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J Reconstr Microsurg 2021; 37(07): 580-588
DOI: 10.1055/s-0041-1723817
Original Article

Distally Based Perforator-Plus Sural Neurocutaneous Flap with High or Low Pivot Point: Anatomical Considerations and a Retrospective Study of a Clinical Series of 378 Flaps

Ling-Li Zhou
1   Department of Orthopedics, the Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
,
Jian-Wei Wei
1   Department of Orthopedics, the Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
,
Ping Peng
1   Department of Orthopedics, the Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
,
Li-Hong Liu
1   Department of Orthopedics, the Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
,
Chao-Dong Yin
1   Department of Orthopedics, the Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
,
Zhao-Biao Luo
1   Department of Orthopedics, the Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
,
Shi-Bin Tao
1   Department of Orthopedics, the Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
,
Zhong-Gen Dong
1   Department of Orthopedics, the Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
› Author Affiliations Funding This work is supported by the National Natural Science Foundation of China (no.: 81672188) and Health and Family Planning Commission of Hunan Province (no.: B20180313).
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Abstract

Background This study is to describe the distribution of natural true anastomoses associated with the distally based perforator-plus sural neurocutaneous flap (sural flap), summarize our experience in the flap with high pivot point, and compare the outcomes between the flaps with high and low pivot points.

Methods Five amputated lower limbs were perfused, and the integuments were radiographed. We retrospectively analyzed 378 flaps, which were divided into two groups: pivot points located ≤8.0 cm (low pivot point group) and >8.0 cm (high pivot point group) proximal to the tip of the lateral malleolus. Partial necrosis rates were compared between two groups.

Results The arterial chain surrounding the sural nerve was linked by true anastomoses from the intermalleolar line to popliteal crease. True anastomoses existed among peroneal perforators and between these perforators and the arterial chain. There were 93 flaps with high pivot point and 285 flaps with low pivot point. Partial necrosis rates were 16 and 9.1% in the high and low pivot point group (p = 0.059), respectively.

Conclusion True anastomosis connections among peroneal perforators and the whole arterial chain around sural nerve enable the sural flap to survive with a greater length. The sural flap with high pivot point is a good option for reconstructing soft-tissue defects in the middle and distal leg, ankle, and foot, particularly when the lowest peroneal perforator presents damage, greater distance to the defects, discontinuity with the donor site, or anatomical variation.

Keywords

surgical flap - peroneal perforator - pivot point - perforator-plus neurocutaneous flap

Note

This article has been presented in the session FP 16, Lower Limb of the 10th Congress of World Society for Reconstructive Microsurgery (WSRM 2019), Bologna, Italy, June 12–15, 2019.




Publication History

Received: 16 July 2020

Accepted: 21 December 2020

Article published online:
16 February 2021

© 2021. Thieme. All rights reserved.

