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Original Article

Lower Limb Reconstruction – Fasciocutaneous Sural Flap*

Reconstrução de membro inferior– retalho fasciocutâneo sural*

Antonio Lourenco Severo1,, Eduardo Felipe Mandarino Coppi1, Haiana Lopes Cavalheiro1, Alexandre Luiz Dal Bosco1, Danilo Barreto1, Marcelo Barreto Lemos1

DOI: 10.1016/j.rbo.2017.12.016


 

ABSTRACT:

OBJECTIVE The present study aims to evaluate the use of the reverse-flow sural fasciocutaneous flap to cover lesions in the distal third of the lower limb.
METHODS A total of 24 cases were analyzed, including 20 traumatic injuries, 3 sports injuries, and 1 case of tumor resection.
RESULTS Among the 24 evaluated medical records, 16 patients were male, and 8 were female. Their age ranged from 6 to 75 years old. Most of the patients evolved with total healing of the flap (n= 21). There was only one case of total necrosis of the flap in an insulin-dependent diabetic, high blood pressure patient, evolving to subsequent limb amputation. In two cases, there was partial necrosis and subsequent healing by secondary intention; one of these patients was a heavy smoker. Complications were associated with comorbidities and, unlike other studies, no correlation was observed with the learning curve. There was also no correlation with the site or size of the lesion to be covered.
CONCLUSION It is clinically relevant that the success rate of the reverse-flow sural fasciocutaneous flap technique was of 87.5%. This is a viable and effective alternative in the therapeutic arsenal for complex lower limb lesions.

Keywords:
surgical flaps; sural nerve/transplantation; fascia/transplantation; leg injuries.

RESUMO:

OBJETIVO Avaliar o uso do retalho fasciocutâneo sural de fluxo reverso na cobertura de lesões no terço distal dos membros inferiores.
MÉTODOS Foram analisados 24 casos, 20 de origem traumática, três por lesões esportivas e um por ressecção de lesão tumoral.
RESULTADOS Dos 24 prontuários avaliados, 16 eram homens e oito mulheres. A idade variou de seis a 75 anos. A maioria dos pacientes evoluiu com cicatrização total do retalho (21). Houve apenas um caso de necrose total do retalho em paciente diabético insulinodependente e hipertenso, evoluiu para posterior amputação do membro. Em dois casos, houve necrose parcial com posterior cicatrização por segunda intenção, um desses pacientes era tabagista pesado. As complicações foram associadas às comorbidades e, ao contrário do evidenciado por outros estudos, não houve correlação com a curva de aprendizado. Também não houve correlação com o local ou o tamanho da lesão a ser coberta.
Tem-se como relevância clinica que a técnica de retalho fasciocutâneo sural de fluxo reverso usada obteve 87,5% de sucesso, é uma opção viável e eficaz no arsenal terapêutico das lesões complexas dos membros inferiores.

Palavras-chave:
retalhos cirúrgicos; nervo sural/transplante; fáscia/transplante; traumatismos da perna.

FIGURES

Citation: Severo AL, Coppi EFM, Cavalheiro HL, Bosco ALD, Barreto Filho D, Lemos MB. Lower Limb Reconstruction – Fasciocutaneous Sural Flap*. 54(2):128. doi:10.1016/j.rbo.2017.12.016
Note: * Work developed at the Hospital São Vicente de Paulo, Passo Fundo, RS, Brazil.
Received: September 26 2017; Accepted: December 14 2017
 

INTRODUCTION

The coverage of the distal third of the leg is still a challenge for reconstructive surgery due to its limited distensibility and mobility, low blood supply, and lack of muscle tissue interposition between noble structures and the integument. These features make randomized grafts and flaps unsuitable for wounds in this region.1-3

The use of microsurgical flaps and pedicle flaps based on the cutaneous perforating arteries of the leg, specifically reverse flaps, leads to the best outcomes. However, some patients require a more complex surgical technique.4

The sural fasciocutaneous flap, popularly called distal sural flap, has become one of the most important tools in the therapeutic armamentarium of reconstructive surgery for lesions in the distal third of the leg, ankle and foot, especially after publications from Masquelet et al.1 It presents advantages, such as greater mobility and versatility, as well as the preservation of important arteries and muscles, in addition to mimicking the receiving area in texture, thickness, pigmentation, and flexibility. The possible complications are the same as other flaps: ischemia, with partial or total necrosis.2,5-7 As such, the present study aimed to evaluate the use of fasciocutaneous reverse-flow sural flap for distal lesions covering the lower limb.

