The distally based sural flap for lower leg reconstruction: Versatility in patients with associated morbidity

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Domenico Mileto, Stefano Cotrufo, Giuseppe Cuccia, Gabriele Delia, Giovanni Risitano, Michele R. Colonna, Francesco Stagno d’Alcontres

Ann. Ital. Chir., 2007; 78: 323-327

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INTRODUCTION: Coverage of soft tissue defects in the lower leg is often made by use of free flap, also because of the
improving of anaesthesiology techniques in the last decades. However, there are disadvantages in the use of free flaps like
the need for a remote donor site, increased operative time, use of a major vessel to the leg, and microsurgical skills.
Besides these, trauma in the lower limb are often cause of damage for a major vessels of the leg, so the use of free flaps
in these patients may be related to an higher incidence of complications; also associated pathologies, like diabetes and
vascular pathology, can increase the incidence of complications when a free flap is utilized. In all these cases local fascio-
cutaneous flaps, like the sural reverse flap, because of their easy and short time harvesting, can be a very good alternative
to free flaps. Superficial sural artery flap is a adipofasciocutaneous flap based on the vascular axis of the sural
nerve, which gets reverse blood flow through communication with the perforating branch of the peroneal artery, situated
in the region of lateral malleolar gutter.
PATIENTS AND METHODS: Between 2000 and 2005, 11 patients, mean age 68 (range 58-78 years), were treated at the
Plastic and Reconstructive Surgery Unit of Messina University, for soft tissue defects of lower limb and foot, using the
distally based sural artery flap. The defects were related to post-traumatic damage of soft tissue, diabetic and vascular
ulcers, osteomyelitis and oncological resection.
Mean follow-up time was 20 months (range 6-55 months). All patients were pre-operatively assessed for vascular patency
of peroneal axis and associated morbidity that could increase risk of flap necrosis. This included diabetes mellitus type
II, osteomyelitis and peripheral arterial diseases.
RESULTS: All flaps survived with the exception of one that sustained partial skin necrosis, in the ratio of 25% of the
skin island. All defects were covered with no major complications and none of the patients required a blood transfusion.
Moreover aesthetic results were good with satisfaction of all the patients.
CONCLUSION: In our cases we found the sural reverse flap to have a good reliability with low incidence of complication
and surgical outcomes. This flap is an excellent option for covering defects of minor deficiency of skin in the third
distally of lower limb, ankle and heel. It allows rapid, reliable coverage of defects extending as far distally as the forefoot.
Because of the sparing of major vessels, the short surgery time in harvesting the flap, and the good vascular pattern of
the flap, we retain the flap a first choose technique for reconstruction in lower leg, especially in politrauma and in
patients with associated pathology as vascular diseases or diabetes.

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