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  • References

  • 1 Crowe CS, Cho DY, Kneib CJ, Morrison SD, Friedrich JB, Keys KA. Strategies for reconstruction of the plantar surface of the foot: a systematic review of the literature. Plast Reconstr Surg 2019; 143 (04) 1223-1244
    CrossrefPubMedGoogle Scholar
  • 2 Tee R, Jeng S-F, Chen C-C, Shih H-S. The medial sural artery perforator pedicled propeller flap for coverage of middle-third leg defects. J Plast Reconstr Aesthet Surg 2019; 72 (12) 1971-1978
    CrossrefPubMedGoogle Scholar
  • 3 Wang M, Xu Y, Wang J. et al. Surgical management of plantar melanoma: A retrospective study in one center. J Foot Ankle Surg 2018; 57 (04) 689-693
    CrossrefPubMedGoogle Scholar
  • 4 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
    CrossrefPubMedGoogle Scholar
  • 5 Liu L, Zou L, Li Z, Zhang Q, Cao X, Cai J. The extended distally based sural neurocutaneous flap for foot and ankle reconstruction: a retrospective review of 10 years of experience. Ann Plast Surg 2014; 72 (06) 689-694
    CrossrefPubMedGoogle Scholar
  • 6 de Blacam C, Colakoglu S, Ogunleye AA. et al. Risk factors associated with complications in lower-extremity reconstruction with the distally based sural flap: a systematic review and pooled analysis. J Plast Reconstr Aesthet Surg 2014; 67 (05) 607-616
    CrossrefPubMedGoogle Scholar
  • 7 Wei JW, Ni JD, Dong ZG, Liu LH, Yang Y. A modified technique to improve reliability of distally based sural fasciocutaneous flap for reconstruction of soft tissue defects longitudinal in distal pretibial region or transverse in heel and ankle. J Foot Ankle Surg 2016; 55 (04) 753-758
    CrossrefPubMedGoogle Scholar
  • 8 Zheng L, Zheng J, Dong ZG. Reverse sural flap with an adipofascial extension for reconstruction of soft tissue defects with dead spaces in the heel and ankle. Eur J Trauma Emerg Surg 2016; 42 (04) 503-511
    CrossrefPubMedGoogle Scholar
  • 9 Lee HI, Ha SH, Yu SO, Park MJ, Chae SH, Lee GJ. Reverse sural artery island flap with skin extension along the pedicle. J Foot Ankle Surg 2016; 55 (03) 470-475
    CrossrefPubMedGoogle Scholar
  • 10 Asʼadi K, Salehi SH, Shoar S, Salehi SH, Shoar S. Early reconstruction of distal leg and foot in acute high-voltage electrical burn: does location of pedicle in the zone of injury affect the outcome of distally based sural flap?. Ann Plast Surg 2017; 78 (01) 41-45
    CrossrefPubMedGoogle Scholar
  • 11 Chi Z, Chen Y, Chu T. et al. Distally based sural neuro-fasciocutaneous perforator flap for foot and ankle reconstruction: Surgical modifications for flap pedicle and donor site closure without skin graft. J Plast Reconstr Aesthet Surg 2018; 71 (02) 224-231
    CrossrefPubMedGoogle Scholar
  • 12 Perumal R, Bhowmick K, Reka K, Livingston A, Boopalan PRJVC, Jepegnanam TS. Comparison of reverse sural artery flap healing for traumatic injuries above and below the ankle joint. J Foot Ankle Surg 2019; 58 (02) 306-311
    CrossrefPubMedGoogle Scholar
  • 13 Roberts HJ, DeSilva GL. Can sural fasciocutaneous flaps be effective in patients older than 65?. Clin Orthop Relat Res 2020; 478 (04) 734-738
    CrossrefPubMedGoogle Scholar
  • 14 Assi C, Samaha C, Chamoun Moussa M, Hayek T, Yammine K. A comparative study of the reverse sural fascio-cutaneous flap outcomes in the management of foot and ankle soft tissue defects in diabetic and trauma patients. Foot Ankle Spec 2019; 12 (05) 432-438
    CrossrefPubMedGoogle Scholar
  • 15 Daar DA, Abdou SA, David JA, Kirby DJ, Wilson SC, Saadeh PB. Revisiting the reverse sural artery flap in distal lower extremity reconstruction: a systematic review and risk analysis. Ann Plast Surg 2020; 84 (04) 463-470
    CrossrefPubMedGoogle Scholar
  • 16 Akhtar S, Hameed A. Versatility of the sural fasciocutaneous flap in the coverage of lower third leg and hind foot defects. J Plast Reconstr Aesthet Surg 2006; 59 (08) 839-845
    CrossrefPubMedGoogle Scholar
  • 17 Dong ZG, Wei JW, Ni JD. et al. Anterograde-retrograde method for harvest of distally based sural fasciocutaneous flap: report of results from 154 patients. Microsurgery 2012; 32 (08) 611-616
    CrossrefPubMedGoogle Scholar
  • 18 Mehrotra S. Perforator-plus flaps: a new concept in traditional flap design. Plast Reconstr Surg 2007; 119 (02) 590-598
    CrossrefPubMedGoogle Scholar
  • 19 Yang D, Morris SF. Reversed sural island flap supplied by the lower septocutaneous perforator of the peroneal artery. Ann Plast Surg 2002; 49 (04) 375-378
    CrossrefPubMedGoogle Scholar
  • 20 Follmar KE, Baccarani A, Baumeister SP, Levin LS, Erdmann D. The distally based sural flap. Plast Reconstr Surg 2007; 119 (06) 138e-148e
    CrossrefPubMedGoogle Scholar
  • 21 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 (04) 1240-1252
    CrossrefPubMedGoogle Scholar
  • 22 Punyavong P, Winaikosol K, Jenwitheesuk K, Surakunprapha P, Chowchuen B. An anatomical study of vascular supply of the distally based sural artery flap: a cadaveric study. J Med Assoc Thai 2016; 99 (Suppl. 05) S182-S186