 

MATERIALS AND METHODS

This is a cross-sectional retrospective study approved by the Research Ethics Committee (CEP) from the Universidade de Passo Fundo, RS, Brazil, under the number 1,854,277. The medical records of the patients submitted to lower limb reconstructive surgery were evaluated, and only subjects submitted to the reverse-flow sural flap technique from August 2001 to December 2016 were included.

The variables collected from the medical records were age, gender, lesion location, diagnosis, date of surgery, comorbidities, and complications.

The dimensions of the flaps ranged from 2 × 3 to 8 × 8 cm2, according to the size of the areas to be covered. The surgical technique used in all of the cases was based on the description by Masquelet et al:1,2

  • Spinal block
  • Patient in prone position: cleansing and debridement of the receiving area.
  • The flap is drawn at the junction of the gastrocnemius muscle heads. A line is drawn distally, following the assumed path of the pedicle to the rotational point of the flap, about 5 cm proximal to the extremity of the lateral malleolus.
  • Gravitational venous drainage and tourniquet at the level of the proximal thigh.
  • Surgical incision from the skin up to the sural fascia.
  • The sural nerve, the superficial sural artery, and the saphenous vein are connected proximally, so the flap is elevated and includes the fascia up to the rotational point. During flap elevation, the small arteries originating from the fibular artery must be ligated.
  • Rotation of the flap to the receiving area.
  • Flap suture in the receiving area.
  • The flap may be sensitized with an end-to-side neurorrhaphy of the sural cutaneous nerve to the tibial nerve, as described by Viterbo et al.8
  • The tourniquet is released, and the perfusion of the flap is assessed. If perfusion is weak, check for compression points and jamming of the pedicle.
  • The donor area can be closed primarily, but most of the time a partial skin graft, removed from the thigh area ipsilateral to the flap, is required.
  • The bandage must be carefully done to avoid compression in the pedicle area; in addition, the patient must be positioned as to not subject the posterolateral region of the leg to external pressure.
  • Postoperative period: foods that can cause vasoconstriction, such as coffee, guaraná, chocolate, chimarrão (South Brazilian traditional tea), stuffed wafer, tea, and other xanthine-rich foods (since they are vasoconstrictors) are avoided for at least 1 month. Smoking is discouraged. An anticoagulant agent (enoxaparin sodium, 40 mg/day) was used for 3 days. Then, treatment with acetylsalicylic acid, 325 mg/day, was introduced and sustained for 30 days. Antibiotic therapy (cefazolin) was maintained for 48 hours postoperatively or per the discretion of the physician.
 

RESULTS

From the 24 evaluated medical records, 16 (66.7%) patients were male and 8 (33.3%) were female. Their age ranged from

6 to 75 years old. The majority (83.3%) of the patients required a flap for cutaneous cover due to trauma sequelae (car accident); 3 cases (12.5%) were due to sports injuries (suture dehiscence in Achilles tendon reconstruction), and only 1 (4.2%) patient underwent a lower limb reconstruction after tumor resection.

Three patients presented associated comorbidities: diabetes mellitus (DM), smoking, and systemic arterial hypertension.

The most frequent sites of injury were the lateral malleolus (20.8%), the back of the foot, calcaneus (16.7%), and the Achilles tendon region (16.7%).

Most of the cases evolved with no complications (87.5%). Only 2 cases (8.3%) had partial necrosis with secondary intention healing, and 1 patient (4.2%) presented with total necrosis evolving to amputation.

The patient in ►Fig. 1, a 45-year-old woman who required a flap after tumor resection of a calcaneal melanoma, had a successful application of the present technique. The patient in ►Fig. 2, a 40-year-old man who required a sural fascio-cutaneous flap after trauma on the back of the foot had a favorable recovery with good healing. The variables age, gender, lesion location, diagnosis, date of surgery, and complications of each case are presented in ►Table 1.

