Neurotized Distally Based Sural Flap for Heel Reconstruction

Mauricio J. Mendieta; Carlos Roblero; Juan C. Vega

doi:10.1055/s-0033-1348034

Journal of Reconstructive Microsurgery, Table of Contents

J Reconstr Microsurg 2013; 29(08): 501-504
DOI: 10.1055/s-0033-1348034

Original Article

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Neurotized Distally Based Sural Flap for Heel Reconstruction

Authors

Mauricio J. Mendieta

¹Department of Plastic and Reconstructive Surgery, Hospital Militar Dr. Alejandro Dávila Bolaños, Managua, Nicaragua
Carlos Roblero

²Department of Plastic and Reconstructive Surgery, Hospital General Regional ‘‘Dr. Rafael Pascacion Gamboa,’' Chiapas, Mexico
Juan C. Vega

³Department of Plastic and Reconstructive Surgery ‘‘Dr. Fernando Ortiz Monasterio’', Hospital General de Mexico, Mexico City, Federal District, Mexico

Abstract

The use of local flaps for the reconstruction of leg has lost their popularity with the more often performed flaps on the basis of perforators and microsurgical technique. Like the head and neck reconstruction, in the lower extremity there are limited units of tissue to base the flaps because of the lack of vascularity and arc of mobilization. The distally based sural flap represents an ideal flap for the reconstruction of heel, and with the inclusion of the sural nerve, we can neurotize the flap to give the stability of a weight-bearing area and provide the necessary sensibility to avoid ulcerations of the reconstructed heel. We present a case of a 32-year-old woman with a traumatic loss of the tissue covering the heel, with a diagnosis of a pseudoepithelial hyperplasia treated in previous occasions with skin grafts that led to chronic ulcerations. A distally based sural flap was planned for a definitive coverage, planning a perineural neurorrhaphy, to the intermediate dorsal cutaneous branch of the superficial peroneal nerve to give sensibility to the flap.

Keywords

sural flap - neurocutaneous flap - heel reconstruction

Full Text

References

References
1 Saint-Cyr M, Schaverien MV, Rohrich RJ. Perforator flaps: history, controversies, physiology, anatomy, and use in reconstruction. Plast Reconstr Surg 2009; 123 (4) 132e-145e
2 Mojallal A, Wong C, Shipkov C , et al. Vascular supply of the distally based superficial sural artery flap: surgical safe zones based on component analysis using three-dimensional computed tomographic angiography. Plast Reconstr Surg 2010; 126 (4) 1240-1252
3 Price MF, Capizzi PJ, Watterson PA, Lettieri S. Reverse sural artery flap: caveats for success. Ann Plast Surg 2002; 48 (5) 496-504
4 Ayyappan T, Chadha A. Super sural neurofasciocutaneous flaps in acute traumatic heel reconstructions. Plast Reconstr Surg 2002; 109 (7) 2307-2313
5 Hollier L, Sharma S, Babigumira E, Klebuc M. Versatility of the sural fasciocutaneous flap in the coverage of lower extremity wounds. Plast Reconstr Surg 2002; 110 (7) 1673-1679
6 Almeida MF, da Costa PR, Okawa RY. Reverse-flow island sural flap. Plast Reconstr Surg 2002; 109 (2) 583-591
7 Follmar KE, Baccarani A, Baumeister SP, Levin LS, Erdmann D. The distally based sural flap. Plast Reconstr Surg 2007; 119 (6) 138e-148e
8 Taylor GI, Pan WR. Angiosomes of the leg: anatomic study and clinical implications. Plast Reconstr Surg 1998; 102 (3) 599-616 , discussion 617–618
9 Pontén B. The fasciocutaneous flap: its use in soft tissue defects of the lower leg. Br J Plast Surg 1981; 34 (2) 215-220
10 Donski PK, Fogdestam I. Distally based fasciocutaneous flap from the sural region. A preliminary report. Scand J Plast Reconstr Surg 1983; 17 (3) 191-196
11 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 (6) 1115-1121
12 Hasegawa M, Torii S, Katoh H, Esaki S. The distally based superficial sural artery flap. Plast Reconstr Surg 1994; 93 (5) 1012-1020
13 Cavadas PC, Bonanad E. Reverse-flow sural island flap in the varicose leg. (Letter) Plast Reconstr Surg 1996; 98 (5) 901-902
14 Townsend PLG. An inferiorly based soleus muscle flap. Br J Plast Surg 1978; 31 (3) 210-213
15 Landi A, Soragni O, Monteleone M. The extensor digitorum brevis muscle island flap for soft-tissue loss around the ankle. Plast Reconstr Surg 1985; 75 (6) 892-897
16 Sönmez A, Bayramiçli M, Sönmez B, Numanoğlu A. Reconstruction of the weight-bearing surface of the foot with nonneurosensory free flaps. Plast Reconstr Surg 2003; 111 (7) 2230-2236
17 Noever G, Brüser P, Köhler L. Reconstruction of heel and sole defects by free flaps. Plast Reconstr Surg 1986; 78 (3) 345-352
18 Stevenson TR, Mathes SJ. Management of foot injuries with free-muscle flaps. Plast Reconstr Surg 1986; 78 (5) 665-671
19 Nakajima H, Imanishi N, Fukuzumi S , et al. Accompanying arteries of the lesser saphenous vein and sural nerve: anatomic study and its clinical applications. Plast Reconstr Surg 1999; 103 (1) 104-120
20 Sladjana UZ, Ivan JD, Ljiljana VP, Natalija SJ, Predrag KT, Vesna SR. Neurovascular stalk of the superficial sural flap: human fetus anatomical study. Plast Reconstr Surg 2005; 116 (2) 546-550
21 Loonen MP, Kon M, Schuurman AH, Bleys RL. Venous bypass drainage of the small saphenous vein in the neurovascular pedicle of the sural flap: anatomical study and clinical implications. Plast Reconstr Surg 2007; 120 (7) 1898-1905
22 Shanahan RE, Gingrass RP. Medial plantar sensory flap for coverage of heel defects. Plast Reconstr Surg 1979; 64 (3) 295-298
23 Durham JW, Saltzman CL, Steyers CM, Miller BA. Outcome after free flap reconstruction of the heel. Foot Ankle Int 1994; 15 (5) 250-255
24 Kuran I, Turgut G, Bas L, Ozkan T, Bayri O, Gulgonen A. Comparison between sensitive and nonsensitive free flaps in reconstruction of the heel and plantar area. Plast Reconstr Surg 2000; 105 (2) 574-580
25 Santanelli F, Tenna S, Pace A, Scuderi N. Free flap reconstruction of the sole of the foot with or without sensory nerve coaptation. Plast Reconstr Surg 2002; 109 (7) 2314-2322 , discussion 2323–2324
26 Jeng SF, Wei FC. Distally based sural island flap for foot and ankle reconstruction. Plast Reconstr Surg 1997; 99 (3) 744-750