease, and vasculitis.

F. Uygur et. al., Annals of Plastic Surgery, July 2009

Donor Site Closure• Primary wound closure

• Close by skin graft

Donor Site Closure

Flap Modification

• Venous supercharged flap

• Delayed flap procedure

• Megahigh flap

Postoperative Care

• Splint

• Dressing

• Flap monitoring

Complications

• Flap congestion

• Partial flap lost

• Total flap lost

• Infection

My Experience…

Case 1

65 years old man:Chronic ulcer on dorsum & anterior ankle

Scar excision

Flap elevation

Flap rotation

Flap inset

5 years postop.

D14 PO Y5 PO

Case 2

39 year-old woman:Skin necrosis after ORIF with screw at the calcaneus

X

D14 Y1 PO Y4 PO

Case 3

28 year-old woman :Open fracture-dislocation of left anklewith loss of anterior soft tissue

STSG Flap

D7 PO M3 PO

Y7 PO

Case 4

8 year-old boy :Posterior heel injury with skin loss

XPivot

Flap Primary Defect

Flap slightly larger than defect

Primary closure

D3 PO

Case 5

Intact posterolateral skin

Fascia sutured to skin as one unit during flap elevation

Flap elevation including cuff of muscle

Passing elevated flapthru subcutaneous tunnel

Case 6

Intact posterolateral skin

Patient positioning

Flap Elevation

Wide pedicle

Sural nerves and vessels including in elevated flap

Tunneling and flap inset

Donor site closing with meshed skin graft

D3 PO

Case 7

Soft tissue defect withpre-existing wound infection

Residual infection after flap coverage

M2 PO

D3 PO

Donor Site

Complication:Partial Flap Necrosis

D1 PO D2 PO D3 PO D4 PO

D5 PO D6 PO M1 PO After debridement

Take Home Messages• If possible, design the longer side of flap along

the vascular axis.

• Flap death began from superficial layer.

• When in doubt about pedicle compression, never hesitate to open the tunnel.

• Preexisting infection should be treated prior to flap procedure.