Table 1. Variables obtained at medical records from patients submitted to the surgical technique of reverse-flow sural flap from August 2001 to December 2016
Case Age Gender Lesion location Diagnosis Surgery date Complication
1 70 M Medial malleolus Distal tibial fracture Oct/14 None
2 23 M Back foot Open fracture-dislocation of the ankle May/2014 None
3 37 M Distal third of the leg, anterior aspect Open distal tibial fracture Dec/2014 None
4 33 M Distal third of the leg, anterior aspect Open distal tibial fracture Jul/2013 None
5 46 M Lateral malleolus Open fracture of the ankle Mar/2012 None
6 18 M Distal third of the leg, anterior aspect + lateral malleolus Open fracture of the ankle Feb/2011 None
7 6 F Calcaneus Loss of calcaneal substance Jul/2010 None
8 39 M Back foot Open fracture-dislocation of the medial foot Oct/2009 None
9 8 F Lateral malleolus Ankle injury Oct/2009 None
10 7 F Calcaneus Open calcaneal fracture Oct/2009 Partial flap necrosis
11 46 M Medial malleolus Open medial malleolus fracture Apr/2009 None
12 60 M Achilles tendon Suture dehiscence Jan/2013 None
13 14 M Distal third of the leg, lateral aspect Leg injury May/2016 None
14 54 F Achilles tendon Suture dehiscence Dec/2004 None
15 63 M Distal third of the leg, anterior aspect Distal tibial fracture Nov/2004 None
16 22 M Calcaneus Calcaneal exposure Sept/2004 None
17 45 M Back foot Open lateral malleolus fracture Aug/2001 None
18 46 F Lateral malleolus Ankle fracture - suture dehiscence Mar/2006 None
19 64 F Lateral malleolus Lateral malleolus fracture Feb/2014 None
20a 45 F Calcaneus Calcaneal melanoma Dec/2016 None
21b 75 M Lateral malleolus Open ankle fracture Mar/2013 Total flap necrosis
22 46 F Achilles tendon Rupture-dehiscence Apr/2016 None
23c 40 M Back foot Crushing injury Feb/2007 None
24 55 M Achilles tendon Tibial and distal fibular fracture May/2015 Partial necrosis

Source: Hospital São Vicente de Paulo, Passo Fundo, RS, Brazil.

a ► Fig. 1: Calcaneal melanoma.

b ►Fig. 2: Bilateral open malleolar fracture evolving to total flap necrosis and subsequent amputation.

c ►Fig. 3: Back foot crushing trauma.

 

DISCUSSION

The main indications for reverse-flow sural fasciocutaneous flap are coverage of chronic skin ulcers, traumatic lesions (mainly secondary to open fractures), oncological resections, and lesions located at the posterior aspect of the heel and of

the Achilles tendon, the lateral and anterior aspect of the ankle, the back of the foot, the lateral aspect of the hindfoot, and the lower third of the leg. Other indications, such as full heel coverage and medial aspect of the distal third of the leg, are considered relative because of the small distance to the rotational point, which may affect the vascular pedicle at attempts to reach these regions, compromising the flap.1-3,6

Severo et al9 state that local pedicled flaps are preferred whenever there is enough vascular and tissue viability in the donor area for lesion filling.

The greater mobility and versatility of the reverse-flow sural flap, in addition to sparing important arteries, has shown increasing success rates and few complications. Studies performed > 10 years ago showed a higher rate of complications (< 35%), with a significant reduction during the last 10 years (< 12%).6,10-12 This fact was also reported by Vendramin et al,13 who found different complication rates after evaluating the outcomes from the same surgical team at different periods of the learning curve. These literature findings do not agree with the present study, whose success rate was of 87.5%, since complications did not have any relation with the learning curve, as this technique was introduced in this service in 2001 and the complications occurred in 2009, 2013 and 2015. Both partial necrosis cases represented about 10% of the flap area, and complete lesion closure occurred by secondary intention.

The patient who progressed to total necrosis and subsequent limb amputation (► Fig. 3) had type 2, insulin-dependent diabetes, and hypertension. We believe that his complications may have occurred due to comorbidities, consistent with Severo et al9 and Parrett et al,14 who found a correlation between complications and comorbidities, such as diabetes, obesity, peripheral vascular disease, and smoking. The latter, however, would be the main isolated risk factor for complications of this flap.

Almeida et al10 found 25.3% of necrosis in 71 cases (21.1% partial and 4.2% total necrosis). The following year, Baumeister et al15 analyzed 70 patients with clinical comorbidities, mainly diabetes, and the rates of partial and total necrosis were, respectively, 17% and 18%. In the study by Belém et al,6 with 22 patients, 22% had partial necrosis, and 4.1% presented with total necrosis. Next, Garcia et al5 reported partial necrosis in only 1 patient (6.6%) from a total of 15 flaps. Dhamangaonkar et al16 reported 81 cases, with partial necrosis in just 9 patients (11.1%). Outcomes from the last two studies are similar to our findings.

