Extended single stage distally based sural flap for reconstruction of mid leg defects

Extended single stage distally based sural flap for reconstruction of mid leg defects

Mahfouz Shehata, MD,MRCS; Hany Mohamed, MD; Emnd Salah Ibrahim, MD

Plastic Surgery Unit, General Surgery Department, Zagazig University, Sharkia, Egypt.

Background: Reconstruction  of middle  third soft tissue  defects  of the legs  have  been a challenge to the plastic surgeons.

Patients and methods:  We report 20 cases in which the extended single stage distally based sural flap was used to reconstruct soft tissue defects at the middle third of the leg over 2 year period.

Result:  Complications occurred in 4 patients (20%). Two patients suffered surgical site infections and another two experienced  distal partial flap necrosis but all flaps survived. We can conclude that the flap is a good option for reconstruction of middle third leg defects of the leg. It has constant and reliable blood supply without sacrifice neither major vessel nor nerve.

Key words: Single stage, extended distally based sural flap, mid third leg defects, reconstruction.

Introduction:

Reconstruction   of  soft  tissue  defects  of the middle third of the leg has remained a persistent challenge to the reconstructive surgeons. This area is liable to bone exposure after  traumas   due  to   its  thin   skin,   less amount of local tissue and poor vascularity.! Many techniques are available for leg reconstruction but each technique has its inherent limitations and costs. Free flap is a good option  but  it has the  disadvantage  of being a sophisticated  and lengthy procedure, involving a high price, advanced  equipment and  a  microsurgical  team.2,3   Local  muscle flaps like soleus or gastrocnemius  flaps are also described for middle third defects but might yield unsatisfactory cosmetic and functional   results_2,4 Since   1st   described by  Masquelet   et  al,   19925  distally   based sural flap has been  limited to defects  in the distal third of the tibia, around the ankle and foot.6,7  This study is to evaluate the outcome of extended single stage distally  based sural flap for reconstructing mid leg post traumatic

defects.

Patients and methods:

From December 2011 to Jan 2014 a total of  20  single  stage  extended  distally  based sural flaps had been done for reconstruction of post traumatic soft tissue defects at the middle third  of the  leg with exposed tibias. All  patients  were  males  with  average  age of 30 years (range from 17-50 years). The length of the flap ranged from  28 to 34 em (average 31.2 em) and the width at the widest point ranged from  10 to 15 em (average,12 em) Table (1).  The  average  time  of follow up  was  9  months   (ranged  from  3  to   18 months).  All  patients  were  firstly  operated upon by orthopedic surgeons where they applied external fixations.  Duplex study was then done for detection of patent peroneal perforators but was not mandatory.

Surgical procedure:

The patient was placed in the lateral decubitus position, under general anesthesia, after marking the axis of the flap, which was the  course  of  the  medial  sural  nerve.  The flap was outlined according to the size of the defect and distance from it. The superior edge of the flap was about one inch just distal to the knee crease. The pivot point was 5 em above the  tip  of  the  lateral  was  malleolus  along the axis of the flap (this level determined by position of last perforator). The incision was made along the superior border of the flap. At mid-calf, the sural nerve and lesser saphenous vein were identified suprafascially. The sural nerve, artery, and lesser saphenous vein were divided and ligated, and was included within the flap. The entire flap was elevated and dissected subfascialy from the proximal to distal end. Then a direct incision between the donor site and the recipient site, rather than a subcutaneous tunnel was done.  The flap was then transposed  and sutured to the recipient site and the donor was then covered by skin graft from the same thigh Figures (l,a,b).

After   the   operation   all   patients   were advised to elevate their legs and also splint immobilization  was recommended  for  2 weeks.

The stitches were removed after 2 weeks.

Results:

We performed 20 extended distally based sural flaps for 20 patients with soft tissue defects at mid leg level either post traumatic or post gunshot. The success rate was 100% with  all  flaps  survived  Figure (l,c).   Only two flaps suffered distal necrosis that were treated conservatively and another two developed  surgical site  infections  and  were also  successfully  treated  with  antibiotic therapy  according  to  wound  swab  culture and sensitivity  Table (1). This flap provided a  satisfactory   coverage   for   such   defects in  all  patients.  Postoperatively   we  noticed slight  venous  congestion  in some  flaps  but these resolved with leg elevation alone. The removal of sural nerve within the flap caused loss of sensation over the outer foot but surprisingly improvement was noted starting

6th months post surgery.

Discussion:

An ideal flap should be easy to raise, reliable, not dependent on microsurgery and should not sacrifice major vessel or major nerve.8, 9

This flap satisfies the previous criteria and covers the mid leg defect with satisfactory result.

It is versatile and can reach the distal third, heel, dorsum of foot and middle third of the legJ-11

This flap has long and narrow pedicle and a wide arc of rotation because its vascular axis has the longest direct artery of the posterior calf and the strongest peroneal  perforator  at its pivot point.15

The local versus free flaps for covering defects  in  mid  leg  involves  long  operative time,  sophisticated  instruments,  a  need  for well trained microsurgery team and high equipment cost ofthe later.16, 17

Local muscle flap like gastrocnemius or soleus total or hemi flaps has proven to be another  option  for  covering  defects  in this area  however   because   of  local  contusion of soft tissues after trauma it is not always healthy. Another   drawback   is  the   limited muscle size in comparison to defect size that sometimes  very big, beside the compromise of limb function.16, 18, 19

In this  study  we  presented  the  reversed sural flap but not only taking the distal and middle third of the leg but also the proximal third to cover a big size defect in mid leg.

The  idea of taking the proximal  third  of

the  leg within the flap has been reported.20

They used it for foot defects on 13 patients without  any total flap loss taking their proximal  incision 1-2 em from knee crease. The  upper  limits  of  the  flap's  dimensions have been best explored by Ayyappan and Chadha,  2002  when  they  reported  that the flap can  be extended  proximally  to  include the entire  upper third  of the  leg  posteriorly with a pivot point only 4 to 5 em proximal to the lateral malleolus but also their work was on heel defects. 21

In this study there was no tunneling, wide segment of tissues around the pedicle of the flap and the skin was also kept on the flap. All these  modifications aimed at decreasing the venous congestion, avoid flap kink and excessive flap tension so only two cases developed   partial  distal  necrosis  and  this proved to be effective in other series.22- 24

Figure (1): (a) After externalfixator application, (b) The extended reversed sural flap raised,

(d) Post operative flap completely viable.

Table 1: Patient's demographics, flaps dimensions and complications.

This flap was a single procedure so it avoided the burden oflong hospital stay and two stage procedures of either delayed or cross leg reverse sural flaps described in other studies.21, 25· 21

Distal flap necrosis was the most encountered complication that developed in two patients (10%) but in other seties the rate of flap necrosis were 15%,16%, 22%7,28,29 and the low incidence in this study might  be due to wide pedicle size and less amount of kinking.

In this study the sural flap was taken in the centre of the flap so affecting the sensation at outer border of the leg but with noted improvement in sensation with time and this also repmted in other studies.3o,31

Conclusion:

Extended   single   stage   distally   based sural flap is a reliable and easy option for reconstmcting  mid  leg  defects  with  vety less morbidity. It does not involve sacrifice of   major  vessel  or  nerve   or   functional impairment.

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