    PubMedGoogle Scholar
  • 23 Wei JW, Ni JD, Dong ZG, Liu LH, Luo ZB, Zheng L. Distally based perforator-plus sural fasciocutaneous flap for soft-tissue reconstruction of the distal lower leg, ankle, and foot: comparison between pediatric and adult patients. J Reconstr Microsurg 2014; 30 (04) 249-254
    Article in Thieme ConnectPubMedGoogle Scholar
  • 24 Wang C, Xiong Z, Xu J, Zhang L, Huang H, Li G. The distally based lateral sural neuro-lesser saphenous veno-fasciocutaneous flap: anatomical basis and clinical applications. J Orthop Traumatol 2014; 15 (03) 215-223
    CrossrefPubMedGoogle Scholar
  • 25 Mok WLJ, Por YC, Tan BK. Distally based sural artery adipofascial flap based on a single sural nerve branch: anatomy and clinical applications. Arch Plast Surg 2014; 41 (06) 709-715
    Article in Thieme ConnectPubMedGoogle Scholar
  • 26 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 (01) 104-120
    CrossrefPubMedGoogle Scholar
  • 27 Zhang F-H, Chang S-M, Lin S-Q. et al. Modified distally based sural neuro-veno-fasciocutaneous flap: anatomical study and clinical applications. Microsurgery 2005; 25 (07) 543-550
    CrossrefPubMedGoogle Scholar
  • 28 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
    CrossrefPubMedGoogle Scholar
  • 29 Tang M, Mao Y, Almutairi K, Morris SF. Three-dimensional analysis of perforators of the posterior leg. Plast Reconstr Surg 2009; 123 (06) 1729-1738
    CrossrefPubMedGoogle Scholar
  • 30 Sur YJ, Morsy M, Mohan AT. et al. Three-dimensional computed tomographic angiography study of the interperforator flow of the lower leg. Plast Reconstr Surg 2016; 137 (05) 1615-1628
    CrossrefPubMedGoogle Scholar
  • 31 Taylor GI, Corlett RJ, Dhar SC, Ashton MW. The anatomical (angiosome) and clinical territories of cutaneous perforating arteries: development of the concept and designing safe flaps. Plast Reconstr Surg 2011; 127 (04) 1447-1459
    CrossrefPubMedGoogle Scholar
  • 32 Taylor GI, Chubb DP, Ashton MW. True and ‘choke’ anastomoses between perforator angiosomes: part i. anatomical location. Plast Reconstr Surg 2013; 132 (06) 1447-1456
    CrossrefPubMedGoogle Scholar
  • 33 Gascoigne AC, Ian Taylor G, Corlett RJ, Briggs C, Ashton MW. The relationship of superficial cutaneous nerves and interperforator connections in the leg: a cadaveric anatomical study. Plast Reconstr Surg 2017; 139 (04) 994e-1002e
    CrossrefPubMedGoogle Scholar
  • 34 Zou T, Gong Y, Lin A. et al. Modified barium sulfate-latex injection technique for angiography. Chin J Clin Anat 2010; 28 (01) 104-106
    PubMedGoogle Scholar
  • 35 Wei JW, Dong ZG, Ni JD. et al. Influence of flap factors on partial necrosis of reverse sural artery flap: a study of 179 consecutive flaps. J Trauma Acute Care Surg 2012; 72 (03) 744-750
    CrossrefPubMedGoogle Scholar
  • 36 Saint-Cyr M, Wong C, Schaverien M, Mojallal A, Rohrich RJ. The perforasome theory: vascular anatomy and clinical implications. Plast Reconstr Surg 2009; 124 (05) 1529-1544
    CrossrefPubMedGoogle Scholar
  • 37 Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J Plast Surg 1987; 40 (02) 113-141
    CrossrefPubMedGoogle Scholar
  • 38 Taylor GI, Palmer JH. ‘Angiosome theory’. Br J Plast Surg 1992; 45 (04) 327-328
    CrossrefPubMedGoogle Scholar
  • 39 Li Y, Xu J, Zhang XZ. Lowering the pivot point of sural neurofasciocutaneous flaps to reconstruct deep electrical burn wounds in the distal foot. Burns 2013; 39 (04) 808-813
    CrossrefPubMedGoogle Scholar
  • 40 Persaud S, Chesser A, Pereira R, Ross A. Sural flap use for the treatment of wounds with underlying osteomyelitis: graft size a predictor in outcome, a systematic review. Foot Ankle Spec 2017; 10 (06) 560-566
    CrossrefPubMedGoogle Scholar
  • 41 Kozusko SD, Liu X, Riccio CA. et al. Selecting a free flap for soft tissue coverage in lower extremity reconstruction. Injury 2019; 50 (Suppl. 05) S32-S39
    CrossrefPubMedGoogle Scholar
  • 42 He J, Qing L, Wu P. et al. Individualized design of double skin paddle anterolateral thigh perforator flaps to repair complex soft tissue defects of the extremities: an anatomical study and retrospective cohort study. J Plast Reconstr Aesthet Surg 2020; S1748-6815 (20)30505-2
    PubMedGoogle Scholar
  • 43 Jandali Z, Lam MC, Merwart B. et al. Predictors of clinical outcome after reconstruction of complex soft tissue defects involving the Achilles tendon with the composite anterolateral thigh flap with vascularized fascia lata. J Reconstr Microsurg 2018; 34 (08) 632-641
    Article in Thieme ConnectPubMedGoogle Scholar
  • 44 Herlin C, Bekara F, Bertheuil N. et al. Venous supercharging reduces complications and improves outcomes of distally based sural Flaps. J Reconstr Microsurg 2017; 33 (05) 343-351
    Article in Thieme ConnectPubMedGoogle Scholar
  • 45 Xu H, Cao X, Kiu-Huen S. et al. A retrospective study of an updated and traditional surgical approach of the distally based sural flap. J Reconstr Microsurg 2021; 37 (03) 227-233
    Article in Thieme ConnectPubMedGoogle Scholar