Most patients from the present study were male, as in several other papers on surgical reconstructions of the lower limbs.1,4,16-18 This fact can be explained by the traumatic nature of most lesions and the higher involvement of male individuals in these incidents.

 

CONCLUSION

It is clinically relevant that the option of reverse-flow sural fasciocutaneous flap technique to cover lesions in the distal third of the lower limbs was safe, easy to perform and did not require a complex microsurgical technique. Therefore, with satisfactory results and a low rate of complications, it is an important option for the therapeutic arsenal in the surgical reconstruction of the lower limbs.

 

REFERENCES

Masquelet AC, Romana MC, Wolf G. Skin island flaps supplied by the vascular axis of the sensitive superficial nerves: anatomic study and clinical experience in the leg. Plast Reconstr Surg 1992; 89(06):1115-1121 Link DOI
Masquelet AC. Sural flap. In: Grabb's encyclopedia of flaps. 3rd ed. Philadelphia: Taylor & Francis; 2009
Mandarano Filho LG, Bezuti MT, Penno RAL, Mazzer N, Barbieri CH. O retalho fasciocutâneo sural de base distal. Rev Ortop Traumatol (B Aires) 2010;2(01):12-18
De Rezende MR, Rabelo NT, Benabou JE, Wei TH, Mattar Junior R, Zumiotti AV, et al. Cobertura do terço distal da perna com retalhos de perfurantes pediculados. Acta Ortop Bras 2008;16(04):223-229 Link DOI
Garcia AM. Retalho sural de fluxo reverso para reconstrução distal da perna, tornozelo, calcanhar e do pé. Rev Bras Cir Plást 2009; 24(01):96-103
Belém LF, Lima JC, Ferreira FP, Ferreira EM, Penna FV, Alves MB. Retalho sural de fluxo reverso em ilha. Rev Bras Cir Plást 2007; 22(04):195-201
Schaverien M, Saint-Cyr M. Perforators of the lower leg: analysis of perforator locations and clinical application for pedicled perforator flaps. Plast Reconstr Surg 2008;122(01):161-170 Link DOI
Viterbo F, Trindade JC, Hoshino K, Mazzoni Neto A. End-to-side neurorrhaphy with removal of the epineurial sheath: an experimental study in rats. Plast Reconstr Surg 1994;94(07):1038-1047 Link DOI
Severo AL, Scorsatto C, Valente EB, Lech OL. Retalhos para reconstrução de perdas musculocutâneas em membros inferiores: análise de 18 casos. Rev Bras Ortop 2004;39(10):578-589
Almeida MF, da Costa PR, Okawa RY. Reverse-flow island sural Link DOI
Turan K, Tahta M, Bulut T, Akgün U, Sener M. Soft tissue reconstruction of foot and ankle defects with reverse sural fasciocutaneous flaps. Rev Bras Ortop 2017;53(03):319-322 Link DOI
Vendramin FS, Silva CS. Retalho sural estendido de pedículo distal. Rev Col Bras Cir 2004;31(04):248-252 Link DOI
Vendramin FS. Retalho sural de fluxo reverse: 10 anos de experiência clínica e modificac ões. Rev Bras Cir Plást 2012;27(02):309-315 Link DOI
Parrett BM, Pribaz JJ, Matros E, Przylecki W, Sampson CE, Orgill DP. Risk analysis for the reverse sural fasciocutaneous flap in distal leg reconstruction. Plast Reconstr Surg 2009;123(05):1499-1504 Link DOI
Baumeister SP, Spierer R, Erdmann D, Sweis R, Levin LS, Germann GK. A realistic complication analysis of 70 sural artery flaps in a multimorbid patient group. Plast Reconstr Surg 2003;112(01):129-140 Link DOI
Dhamangaonkar AC, Patankar HS. Reverse sural fasciocutaneous flap with a cutaneous pedicle to cover distal lower limb soft tissue defects: experience of 109 clinical cases. J Orthop Traumatol 2014;15(03):225-229 Link DOI
Yildirim S, Akan M, Aköz T. Soft-tissue reconstruction of the foot with distally based neurocutaneous flaps in diabetic patients. Ann Plast Surg 2002;48(03):258-264 Link DOI
D'Avila F, Franco D, D'Avila B, Arnaut M Jr. Use of local muscle flaps to cover leg bone exposures. Rev Col Bras Cir 2014; 41(06):434-439 Link DOI

* Trabalho desenvolvido no Hospital São Vicente de Paulo, Passo Fundo, RS, Brasil. Publicado originalmente por Elsevier Ltda.